Open Letter to the Home Care Community (Part II)

This is part II of this letter. You can read part I here

Dear Home Care Community,

(older Australians, participants, representatives, carers, family members, advocates, providers, workers, associate providers, peak bodies, Department, Commission, ministers, aged care assessors, consultants, vendors, suppliers, taxpayers and other interested stakeholders)

I’m writing to provide my perspective which is that elements of the home care system and current Support at Home (SaH) program rules have the potential to result in inequitable, and perverse outcomes for different stakeholders including participants and their families, providers and their workers, and the Government and society at large.

The ideas are presented using the SBAR handover format which stands for Situation (S), Background (B), Assessment (A), and Recommendation (R).

11. Assistive Technology & Home Modifications Scheme (AT-HM)

S: The AT-HM scheme is a good idea in principle in that it quarantines specific funding for the purchase of assistive technology or the completion of home modifications that is linked to a participants assessed needs.

B: The AT-HM List that accompanies the AT-HM Scheme represents a significant shift in funding level control when compared to the current HCP rules. The discrete Low / Medium / High funding tiers coupled with specific itemised inclusions and prescription requirements is likely to cause a significant challenge for the sector to transition to.

A: There is still a lot of unknowns relating to the operationalisation of the AT-HM Scheme and the associated AT Loans Scheme. There is also a seperate potential perverse outcome relating to the capped High tier home modification funding but others are advocating strongly in this space already.

R: a) The finalisation and release of the AT-HM Guidelines with worked through pricing and claiming scenarios of common items that track requirements from the clinical prescription, the purchase order to the supplier, the delivery and setup, the clinical review, through to the claiming and participant statement.

b) Specific advice is required as to whether the monitoring costs associated with personal emergency response systems (PERS) devices can be funded within the AT-HM scheme.

c) Worked examples are required in terms of what is claimable for participants who rely on oxygen therapy and from which funding sources (including for participants who are eligible for the oxygen supplement).

12. Supplements

S: I’m just going to come right out of the gate here and say that I am not a fan of the current care management supplement arrangement which also ties back to idea #7 relating to care management.

B: The current SaH rules specify some very specific eligibility criteria which attracts 12 additional hours of care management funding support for a participant per annum. The supplement is only applied once and is paid into the providers care management pool.

A: The perverse reality of the current arrangements is that the additional funding that is driven by the participants perceived increased care management support requirement is in no way linked directly to the participant. There are also some very prevalent participant care complexity indicators that have been ignored or removed.

R: a) Firstly, as per idea #7, lets keep the participants care management service budget within their quarterly budget (ie. no pool, no 10%).

b) Secondly, lets then pay the equivalent of the 3 hours of care management support as a top up to the participants quarterly budgets (making it a primary supplement).

c) Thirdly, lets keep the dementia and cognition primary supplement and also add an eligibility criteria for all culturally and linguistically diverse participants.

13. Transport Pricing and Claiming

S: If I had a $1 for every time I have heard someone ask how transport is to be priced and claimed under SaH… I can understand the principle of the Department seeking to create all inclusive pricing transparency for participants but the current reality is creating all sorts of differing interpretations and is quite confusing for everyone.

B: To unpack transport within SaH would be a whole separate thesis. Essentially providers are being asked to work with three different pricing and claiming paradigms:

a) Including travel costs within the service price when participants are being escorted away from the vehicle as part of the service delivery (eg. shopping assistance, individual social support, accompanied activities).

b) Defining a tiered pricing structure for ‘Direct Transport’ that is delivered and claimed ‘per trip’ (eg. Worker acts like a taxi and picks up the participant from one point and then drops them off at a destination).

c) A completely uncontrolled service pricing model linked to ‘Indirect Transport’ which is where a participant is using external services such as a Taxi or Uber and a provider can have very little impact on the cost or distance of the service in advance of it being delivered.

A: The transport service pricing guidance that has been released to date has not been sufficient for the sector to clearly understand how to both set pricing and structure claiming.

R: a) Detailed worked examples need to be provided that outline what the expected service pricing and claiming structures look like for each form of transport under SaH (including for regional and remote service locations).

b) I would strongly urge the Department to consider continuing the current arrangements under HCP whereby direct transport is priced on a per km rate which I believe is the most transparent we can be for participants.

14. Clinical Services Pricing & Claiming

S: Whilst we are on the claiming confusion theme we need to discuss the current requirement to only price and claim clinical services based on direct care (eg. Face to face or telehealth).

B: Again, it's understandable that the Department are trying to achieve an upfront, all inclusive, transparent hourly service rate. The reality however is that most clinical services operate in a combination of direct and indirect care with ratios that are unique to the individual participant requirements.

A: This is another issue that could easily fill an article of its own but the current rules will create grossly inflated hourly service rates for services like Occupational Therapy in particular that will be very confusing for participants as well as create scheduling mayhem for providers.

R: Treat all services within the ‘Clinical Supports’ category in the same way as the ‘Care Management’ service which allows for the claiming of both direct and indirect care delivery. Each clinical service can then be set a service rate ($/hr) with the volume (hours of direct + indirect work required) agreed to in advance (total $ cost) with the participant. Providers (and associate providers) can then schedule their workers to these specific direct and indirect tasks which are typically completed in separate locations and at separate times.

15. AT and HM Claiming

S: Claiming requirements for assistive technology (AT) and home modification (HM) represents one of the more complex elements of the SaH program that I am not confident anyone actually fully understands at this point.

B: To try and get a sense of the complexity of the current AT and HM claiming system requires a working understanding of the AT-HM List, the Claiming and Payments Business Rules, the Services Australia API specifications, and some creative assumptions.

A: The addition of wraparound services, prescription criteria, administration or coordination fee caps, and invoice, delivery and prescription evidence requirements is causing confusion in both the pricing and claiming of elements of AT or HM.

R: a) The prioritised finalisation and release of the AT-HM Guidelines with numerous end to end worked through scenarios as per idea #11.

b) Scrap the document attachments requirements as part of the claiming criteria. Providers could instead be required to present this evidence if requested by the regulator as part of an audit or external complaint response but the volumes of document attachments required in order to form a claim is an absurd imposition for both providers and Services Australia to manage.

16. Interim Funding

S: “Decisions to allocate interim funding are subject to further consideration by government. Interim funding is not designed to be part of the program launch”. The inclusion of these statements in the most recent SaH program manual sounded alarm bells in my ears that interim funding may never see the light of day.

B: “The intent of interim access to funding is to ensure people are not waiting any longer than necessary without access to care. Interim funding is an allocation of 60% of the total funding for their classification”. The initial time frame that was floated as the eligibility criteria for interim funding was a wait of 3 months. On the surface the ability for participants to commence any funding whilst they are awaiting their approved funding to become available sounds like a good rule change. There is however the question to consider of why is there the need for interim funding in the first place?

A: If the Government has a 3 month funding approval to allocation KPI and the SAS and package funding mechanisms are supportive of this KPI then interim funding becomes redundant. The reality is that this 3 month KPI is a very ambitious target when held against the current reality of approx. 90,000 older Australians waiting considerably longer times to access approved funding.

R: Option a) The obvious starting point would be to eliminate a waiting list for ongoing home care. (ie. If you are approved for care, the funding is available immediately).

Option b) A tweak on the first option would be that the interim funding (60% of approved classification) is available immediately upon approval until such time as the full funding becomes available.

Option c) Participants are referred to the relevant CHSP services (+ RCP / AT / HM if relevant) whilst they are awaiting their ongoing funding to become available (but would only work if CHSP funding is readily available in the respective region).

17. Participant Statements

S: The SaH Monthly Participant Statement Guide that was released in late April was a pivotal moment when I felt that a lot of stakeholders finally grasped how the complexity of the currently proposed SaH funding rules will play out. The 10 page document was indicative of the volume of detail required in order to try and explain the income and expenditure across a program where multiple funding classifications can be accessed simultaneously.

B: Participant statements are a critical element of home care to provide transparency to participants (and regulators) in how Government funding is being utilised. The current requirement will be for each individual provider to create and deliver a monthly statement to each participant they are providing services to utilising SaH funding (which is the same requirement as currently under HCP).

A: Given the complexity of the SaH funding arrangements there is a very high likelihood that providers will struggle to deliver on this requirement. Statements will likely vary considerably between providers and be a potential source of confusion for participants and a real headache for the regulator to enforce.

R: a) The solution is to have a consistent monthly participant statement for every SaH recipient. The next logical conclusion is that Services Australia are in the perfect position to create these uniform statements as they will have the validated participant and financial details required to form them and are familiar with generating and mailing financial statements as part of their wider business operations. We need providers to be able to focus on delivering care, not statements.

18. Thin Markets

S: For providers who service regional and remote regions there are very real additional considerations that impact how the SaH program can be delivered in a sustainable way. The obvious factors relate to the additional worker travel costs but there are also challenges in resourcing sufficient workforce and suppliers in order to support participants assessed needs.

B: The current SAH rule that is designed to support regional and remote providers is the thin market grant. As part of the tender process providers justify their need for additional funding support based on the numbers of participants they support in Modified Monash areas 3, 4, 5, 6 or 7. The initial grant opportunity provides 1 year of funding for 2025-26 (but not sure how the deferred Act impacts this yet).

A: The issue with this grant is that it does not provide regional and remote providers with any confidence that this grant will be available beyond the initial 1 year timeframe (which has already been watered down from the 2 year time frame that was originally linked to the grant). It also doesn’t support new providers to enter the regional or remote area.

R: a) Rather than being a grant that is provided for limited timeframes there needs to be a SaH thin market loading that is available to all providers each and every year based on the numbers of recipients they service in the designated MM areas. Services Australia have all of this participant demographic information for every provider so they should be able to easily calculate and apply this loading to providers without the need for a grant process each year.

b) Their also needs to be a separate grant opportunity to support providers to enter or expand their services within regional or remote areas that isn’t based on existing MM3-7 recipient numbers.

19. Restorative Care Partner

S: This idea is another one that may lead to me having my clinical membership card torn up but I don’t agree with the current SaH rules that apply to restorative care partners.

B: The current rules specify different roles and qualifications that can deliver the 'Care Management' service within different funding classifications. Ongoing, AT-HM, and EOLP classifications are linked to the ‘Care Partner’ role (no specific qualification requirement), and the RCP is uniquely linked to the ‘Restorative Care Partner’ role (must have a clinical qualification) and the associated 'Restorative Care Management' service.

A: a) I have worked with 100’s of different case managers / care managers over the years that have both had, or didn’t have a clinical qualification. The reality is that having a clinical qualification is not a guarantee of good care management. Care management is a very specific skill that requires high levels of organisation, empathy, advocacy, people management, budget management and good old fashioned ingenuity and gumption. These skills and attributes can be present (or not present) in people from all different backgrounds and qualifications.

b) Participants accessing the RCP are needing the same care management skill set as those accessing any other classifications. I would argue that trying to attach care management activity to one of the clinical MDT members involved in delivering care under an RCP episode can actually impede outcomes rather than support them as there is not a separate dedicated care partner.

R: Get rid of the separate 'Restorative Care Partne'r role and its associated ‘Restorative Care Management’ service. Apply the team-based 'Care Partner' model are 'Care Management' service to all funding classifications which is then claimed against the relevant classification in the frequency and volumes as required and agreed to by the participant (refer also to idea #7).

20. Digital Transformation

S: This last idea is not a specific element of the Act or SaH rules but is one of the foundational elements that will enhance the coordinated experience and quality of care for recipients accessing SaH. The aged care digital network is currently a very disjointed series of siloed data structures but there are promising signs on the horizon.

B: Spending time within the Digital Transformation Sector Partners (DTSP) group this past year has exposed me to a whole new community that is influencing the way that home care (and aged care more broadly) is, and will be delivered into the future. The current work being undertaken on aspects like the Government Provider Management System (GPMS) and Aged Care Provider Portal (ACPP) are laying foundations to digitise information management in a more sophisticated way throughout aged care (and health more generally).

A: Don’t get me wrong, things are currently very clunky, and there are a lot of digital chefs working in a lot of different digital kitchens so we may not have our perfectly synchronised digital croquembouche any time soon but I’m excited to see how technology can and will support our human workforce to deliver more of the very human centric task that is home care.

R: a) Obviously the GPMS and ACPP are taking priority at this point but I would encourage the Department and DTSP to rapidly explore and develop the API capability with systems such as the Service Provider Portal with a goal of establishing a shared digital aged assessment and care plan that is developed and maintained in real time between all of the care stakeholders involved in a participants care (eg. Participants, Registered Supporters, My Aged Care, SAS, Providers, Clinicians, Associated Providers, GPs, Pharmacists, Specialists, Hospitals, Residential Aged Care Facilities etc etc). The realisation of this goal will be a watershed moment for the quality of home care services.

Incredible effort if you made it this far. I encourage anyone to add comments and challenge or add to these ideas from your own perspective. The only way we will achieve a more equitable and sustainable home care model is if we are all a part of the solution.

Be brave, everyone's perspective is valid and valued.