HLB

Critical Review of the Home Care Package Program

Overview

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). My Aged Care was introduced by the Australian Government in 2013 to streamline the way consumers and their families accessed aged care, including assessment for a HCP (Australian Government, 2022) with the State and Territory governments delivering the Aged Care Assessment Program locally. 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 critically analyse a number key factors of the HCP program that impact on the population, while the Appendix, Systems theory overview of Home Care Package program, provides a broad overview of the HCP program.

Inputs

Population

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. 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).

Funding

The Australian Government provides approximately $7.8 billion in funding towards aged care at home with this amount expected to rise annually with growth of the ageing population (Australian Institute of Health and Welfare, 2022b). The program consists of four package levels which provide a set amount of funding annually, ranging from $9000 to $52,000 depending on care needs (Department of Health and Ageing, 2022a). Client contributions towards care costs are expected with means testing in place to determine the amount an individual is required to contribute.

Guidelines

The program provides consumer directed care to people aged 65 years and older, or 50 years and older for Aboriginal and Torres Strait Islanders (45 and older in remote areas). Aged Care Assessment Teams are required to comply with the My Aged Care Assessment Manual when determining eligibility for aged care services in accordance with the Act (Department of Health, 2021b). As approvals for HCP’s do not expire and cannot be downgraded, it is essential that Assessors follow best practice to ensure appropriate allocation of taxpayer funded resources. The Home Care Package Program Operational Manual provides guidance to approved service providers on delivery of the program and their responsibilities under the Act (Department of Health, 2021a).

Throughputs

Assessment

The ACAT is conducted by the Assessment Team using the 65-page National Screening Assessment Form, known as the NSAF. The NSAF addresses care needs across multiple domains and considers care needs which are unmet, resulting in development of a support plan and consumer directed goals (Department of Health, 2021b). Only current care needs can be considered, with reassessment required when an individual experiences a decline in function. Once the assessment is completed, it is submitted to an approved Delegate who must review the NSAF, support plan and any recommendations made before approving the level of care (Department of Health, 2021b).

National Priority System (NPS)

Consumers are placed on the National Priority System from the date their assessment is delegated while they wait for their HCP to be assigned. The system was established to ensure equity for all Australian’s regardless of geographic location. The default priority is medium, however in exceptional circumstances an assessor may recommend high priority which moves a consumer ahead of all assigned medium priority, expediting access to their HCP (My Aged Care, 2019).

Consumer Directed Care

In 2017, the Increasing Choice in Home Care reforms saw a shift towards Consumer Directed Care (CDC) which would shift power from the provider to the consumer and increasing flexibility and choice. While CDC is a popular model throughout the world there are concerns that care may not be delivered as intended, addressing wants as opposed to needs, or place already vulnerable people at increased risk of exploitation (Hill, 2022; Moore, 2021). 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 as they do not address assessed needs (Commonwealth of Australia, 2021). This may include forgoing support such as medication management or personal care to access cleaning, gardening or purchasing items outside the scope of the program.

Outputs

Services in place

As of March 2022, there were 208,512 HCPs in place across the nation, which was an increase of 25 percent from the 12 months prior. 18 percent of all HCPs approved during this period were given a high priority, placing them towards the front of the 57,000 person National Priority System (Department of Health and Ageing, 2022a). This figure had dropped significantly from December 2019 when over 100,000 people were reported to be on the wait list (Khadka et al., 2020). The current wait time for a HCP with medium priority was reported to be 3-6 months. No wait times were published for those assigned a high priority.

Unspent funds

In September 2021, there was $1.5 billion in unspent HCP funds held by providers (Department of Health and Ageing, 2022b). Funds accrue where a consumer chooses to save for a specific purpose, such as an expensive piece of equipment or home modifications, or where the funding allocated is in excess of what is required to meet assessed needs. While the government has implemented strategies to reduce the amount of unspent funds accumulating, the Royal Commission identified concerns regarding inaccurate reporting by providers in relation to fund use and surplus and called for more rigorous processes (Commonwealth of Australia, 2021).

Outcomes

Poor delivery of consumer directed care

The HCP operational manual provides guidance on delivering consumer directed care within the scope of the program and available budget. It recommends that requests for services or purchases that do not address an identified need or result in a consumer missing out on required care should not be approved by a care provider (Department of Health, 2021a). In practice however, care providers who are unskilled or seeking increased profit have allowed consumers to exhaust their funding inappropriately and request reassessment for a HCP upgrade to address unmet needs. Phillipson et al. (2022), report limited evidence to suggest improved outcomes for services delivered under a consumer directed model and raised concerns around the appropriateness for vulnerable consumers, such as those with dementia.

Inequity

The National Disability Insurance Scheme (NDIS) provides support to eligible Australians with permanent disabilities. Older adults are ineligible for the NDIS if they have not applied prior to their 65th birthday however participants of the NDIS, 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).

Impacts

Unsustainable model

The demand for aged care is expected in 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). 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. This will include taking steps to address shortages of skilled workers necessary to provide the required care.

Allocation of resources

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Current legislation does not allow for HCP approvals to be reduced where funding is in excess of what a person requires, unlike residential respite funding which is adjusted higher or lower, depending on the outcome of the Modified De Morton Mobility Index (DEMMI) assessment. Nor does not specify how funds should be used or cap amounts for specific services, as with the NDIS. This results in a number of undesirable outcomes such as $1.5 billion in unspent funds accumulating, inappropriate use of government funds 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 an abolishment of the National Priority System (Commonwealth of Australia, 2021), improved use of existing funding may better meet the needs of Australia’s ageing population.

References

Australian Bureau of Statistics. (2018). Population projections, Australia. Retrieved from https://www.abs.gov.au/statistics/people/population/population-projections-australia/2017-base-2066

Australian Government. (2022). My Aged Care. Retrieved 05/11/2022 from https://www.myagedcare.gov.au/about-us

Australian institute of Health and Welfare. (2022a). Older Australians. https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/summary

Australian Institute of Health and Welfare. (2022b). Spending on aged care. Retrieved from https://www.gen-agedcaredata.gov.au/Topics/Spending-on-aged-care

Bloom, D. E., Chatterji, S., Kowal, P., Lloyd-Sherlock, P., McKee, M., Rechel, B., Rosenberg, L., & Smith, J. P. (2015). Macroeconomic implications of population ageing and selected policy responses. The Lancet, 385(9968), 649-657. https://doi.org/http://dx.doi.org/10.1016/S0140-6736(14)61464-1

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 Ageing. (2022a). 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

Department of Health and Ageing. (2022b). Improved payment arrangements for home care. Retrieved 21/11/2022 from https://www.health.gov.au/health-topics/aged-care/aged-care-reforms-and-reviews/improved-payment-arrangements-for-home-care

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

Khadka, J., Visvanathan, R., Theou, O., Moldovan, M., Amare, A. T., Lang, C., Ratcliffe, J., Wesselingh, S. L., & Inacio, M. C. (2020). Development and validation of a frailty index based on Australian Aged Care Assessment Program data. Medical Journal of Australia, 213(7), 321-326. https://doi.org/10.5694/mja2.50720

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

My Aged Care. (2019). ACAT Guidance for Home Care Package High Priority. Retrieved from https://www.health.gov.au/resources/publications/acat-guidance-for-home-care-package-high-priority

Nguyen, L. T., Nantharath, P., & Kang, E. (2022). The Sustainable Care Model for an Ageing Population in Vietnam: Evidence from a Systematic Review. Sustainability, 14(5), 2518. https://doi.org/10.3390/su14052518

Phillipson, L., Smith, L., & Duncan, C. (2022). Perspectives and practices associated with consumer‐directed care in Australia: Synergies and tensions in supporting planning and delivery of home care for older people with dementia. Health & Social Care in the Community, 30(5), e2772-e2781. https://doi.org/10.1111/hsc.13721

Appendix – Systems theory overview of Home Care Package program