streamlined consumer assessment for aged care

1. Design Principles (see chapter 3 of the discussion paper)

Are the proposed design principles appropriate for a streamlined assessment model? Are there any other principles that you believe should be included?

cohealth broadly supports a more streamlined assessment model and supports the proposed principles which will underpin the new model. However, cohealth has some concerns and propose the following additions to the model.

Greater attention needs to be placed on access especially for special needs groups. Free assessment needs to be maintained however consumers with special needs are continuing to be disadvantaged at access to MAC and at assessment. One way to address this is through more flexible entry and assessment options. To fully engage special needs groups, CHSP needs to offer face to face entry options through hubs or access centres and acknowledge that home assessment may not always meet the needs of some consumers.

The system must recognise that other sector stakeholders such as health professionals and GP’s have strong relationships with consumers which can be leveraged to create additional efficiency and effectiveness.  This could be addressed in many ways such as improved communication and feedback with the referring agent. This is a fundamental component of the health system and must be embedded in the Aged Care assessment process if addressing health needs remains within scope. Better communication between the assessor and the referring agent will ensure the referrer’s often deep knowledge of the client`s needs can inform the plan and that the assessor and client`s agreed plan is optimally enacted.

cohealth supports that assessment needs to be outcome focused however more importantly assessments need to be client led. This principle needs added detail which includes consumer rights, dignity of risk and full and informed consent. Ideally this should include consent about the assessment process, the degree of assessment consumers are going to receive and their options if they decline a service. The inbuilt contradiction in the My Aged Care system is the client has no control whatsoever over the nature, location and degree of their assessment. Their participation is binary: in or out and this does not result in comprehensive and full assessment based on trust.

cohealth support the inclusion of quality assessment in the model. To fully address this timeliness of assessment needs to be a quality standard which can be reached. Such as increased resources in areas where waiting times for assessments mean consumers are put at risk. Quality assessment for special needs groups means that the assessor is highly trained and qualified and has experience with care planning, motivational interviewing and understanding local community networks and services.

2. Entry process (see section 5 of the discussion paper)

What issues need to be considered for assessment providers to manage intake and triage under a streamlined assessment model? (e.g. staff skills required of a triage function; consistency of operational processes; and resource implications)

cohealth acknowledges that there have been some issues with the current system which has resulted in the health of consumers worsening while waiting for assessment or that inadequate services have been approved. In addition, cohealth observe inefficiencies in processes, confusion, consumers being asked to repeat their information and the assessors are now seen as the approvers of funds rather than working together to meet the client’s goals. The proposed model goes some way to addressing these challenges.

cohealth strongly support the need to have experienced, trained and skilled staff undertaking intake and triage especially when there is an urgent consumer need, a significant change to a person’s circumstances or the consumer identifies with a special needs group and are at risk of falling out of the system. There needs to be a greater emphasis on enabling consumers to understand their packages and plans and empowering them to action these.

Having skilled staff undertaking triage will assist to maintain contact with consumers, ensuring they are not “lost”, and to take an individual approach to help guide them through the process. Furthermore, skilled and experienced staff will have a clear sense of consumers who are vulnerable to falling out of the system and would be sufficiently skilled to implement strategies to minimise this risk. Skilled and experienced staff have more ability to understand the aging process, especially complex care needs, wellness and reablement and the benefits to health and wellbeing that specific services can have and the local knowledge to implement this.

cohealth holds the position that only skilled staff should be triaging based on a consumer’s functional status and support needs. We propose that assessment staff should be required to have a tertiary clinical health qualification such as such as nursing or allied health. Although not always possible ideally assessment staff should be required to have assessment and triage experience and a number of years working with older people or in a community based or residential aged care setting.

How can a streamlined assessment model enhance referrals and collaboration between health professionals, My Aged Care and a national assessment workforce

cohealth fully support collaboration between MAC call centre, assessment services and health professionals. cohealth believes that outreach and community development workers should be included in the definition of health professionals as they know consumers well, understand their functional needs and can identify early when care needs have changed and are well placed to assist to deliver a streamlined assessment model.

There has been a lack of engagement by GP’s which has created a burden in community health as we are now undertaking supported referrals into MAC. This creates additional confusion for both consumers and GP’s as in the past they were able to come direct to a service provider to have a need met and now they are being pushed to an assessment service only to come back again. More effort needs to be directed to engage GP’s, hospitals and health professionals in the referral process and the benefits to assessment. It is possible that health professionals who know consumers well could undertake some elements of triage and diminish need for a triage contact. Including having the option of completing part of the NSAF and goals so as the client doesn’t have to repeat their story. This will foster collaboration as health professionals are frustrated that at the end of a long waiting and assessment period their client does not receive the services in which they were referred and the client has deteriorated.

cohealth supports work underway to enable medical and health professional client management systems to integrate with the MAC portal and online referral. More engagement with GP’s and health professionals is required, so they understand the process and feel confident that their referrals will be actioned in an accurate and timely manner.

There are current inefficiencies in the support plan review process for health professionals. Creating more clear path ways and triggers for health professionals and GP’s to request a support plan review will be essential to creating efficiency in the new model.

The new model needs to facilitate feedback between providers on the outcomes of referrals including when services are in place. Currently GP’s and health professionals receive a referral acknowledgement and support plan upon their referral, however formal feedback on when services have commenced is required to ensure continuity of services and risk is managed. This is more important when consumers are having difficulty understanding and navigating the My Aged Care system and assessment process.  Often referrers such as GP’s nurses and health professionals can support clients through the process if they are advised of the progress and outcome of their referral.

How do you think the triage process should operate to expedite access to a single time-limited CHSP service? What are the risks and how could these be managed?

cohealth strongly supports the development of expedited access to single and time limited CHSP services. This will have significant benefits for both the assessment services, consumers and referrers. cohealth strongly advises streamlined referrals for simple health needs where intervention is short term and health promoting and where a quick healthcare response prevents an issue from becoming chronic.

Furthermore, cohealth propose that referrals which are confined to one sub-programme, such as allied health and therapy (inc home mods), also be fast tracked. For example when a referral is made for social work and occupational therapy, that these referrals are fast tracked. This will have significant efficiency gains as assessments won’t be duplicated and more resources can be placed into service rather than assessment. Consumers requiring more than one sub-programme such as personal care and allied health could still be triaged to ensure that all the needs are able to be addressed and an overarching care plan developed.

The level of assessment provided to consumers should be directed by them, if clients are seeking a single service and not wishing to undertake a full assessment they should not have to have the full assessment.  Support plan reviews can be requested if needs change or when client is ready to engage more fully. The current system is overwhelming and excessive for clients seeking a single time-limited service and deters many from engaging at all.  Many referrals made by assessors are rejected by clients at the service level as they never asked for this service. This is a huge waste of resources all round.

cohealth would like to see all referrals from health professionals and GP’s to be expedited without requiring further approval from non-health professionals. Health professionals are more than capable of determining the degree of assessment and services their clients require to live an independent life. Such referrals and services would be documented in the portal to ensure services are not duplicated and all stakeholders have access to the clients full service support program.

How can support plan reviews be better managed under a streamlined assessment model?

Once older consumers are receiving aged care services despite taking a Reablement approach a client’s function may continue to decline and require additional services. Health professionals and other service providers are regularly interacting with aged care consumers and are very capable of responding to a person’s changed needs.

Assessment workers should continue to follow the advice and input of Health Professionals with close relationships to the client. If a detailed change of status update is received by a health professional using the support plan review process, cohealth believes that this should not require further substantiation and quickly be approved by the assessment service. The system must use its Health Professional service providers as an ongoing source of assessment and feedback. If this is not properly respected the system will lose a key potential for efficiency. Where requests for review come from less qualified sources, or indeed from self-referrals, further assessment and substantiation would be required. Furthermore, cohealth would like to see the functionality of the portal’s support plan review process improved so that it supports a more efficient process when allied health are making referrals to other CHSP providers.

It is cohealth’s experience that “vulnerable” consumers frequently do not have the capacity to enact their care plan and package. In many cases, they are unaware that they have received one. If the consumer is aware it is often up to GP’s, nurses and other health professionals to support the consumer through the package process. This process is difficult as GPs and nurses are not CHSP funded and are working outside the MAC portal. Having a more flexible approach to the approval and commencement of services as well as a more skilled and qualified assessment workforce (including Access and Support) who are able to spend time with consumers until their plans are enacted will assist to address this.

A more flexible approach to approval and commencement of service will assist consumers to build trust with care providers and over time put the right services in place. An example of this could be that clinically proven services are approved in advance and over time the client empowered to be able to pick these services up as the further engage with the service or when their needs change such as in the case of Motor Neuron Disease. It is often the case that consumers decline services or only want one of the recommended services, but through a trusting relationship of a health provider the consumer becomes ready to engage in further services. This client should not have to be re-assessed to receive services which were clinically relevant at the beginning.

4. The assessment workforce (see section 6 of the discussion paper)

What qualification and competency requirements do you believe are needed for a national assessment workforce? What particular areas of assessment practice require clinical expertise and/or multidisciplinary team-based approaches?

cohealth supports defined qualifications and competencies for all assessment workers.

For Regional Assessment Services: a qualification such as a certificate in training which has a health or social assessment module would be important. As well as skills and experience in the community and home support programs such as mental health outreach, disability worker, community development or personal care attendant.

For ACAT: a tertiary level of education in a health field with some skills and experience working in that discipline would be important. It is also important to identifying that other allied health professional are eligible to participate in the ACAT workforce such as Speech Pathology, Dietetics and Podiatrist.

For both assessment levels it would be important to have competency in Reablement, linking support, health service system including roles of health professionals, client care planning and goal setting, understanding of how aging occurs and the impact on individuals and general understanding of common diseases and disease management, including dementia. And experience working with diverse and vulnerable groups including elder abuse and older age groups.

Assessment teams work in the community and enter people’s homes, and as such should reflect the community in which the service is provided.  Therefore, cohealth support recruitment and retention strategies which are appropriate to reflect the often diverse communities in which the assessment services operate. cohealth acknowledges that this is a long-term strategy however one that will result in the consumers having trust in the system.

Clinical expertise and Multi-Disciplinary team-based approaches work well for more complex clients, consumers from special needs groups or who require level 3 and 4 level packages and have changing health needs. cohealth support the approach for more experienced and qualified ACAT teams to provide support to the RAS including structured orientation and learning of local service systems and consumer’s needs. There would be opportunities to case conference and undertake shared learning and reflective practice. The effect of this would be a workforce which is supported and have ongoing opportunities for professional developed which is required in a professional and high-quality service.

What design features will enable assessment providers to operate an integrated workforce which is capable of delivering assessment for people across the full continunum of aged care needs?

Having an integrated workforce where the RAS, ACAT and health professionals are conducting assessment and care planning requires structured approaches to working together. When functioning optimally such structures would see care delivered consistently, the needs of the consumer met, barriers to access reduced and staff satisfied at having opportunities to learn from each other.

Having ACAT and RAS teams situated together in the same location with strong links to clinical staff (or having clinical staff situated in assessment teams) is one method in achieving a structured approach to integrating the work force. Such a structure would allow them to function as one team with one goal, allowing senior or more clinically trained staff to mentor less qualified or experienced staff.

cohealth has had positive outcomes from placing a part time Occupational Therapist in a RAS team for around 2 years. This integrated approach has provided more structured opportunity to undertake joint assessments, providing building the capacity of the RAS Assessors in the area of OT and other allied health disciplines and how to screen and consequently refer appropriately for functional decline. The benefits of this are that clients are provided with care more rapidly, it limits communication error, the care plan is shared and understood and the services which are approved meet the client’s needs and goals. It is cohealth’s belief that having an integrated approach to assessment provides real benefits to a consumers reablement and this type of integration needs to be considered when revising the assessment service structure.

What training and other initiatives should be considered to build the capability of the national assessment workforce?

Building capacity of the assessment workforce to provide high quality care to vulnerable and diverse older people in their homes requires consideration of all the aspects of care they provide. This included ensuring consistent knowledge, skills, risk management as well as having the opportunity to participate in continuous professional development including allocated time, funds and opportunity such as a training calendar to support a high-quality assessment service.

Topics which address knowledge include working with socially and financially marginalized groups, working with people with mental illness, disability, homelessness, drug and alcohol use, First Australians, refugees and asylum seekers, sexuality, LGBITQ+ as well as chronic disease and ageing. In addition knowledge of the local health service system for services outside of CHSP such as dental, medical, optometry and specialist services such as falls clinics.

Initiatives to ensure staff and client risk is managed include: first aid, CPR, elder abuse, managing challenging behaviors / de-escalation and suicide risk response.

Training to enhance the quality of care may include; Reablement, health literacy and communication skills, using interpreters, motivational interviewing, care planning, human rights approach to health care, advanced care planning and self-care.

To embed training the assessment workforce may benefit from opportunities offered in clinical health services such as reflective practice, cased based learning and case conferencing.

What assurance mechanisms should be put in place to ensure the achievement of quality assessment outcomes for senior Australians

Currently there is not opportunity for assessment teams to receive consumer, carer or other service system or stakeholder feedback. These are built into community health accreditation standards however there does not appear to have a well-developed system for this in the assessment services. From consumers and carers this may include satisfaction and complaints feedback as well as wait times and other KPI data, assessor skill and knowledge and if the client felt listened to and at the centre of their care. To further improve the quality stakeholders and service providers may also provide regular feedback on areas such as quality of care plans, communication pathways and waiting time for home modifications or support plan reviews. It is cohealth’s experience that feedback is as required and not supported by a structured and formal approach to quality improvement.

It is well known that many older people lack the resources and support networks to really engage with MAC or in health interventions. This can lead to cancellations, “failures to attend” and the derailment of “best laid plans”. Case management and /or care facilitation for eligible consumers post-assessment is likely to achieve efficiencies in the system and health benefits for consumers. This could be achieved by an extension of the Access and Support role.

What should be considered in the design of a streamlined assessment model and a new national assessment workforce to achieve efficiency and deliver the best value for money?

cohealth support a streamlined assessment model which delivers value for all. Consideration around what is value to consumers would also be important in having an efficient system.

A streamlined model where assessment is undertaken for multiple new care needs, annual assessments, significantly changed care needs requiring further evidence or substantiation or complex care needs compared to simple health promoting and reablement care needs would be a significant step in having an efficient system. Enabling more efficient and fast-tracked methods of health professional referral into services and the sector having a greater understanding or incentives to refer appropriately will also achieve value for money. Ensuring there is a flexible approach to referral in and assessments will minimise clients lost to the system and improve engagement in services. And better resourcing of community health (or other services) to engage with special needs and vulnerable groups such as Access and Support workers, Case Managers and Intake Officers.

Having the right number and mix of assessment personnel which are matched to the demographics and needs of the region is an important factor in ensuring that the assessment workforce is responsive and efficient.  Planning to ensure that population changes are accounted for which includes possible transfer of NDIS participants to CHSP. This is especially important for regional and remote areas where recruitment into assessment positions can take more time or there is a lack of suitably qualified staff.

Cost is an important consideration however services cost more in rural and remote areas and this need to be factored in to the new model. Telehealth is an efficient way around this and support to operationalise this for rural and remote areas and needs to be a priority.

5. Assessment in a hospital setting (see section 7 of the discussion paper)

How should aged care assessment work for people in a hospital setting under a streamlined assessment model? What issues need to be considered?

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6. Assessment in Remote Australia

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7. Wellness and Reablement (see section 9 of the discussion paper)

How should wellness and reablement be further embedded in assessment practice under a streamlined assessment model? What strategies do you support and how should they be implemented?

cohealth believe in the wellness and reablement approach as it is embedded into our current service models even for more long-term clients.

However, because there is currently one KPI time frame from point of RAS referral through to discharge from service it is almost impossible to deliver an effective outcome. It would make greater sense, with no impact on accountability, to break this into two separate KPIs one for referral and service intake and another for service delivery. In addition, it is important for wellness and reablement service referrals to be clearly identifiable at the outset so they can be prioritised upon arrival at the CHSP agency and length of episode KPI’s can be achieved. This would ensure that full emphasis was given to the treatment side of the episode while not disregarding  responsiveness.

Taking a long-term approach to ensuring wellness and reablement is embedded in assessment will be important. More structured and ongoing training and support for assessors in this area will be important. Topics that may assist in this include: behavior change, goal setting, motivational interviewing and how to develop, review and enact plans.

8. Linking Support (see section 10 of the discussion paper)

How can more effective and consistent linking services to vulnerable older people be delivered under a streamlined assessment model?

Greater and more flexible funding needs to be directed to “Access and Support” workers within CHSP. These services could become the ‘face-to-face’ option for engaging with MAC. There would be clear indicators for eligibility, but we believe appropriate clients would include:  clients with limited health literacy, clients who “failed to navigate the system in the past, those with limited social, community and family networks and those who cannot engage effectively over the phone or internet. Clearer identification of “vulnerable” clients (those at risk of being lost by the system) should be made up front at the point of referral and an “access and support” style worker should be assigned to that client to directly assist their navigation through to service delivery- including choosing HCP providers.

It is when catering for “vulnerable” clients that improved communication, collaboration and flexibility between assessment and service providers becomes crucial. It is in dealing with this demographic that a rigid “one size fits all” system will be found wanting.

9. Additional Comments

What do you believe are the key benefits, risks and mitagation strategies of a streamlined assessment model for aged care?

What implementation and transition issues will require consideration in the design of a streamlined consumer assessment model?