No more service for you

Image from shalomlife.com

Image from shalomlife.com

THIS blog has not focused much on home care, but there are a couple of major reforms of home care coming up which threaten to cut services to current care recipients.

Let’s first look at the Home Care Packages Programme, which delivers coordinated services to around 83,000 older people in their homes each year. These are people who would likely otherwise have to move into a nursing home.

From 1 July this year, this program will be delivered on a consumer directed care basis. Known as CDC, consumer directed care is designed to give care recipients more say over what care and services they receive and when. Care recipients will have some control over their care package’s budget and will be able to choose the services they want rather than be told which services they will get.

Sounds like a great reform. However, under CDC, providers will have to spend an individual package’s budget on the individual concerned. Although this sounds fair and sensible, it removes a provider’s ability to cross subsidise, which is currently quite common to ensure high needs clients get enough services. In other words, no longer will providers be able to take money from low needs clients who tend to under-spend their package and give the remaining amount to high needs clients.

From 1 July many high needs clients will lose services because without extra funding from the provider, their packages fall short. Unless they can make up the difference themselves (and some people are being told it will cost hundreds of dollars extra per week) they will have to cut back services or move into a nursing home.

Some high needs clients are actually receiving a low care package because of a huge under-supply of the high care packages, and they have that package boosted by funds from cross subsidisation. These clients will very likely have to move into a nursing home after 1 July.

The Department of Social Services has been aware of this problem at least since April last year when providers gave clear examples of the impact on their care recipients. Yet, nothing has been done by the Department to at least ensure existing home care recipients don’t lose services.

There are also changes afoot in Home and Community Care, which is being re-badged the Commonwealth Home Support Programme (CHSP).

As part of the Australian Government’s push to make aged care more user pays, it has proposed to increase fees for the bulk of the program’s 550,000 care recipients from 1 November 2015.

Meals on Wheels fees will rise to a minimum of $9 per meal plus the cost of ingredients. Domestic assistance will be $10 per hour for pensioners, social support will be at least $9 per hour and flexible respite will be charged at a minimum of $11 per hour.

The draft fee proposal has now closed for consultation. However, providers and groups like CPSA were unanimous: these fees are prohibitive and will see people stop getting services.

The Department of Social Services claimed that the fees reflect current charges across Australia. However, a comparison with fees charged in Victoria (where the CHSP will not operate) shows that the new CHSP fee schedule greatly exceeds that of Victorian charges for people on very low incomes.

Comparison of proposed CHSP fees with the Victorian HACC program:

Proposed CHSP fees for a full-rate pensioner Victorian HACC fees for a full-rate pensioner (2014) CHSP fee difference
Allied health $10 per hour $9.40 per consultation + 6.3% and up
Nursing $10 per hour $3.60 per visit +177% and up
Domestic assistance $10 per hour $5.80 per hour +72%
Personal care $10 per hour $4.30 per hour +132%
Respite $11 per hour $2.90 per hour +279%
Home maintenance $12 per hour $11.60 per hour +3%
Meals $9 plus ingredients $8.70 +3% and up

Equally, CPSA has spoken to a number of not-for-profit NSW providers who are horrified at the proposed fees and say that their clients simply won’t be able to afford home care.

What is puzzling about the proposed fees is that none of the extra revenue will offset government subsidies, so providers will make a windfall gain. However, not-for-profit providers claim to not need the extra revenue, with at least one provider telling the Black Box that the only way they see fit to expend the extra cash is to give it back to their clients.

There is strong opposition to these higher fees and hopefully the Department will redraft them so that a pensioner can afford home care in the future. But these home care reforms seemingly go against the rhetoric of giving older people the services they want: care in the home.

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3 responses to “No more service for you

  1. Thank you for your summary on the Consumer Directed Model of Care (CDMC) packages. I would like to add my experience having fought hard to be involved in the pilot program which was trialled approximately four years ago. Managing a CDMC was not rocket science despite the fact that many of the services providers thought that it was.

    Prior to the CDMC’s pilot, Service Providers were allocated approx. $48,000pa for each high care dementia patient. From that amount of funding, the organisation provided my father with a lowy 9 hrs. of services per week and were very inflexible as to what services they provided either because it was put in the “too hard basket” or because of the organisation’s policy protocols. In any event, the care recipient (my father) was short changed quite considerably from that Govt. allocation. The service providers benefited from the balance of funds.

    When I eventually obtained the CDMC, I totally managed the budget.
    The Govt,. allocation was $48,000pa less the agency commission of 18% (from my recollection).

    I was allocated a paper budget (not actual funds) of approximately $750 per week. I maintained a daily spreadsheet which itemised the care workers, date, time, hours, cost and services. I also selected the care agency. This allowed me to employ the worker with whom my father and I had a rapport and enabled him to have the same care worker(s) which was very important to him and facilitated an easy and comfortable routine.

    However, my selection of care agencies was restricted to those nominated on the service provider’s panel (which was contrary to the rules of the Govt. pilot program). The input from the service provider was NIL for which they retained 18% commission from the Govt. budget allocation. They also had the cheek to ask me to give them copies of my spreadsheet to use as a blue print for their organisation because their case managers and staff found management of the CDMC too difficult to execute and/or understand.

    All this was done whilst I provided round the clock care (sometimes with only 3 hrs.unterrupted sleep a few nights a week). Nonetheless, the CDMC was a God send and because of that program I was able to provide excellent care for my father and keep him living at home with me until he passed two years ago. I had the great privilege of being his carer for 7 years and thankfully to by pass the nightmare of a nursing home placement.

    In general, I managed a service allocation of between 25 and 32 hrs. per week on my budget. Some weeks I had less services and saved up the cost for a special service I required the following week(s). This is a far cry from the miserable 9hrs that the service provider previously allocated to my father whilst administering the $48,000pa . I managed almost all we needed each week and totally within the allocated budget. I never had a budget blowout.

    I believe the only way that people can remain at home, cared by their loved ones, is if the CDMC is managed properly by the care recipient (and carer) and/ or with a competent case worker. Not everyone wants to or is able to manage the budget in the necessary manner to optimise services as I did but it can be done with the right assistance from the service provider.

    Unfortunately, from what I have seen and experienced during the two years I was operating under the CDMC pilot program, provision of home care services will fail only if the following issues are not addressed and remedied:-

    1.Mindset:
    Service Providers do not want to relinquish ownership of the Govt.
    funding and control over the care recipient. A lot of the funding goes on administration and other non care costs. It is a business!

    2.Education and qualifications:
    Case Workers are ill trained both in understanding the different needs of different care recipients and the need for flexibility. The calibre of staff I came across, in generally, was of a low level or standard. The competent ones I valued left the organisations and regretfully went elsewhere because of restrictive protocols and policies.

    3.Safeguards:
    Case Workers had no ability or understanding of the need to maintain budgets in a manner which optimises care services. Nor did they have the time (or interest) to oversee the budgets to ensure that there were no over-runs or fraud and that the care recipient was being well looked after. Too bad if the carer was a rotten apple!

    4.Policies:
    Service providers generally wanted you to use their own staff for the provision of care (at a high $hourly rates) and prevented you from using a more competitive agency. In short, they acted as employment agencies for their staff and did not act in the best interests of their care recipient. The did not give the consumer the control they were entitled to under the CDMC regarding services or care recipient’s needs.

    5.Support:
    In my case, there was none. I did not even receive a note of condolence when my father passed. This was a “not for profit” organisation yet all I saw was policies, protocols and politics of envy.
    For example, when I used the service provider’s satff, if I wanted a care worker to iron my father’s clothes and in exchange I would do the personal care, I was denied the right to do so. Why? If I was working round the clock, cooking, washing, attending to my father, cleaning the house etc. and did not have the time to iron his clothes, why was he denied the right to look well dressed and well kept. I was told “well, we are not an ironing service you known – you can’t have it”. Yet, when I eventually engaged my own care workers from an independent care agency, they were willing to do whatever was required. Care also includes quality of life! Thankfully, those workers from culturally diverse agency were wonderful and made a positive difference in both my father’s and my life.

    I do not believe that a consumer directed model cannot work, even within the proposed fee structure. If the comsumer is in control and has the assistance (if not the ability) to secure services in an optimum manner,
    – and –
    the service provider charges the services of a case worker on an hourly basis (as needed) and does not take the 18-20% commission on the Govt. funding, I believe the Govt. allocation can go a long way to providing a reasonable $ assistance to allow the elderly and disabled to remain living in their own homes. It is the service providers who have to lift their game and actually care about the quality of service they provide and reconsider the profits they are chasing. All the blurb they come out with is just propaganda and window dressing. They are expert at it and the Govt. falls for it every time. If the service providers ran a tight ship, slashed their administrative costs and revamped their service provision model then they could actually provide the care that is required and still make a profit supported by the Govt. purse.

    Clearly, I do not hold many of the service providers in high esteem. The CEOs are running a business and a lucrative one at that. It is the
    care recipients who are held to ransom and the actual care workers who are simply grist for the mill. Aged Care is big business on all levels – just look at the coffers of the Public Trustee and Guardian which is the commercial arm of the Govt – with a guaranteed clientele and secure income. Who wouldn’t want a piece of the action in this industry particularly when there is no real accountability, transparency or any repercussions for wrongdoing.

    I had to fight very long and hard to get the best care for my father. Most people just end up giving up because the fight is just so exhausting and demoralising and the system so exploitative. Yet, even though our loved ones have passed, I and many like me, are still trying to change a system which needs a major overhaul and a conscience. It needs to start with the CEOs who pretend to run a benevolent ship but don’t.

    Aged Care is big business – just ask the genius with no moral compass who suggested a Robo nurse in one of your previous commentaries.

    Bridgette Pace

    • Hi Bridgette

      Thanks for your comment and sharing your and your father’s experience of consumer directed care. Many care recipients will find issue with administration costs under CDC. The difficulty is that the only recourse they have if they feel admin costs are too high is to change provider. Providers should be made to publish what they charge in administation in a standard form so as to at least foster some kind of competition. Care recipients should also get a breakdown of where their admin fees are going.

  2. I have read the Home Care Package Guidelines for service providers. It seems to me that the role of the service provider is such that it does not really allow the consumer to have control over their services. The service provider is managing the care not the consumer. In fact, the guidelines are what I would have expected from service providers PRIOR to the CDCs. A futile wish in retrospect.

    The reason why the CDC worked for me was because I was managing it to accord with the changing needs of my father, sometimes, on a daily basis. With the current model there really is no consumer directed flexibility because the care plan would require considerable interaction with and place a burden on the case worker who will not have the time or availability to attend to the requisite change when needed (or regarded as a pest!). It is the carer who is at the coalface and knows and understands the needs of the care recipient and can act promptly to change the services as required. The specified level of control by the service provider over the care recipient does not translate to an honest assessment of consumer directed care. The carer should be entitled to manage the budget and purchasing the services.

    The types of services the care recipient may need should be discussed in the initial consultation with the case worker. As long as those services fall within the prescribed funding guidelines then the carer should be able to choose those if and when they are needed. Instead, they are restricted to a care plan prepared weeks or months in advance and then managed by the service provider. For example, if the care recipient did not feel well enough to go on an outing scheduled for the next day, then the carer could contact the agency directly and cancel that service and replace it with, say, a cleaning service instead. As each agency requires at least 24 hrs. notice, it is likely that there would not be sufficient time to cancel the service and the charge would be levied against the budget anyway. The carer would be in a position to do it immediately rather than go through the rigmarole of contacting the case worker (if available) and requesting the changes.

    Whilst there are cases of mismanagment, rorts etc, they are in the minority and they happen across the board – by both carer and service provider! If the appropriate safeguards are in place, i.e. a diligent and competent case worker made regular calls and visits to the care recipient (via carer if that is the circumstance) and audited the budget with accompanying invoices, then that should be sufficient to satisfy the service provider and comply with the Govt. requirements regarding spending transparency. It would certainly surpass the supposed acquittals that nursing homes and other associated organisations currently provide to the Govt. to justify their funding allocations. The Public Trustee has none and if ever there was a case to answer regarding mismanagement, policing the PT would be the first port of call and not the lowly carer.

    It is a given that not all care recipients/carers require identical levels of care from the service provider. Therefore, I do not see why a carer who is willing and able cannot be in control of the management of the CDC budget with only limited oversight by the case worker. Being a carer is a very demanding role, usually resulting in a personal and financial disadvantage. No one would do it if they did not greatly love or care about their loved one. Yet it appears to me that all carers are viewed as potential fraudsters hoping to feed from the Govt. trough and therefore need Big Brother to row their boat.

    It is my opinion that Aged care is a very profitable business. The organisations operate like an employment agency feeding on commissions and Govt. funding. Carers does not need a top heavy administration to row their boat. Their needs are simple. Allow them to purchase directly the services they need, from whom they need and when they need them from the budget they are given. The administration charges deducted from the package allocation would buy a large number of extra hours that the carer needs to provide optimum care for the care recipient.

    The whole industry could be streamlined into a more efficient vehicle providing care to those who need it; Govt. funds could be spent in a more judicious and effective manner. There are too many middle men taking a bite from the apple, leaving only the core to purchase services the care recipient needs.

    The Home Care Package Guidlines do nothing to change the carer’s ability to purchase more service hours – and that is what they need.
    And changing service providers without extreme difficulty and angst is hardly another stress that the carer needs. Suffice to say, theory and practice very rarely make good bedmates.

    Bridgette Pace

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