HLCA

Learning from Failures of Australia’s Home Care Package Program

Context

The Home Care Package (HCP) Program is funded by the Australian Government to support older Australians to remain living at home and connected with their community (Department of Health, 2021a). The program is intended to provide coordinated, consumer directed care which meets the individual’s identified needs in accordance with the Aged Care Act 1997 (the Act). Despite the best intentions, the current system is complex and flawed as highlighted by the Royal Commission into Aged Care Quality and Safety (Commonwealth of Australia, 2021). This paper will use a systems approach to analyse key interconnected factors which have contributed to failures within the HCP program and their impact, depicted in Image One. Lastly, it will explore what can be learned from previous system failures and identify strategies for the future.

Image One

Systems view of HCP program

Critical Examination of System Failures

Inequity for older adults with disabilities

The National Disability Insurance Scheme (NDIS) is jointly funded by the Commonwealth, State and Territory governments to provide support to eligible Australians with permanent disabilities. Unlike the HCP program which provides a set amount of funding annually (Department of Health and Ageing, 2022), NDIS funding plans are individualised and not capped to a specific amount (Schwarzman et al., 2022). People over the age of 65 are ineligible for the NDIS regardless of the severity of their disability or their age when diagnosed (National Disability Insurance Agency, 2022). Participants of the NDIS however, including those under the age of 65, can access both NDIS and aged care funded services if deemed eligible, provided there is no duplication of support (Department of Health, 2021a). This inequity places older Australians with a disability at increased risk having poor outcomes or living with unmet care needs (Hill, 2022; McPake et al., 2017).

The HCP program includes four package levels, with funding ranging from $9000 up to $52,000 for individuals with high and complex needs (Department of Health and Ageing, 2022). NDIS plans are almost quadruple for participants with high care needs, with the average funding reported to be $199,601 per year. For those also requiring specialist disability accommodation, the average figure is reported to be $493,170 (Speirs et al., 2021) Within the HCP program there is no additional funding available to meet disability needs. Those receiving a level three of four HCP become ineligible for state and territory based equipment funding and subsequently need to purchase any equipment or additional support required through their available HCP funds, pay privately or forgo care to remain living at home (Speirs & Hicks, 2021). Concerns regarding this disparity was raised in Parliament in 2013, yet almost 10 years later this inequity has not been addressed in subsequent reforms to the HCP program. As a result, many consumers are forced to enter permanent residential aged care as their HCP funds are insufficient and unable to meet needs that would be addressed if they had NDIS support (Schwarzman et al., 2022).

Poor delivery of consumer directed care

In 2017, the Increasing Choice in Home Care reforms saw the introduction of Consumer Directed Care (CDC) with the intention to shift power from providers to the consumer to make informed choices and have flexibility regarding the care they receive. While consumer directed models have become more popular throughout the world, the evidence to support their efficacy is limited and mixed (Bulamu et al., 2017; Carey et al., 2019; Tran et al., 2021). Concerns include care not being delivered as intended, addressing wants as opposed to needs, or placing already vulnerable people at increased risk of exploitation (Hill, 2022; Moore, 2021). The HCP Program Assurance Framework (Department of Health and Aged Care, 2022), was established in response to the Royal Commission to protect the integrity of HCP funding and mitigate four key risks including consumers being unable to exercise choice and inappropriate or fraudulent use of taxpayer funds.

The process of determining eligibility for a HCP and develop a support plan is comprehensive and comes at great expense to the federal government at $129 million dollars annually (Department of Health, 2021a). Currently the assessment content has limited guidance over delivery of the HCP, bringing into question the relevance of the assessment model. There is a brief list of specified exclusions however some categories, such as those relating to home modifications and capital items, are ambiguous. In practice, the resulting flexibility has enabled HCP funds to be used to provide services or goods which are not in keeping with the program guidelines or in a manner which could be considered as inappropriate or fraudulent (Department of Health and Aged Care, 2022). Providers often express frustration with the guidelines as they feel unable to deny requests seen to be inappropriate. Reports include construction of a $12,000 deck, purchase of high-end equipment such as laptops or furniture, or using entirety of funds on cleaning and gardening (C. Linden, personal communication, 2022). The ambiguity of program guidelines or input, designed to improve flexibility, has resulted in consumers either being dishonest about actual care needs or forgoing necessary care to access excessive supports in other areas. The impact of mismanagement is significant given the finite resources which could be better used by consumers waiting to receive a HCP for essential support, potentially placing increased strain on the hospital and residential aged care systems if their care is inadequate at home.

Unsustainable model of care delivery

Population ageing has become a global concern as the number of people over the age of 65 increases and fertility rates decline (Bloom et al., 2015). Approximately 4.2 million, or 16 percent of Australia’s population are aged 65 years or older (Australian institute of Health and Welfare, 2022a) with the Australian Bureau of Statistics (2018), predicting this number will rise to 6.7 million over the next 20 years. Improved access to healthcare has resulted in people living longer, often with chronic health conditions, increasing the length of time they are likely to require health and aged care. Subsequently the demand for aged care is expected to increase significantly over the next 20 years. With this come concerns about the economic impact and sustainability of tax payer funded services as growth of the labour force decreases (McPake & Mahal, 2017). This has been reflected in the number of older Australian’s accessing care at home increasing 245% over the past 10 years from 51,000 to 176,000 people (Australian Institute of Health and Welfare, 2022b).

The HCP program is said to be designed around a model of frailty with the presumption that all aged care consumers will experience progressive decline in function with limited opportunity to improve (Schwarzman et al., 2022). Current legislative inputs do not allow for HCP approvals to be reduced where funding is in excess of what a person requires or be responsive to sudden, temporary changes in health and function which can become more frequent with age. This results in many undesirable outcomes such as $1.5 billion in unspent funds accumulating, inappropriate use of funding and premature reliance on support while almost 60,000 people are unable to receive care. While the Royal Commission recommended release of additional HCP’s and abolishment of the National Priority System (Commonwealth of Australia, 2021), this would likely be a fix that fails from a system archetypes perspective (Zaidi, 2022). Without legislative or policy changes to improve use of existing funding, the current system will not be cost efficient or sustainable and unable to meet the needs of Australia’s ageing population.

Care at Home for Older Adults: A Future Vision

Service equity for older adults with disabilities

The inequity experienced by older Australians with disabilities through siloing of aged and disability services is significant, as previously highlighted. Review of community care models delivered in the United Kingdom and Ireland, who utilise variations of CDC, highlight some key differences between policies and practices. Schwarzman et al. (2022) report the two sectors work more collaboratively improving delivery of services to meet complex needs. The current legislative and policy inputs of Aged Care and NDIS would need to undergo reforms to support appropriate access to specialised care and/or equipment required to improve functional outcomes and quality of life.

Within a new program, greater emphasis needs to be placed on rehabilitation and the ability to improve function through reablement and compensatory strategies. There is much literature which reports benefits associated with provision of such care, including access to timely support following injury or illness leading to better health, mental and functional outcomes (Kingston et al., 2022; Schwarzman et al., 2022). While costs may be more significant in the initial provision of equipment or rehabilitation services, the longer term impact of improving or maintaining health and independence is likely to reduce spending in the future and reduce need for premature entry to residential aged care (Kingston et al., 2022).

In order to prepare for such reforms, policy makers would need to engage with the relevant stakeholders and consider learnings from other programs internationally. Predictions of possible costs, based on disability and diagnostic data from the population would provide insight into anticipated costs to the service. Eligibility for disability support through the HCP program would need to be considered as the NDIS and HCP program have different residency criteria. NDIS participants must be Australian citizens or permanent visa holders whereas the HCP program does not have residency requirements (Department of Health, 2021b; National Disability Insurance Agency, 2022). Without addressing such matters, younger people with disabilities who are not Australian citizen’s or permanent visa holders may request a HCP, increasing burden on the system intended for older adults.

Delivery of flexible and appropriate care

CDC in its current format has failed to meet the objectives of the HCP program. In redesigning the way CDC is delivered, it is important that consumers maintain choice and flexibility in the care they access however increased guidance and regulation is required to ensure funds are used in the manner intended. Review of both the assessment and documentation processes is necessary to enable development of a support plan which will guide delivery of services. Developing specific domains for support within the assessment could support this process and ensure funds approved with the intention of providing a service such as wound care, hygiene or medication management are used appropriately. Consumers would maintain choice regarding delivery of those services however would not be able to reallocate funds to a different domain. Image Two presents possible care domains, however these would need to be developed in collaboration with relevant stakeholders such as consumers, care providers, assessors and health professionals.

By improving delivery of CDC to ensure care needs are met and consumers are better supported to make informed choices, it is anticipated their health and functional outcomes will improve (Gill et al., 2015). Zaidi (2022), discusses anti-archetypes such as ‘fixes that fuel’, where solutions result in additional positive outcomes which were not intended. In this instance, the fix of allocation of funds to meet specific needs could see a reduction in misuse or fraudulent use of funds and reductions in the number of referrals requesting review of HCP level. In practice, ACAT Assessors report incidents where consumers or HCP providers have identified the need for support with activities likely to attract higher levels of funding, such as personal care or medication management, with the intention to use it for other supports which should be funded through their existing HCP (C. Linden, personal communication, 2022). Monitoring and evaluation of changes would include a mix of methods, client satisfaction, review of re-referral data which is presented in Image Three.

Image Two

Possible HCP Domains

Sustainable care in an ageing population

Nguyen et al. (2022) highlight the need for reforms in both health and aged care policies to enable societies to meet the needs of the ageing demographic. These would include taking steps to address shortages of skilled workers necessary to provide the required care and greater integration of services, however these matters are beyond the scope of this paper. Two strategies have been identified for urgently needed HCP reforms, which have the potential to fuel benefits to both the aged and health care systems, with longer term positive impacts for the Australian population.

Under a new system, consumers would no longer be able to accumulate unspent funds for “future planning” or large purchases. Instead, services would be accessed from the funds available under each domain in their monthly budget, except for home modifications and equipment which would be allocated annually. Requests for items which exceed the annual allocation for that domain would require application to a specialist team who would be responsible for assessing and approving. Consumers would be funded for what is reasonable and necessary and be responsible for additional costs associated with aesthetics or personal choice. Additional funds would be allocated to provide short term services during illness or following injury, which could be requested by the service provider for a rapid response. Provision of such support would improve health and function outcomes, reducing risk of ongoing functional decline or need for residential aged care (Ottmann et al., 2013).

Caps would be introduced for domestic assistance and gardening which have proven to be contentious services and often exceed what would be considered appropriate use of public expenditure. Hill (2022), suggests discussions between policy makers and relevant stakeholders are needed to determine the amount of taxpayer funds which are seen as appropriate to meet specific needs, and considering the value and risk of providing or not providing a service to ensure sustainability. This measure would set realistic expectations for both consumers and providers and ensure greater equity Australia wide.

Recommendations

1. Legislative, policy and program reforms to ensure older adults with disabilities have equitable access to the services and resources as NDIS participants.

2. Timely access to short-term rehabilitation, reablement and care services to improve functional outcomes following injury or illness.

3. Use of care domains to ensure taxpayer funds are utilised to access the care required while enabling consumers to maintain flexibility and choice within the scope of the HCP program.

4. Implementation of caps on cleaning and gardening supports to reduce risk of inappropriate use of funding.

5. Improved monitoring of expenditure

6. Ceasing accumulation of unspent funds to enable finite resources to be allocated to people who require support, when they require it.

7. Establish a clinical panel to approve and regulate major modifications and equipment purchases beyond the allocated domain budget.

2

Image Three

Evaluation and monitoring

References

Bulamu, N., Kaambwa, B., Gill, L., Cameron, I., McKechnie, S., Fiebig, J., Grady, R., & Ratcliffe, J. (2017). Impact of consumer-directed care on quality of life in the community aged care sector. Geriatrics and Gerontology International, 17(10), 1399-1405. https://doi.org/10.1111/ggi.12872

Carey, G., Crammond, B., & Malbon, E. (2019). Personalisation schemes in social care and inequality: review of the evidence and early theorising. International Journal for Equity in Health, 18(1). https://doi.org/10.1186/s12939-019-1075-2

Commonwealth of Australia. (2021). Royal Commission into Aged Care Quality and Safety. Retrieved from https://agedcare.royalcommission.gov.au/publications/final-report-volume-1

Department of Health. (2021a). Home Care Packages Program - Operational Manual. Retrieved from https://www.myagedcare.gov.au/publications/home-care-packages-manual

Department of Health. (2021b). My Aged Care Assessment Manual. Retrieved from https://www.health.gov.au/resources/publications/my-aged-care-assessment-manual

Department of Health and Aged Care. (2022). Home Care Packages Program Assurance Framework. Retrieved from https://www.health.gov.au/resources/publications/home-care-packages-program-assurance-framework

Department of Health and Ageing. (2022). Home Care Package Program - Data Report 3rd Quarter 2021-22. Retrieved from https://www.gen-agedcaredata.gov.au/Resources/Reports-and-publications/2022/August/Home-care-packages-program-data-report-1-January-%E2%80%93

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Hill, T. (2022). Understanding unmet aged care need and care inequalities among older Australians. Ageing and Society, 42(11), 2665-2694. https://doi.org/10.1017/s0144686x21000222

Kingston, A., Wittenberg, R., Hu, B., & Jagger, C. (2022). Projections of dependency and associated social care expenditure for the older population in England to 2038: effect of varying disability progression. Age and Ageing, 51(7). https://doi.org/10.1093/ageing/afac158

McPake, B., & Mahal, A. (2017). Addressing the needs of an aging population in the health system: The Australian case. Health Systems & Reform, 3(3), 236-247. https://doi.org/10.1080/23288604.2017.1358796

Moore, C. B. (2021). Consumer directed care aged care reforms in Australia since 2009: A retrospective policy analysis. Health Policy, 125(5), 577-581. https://doi.org/https://doi.org/10.1016/j.healthpol.2021.03.012

National Disability Insurance Agency. (2022). Applying to the NDIS. Retrieved from https://ourguidelines.ndis.gov.au/home/becoming-participant/applying-ndis

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Schwarzman, J., Lalor, A., Reeder, S., Callaway, L., Aburumman, M., Gabbe, B. J., & Ekegren, C. L. (2022). Factors influencing care and support for older adults with traumatic injury in Australia: a qualitative study. Disability and Rehabilitation, 44(22), 6692-6698. https://doi.org/10.1080/09638288.2021.1970258

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