5.1 Introduction This chapter considers issues relating to the implementation of the initiative by the Department and by providers, and the operationalisation of the initiative by providers – that is, how providers put the initiative into practice. In particular, it discusses the following evaluation questions: How effective were the CDC/CDRC initiation processes? This encompasses program implementation by the Department, implementation of the initiative by providers, and recruitment and selection of CDC and CDRC participants. How effective were the CDC/CDRC planning processes? This encompasses the different approaches to planning and budgeting used by providers, key elements of planning, and the degree to which planning was different for CDC and CDRC compared with standard packaged care and NRCP services. How effective was the delivery of CDC? This encompasses approaches the coordination of packages and the extent to which participants self-managed their package. The information presented in this chapter draws on the interviews with CDC and CDRC providers conducted as part of the evaluation, as well as interviews with Departmental representatives. 5.2 Provider motivations for participating in the initiative The motivations of CDC providers and CDRC providers for participating in the initiative differed. For CDC providers, there were a number of reasons which influenced their decision to participate, including their commitment to person-centred approaches, their desire to respond to anticipated future consumer demand for increased choice and control, or their desire to access additional community aged care packages. Motivations were sometimes a combination of these factors. For CDRC providers, the motivation to participate in the initiative was strongly linked to their identification of limitations in the traditional respite approach for some carers. CDRC providers saw the initiative as an opportunity to offer a more planned approach and secure additional funding for carers with ongoing, unmet respite needs. CDRC providers universally saw the initiative as an entirely new approach from traditional responses. Consumer-directed care providers There were a number of reasons why providers chose to participate in the initiative. Providers already had a strong commitment to person-centred approaches and saw CDC as consistent with their organisation’s values and culture These providers spoke about consumer empowerment, choice and control being part of their organisational values and underlying approach to service delivery, and spoke of goals-focussed, strengths-based or enabling approaches to care planning and service delivery. Several had prior experience with consumer-directed approaches in the disability field, and were already considering options for more consumer-directed approaches in their delivery of community aged care prior to the current initiative. They saw CDC as being significantly different from the
Much more satisfied 12% 13% Based on responses received from 124 CDC participants and 126 standard packaged care (comparison group) recipients. ‘Don’t know’, multiple and blank responses have not been reported in this table. Source: CDC and comparison group surveys, conducted August 2011. Table 24: Compared to six months ago, how satisfied are you with the quality of your home life and close relationships? Answer Received packaged care before Did not received packaged care before Not satisfied 0% 4% Somewhat less satisfied 2% 2% No different 41% 53% Somewhat more satisfied 29% 20% Much more satisfied 22% 20% Based on responses received from 124 CDC participants and 126 standard packaged care (comparison group) recipients. ‘Don’t know’, multiple and blank responses have not been reported in this table. Source: CDC and comparison group surveys, conducted August 2011. Health and wellbeing There was also some evidence that CDC was having a positive impact on CDC participants’ health and wellbeing. While some participants interviewed stated that their physical health had improved since being on CDC (mainly due to direct access to health-related supports), a number of participants and their carers identified an improved sense of ‘wellbeing’ and a different outlook or perspective on life – predominantly due to feeling more in control of their care (and their lives). Survey responses also indicated a greater level of satisfaction among CDCH participants compared with EACH package recipients – as illustrated in the table below. “After my wife died, I didn’t really care what happened to me. Now, I am starting to care a bit, and even think about the future. (The CDC coordinator and support workers) have helped me start thinking about the future.” CDCL participant, formerly homeless aged in his 60s Table 25: Compared to six months ago, how satisfied were you with your general health and wellbeing? Answer CDCL CACP CDCH EACH Not satisfied 7% 4% 3% 14%
Australia care funds care planning agency services Austria Long-term care insurance (‘cash for care’) Direct payment care planning. Funds can be used at consumer’s discretion Canada (British Columbia) Choice in Supports for Independent Living (CSIL) (‘cash for care’) Direct payment care planning (with agency/ broker). Employment of carers (including relatives) France Long-term care insurance Consumer- directed Direct payment Co-managed funds care planning. Employment of carers (including relatives) and equipment purchase Germany Care allowance Direct payment Co-managed funds funds Direct payment option: care planning. Co-managed or agency managed option: care planning Direct payment option: funds can be at consumer’s discretion Co-managed or option: agency services Netherlands Personal budget (‘cash for care’) Direct payment care planning. Employment of carers (including relatives) and equipment purchase Sweden Self-managed care (‘cash for care’) Direct payment care planning. Employment of carers or purchase of agency services United Kingdom Personal budget Direct payment Co-managed and planning Purchase of agency services or
(England) funds funds (with broker/ facilitator) employment of carers United States (various states) care (cash and counselling) (‘cash for care’) Direct payment care planning (with agency/ broker). Purchase of agency services or employment of carers (including relatives) United States (California) In-Home Supportive Services (IHSS) (‘cash for care’) Direct payment care planning (with agency/ broker). Purchase of agency services or employment of carers (including relatives) United states (Washington State) Home and Services (‘cash for care’) Direct Payment Co-managed funds care planning (with agency/ broker). Purchase of agency services or employment of carers (including relatives) United States (Wisconsin) Family Care Program care planning agency services Source: Information in this table has been primarily drawn from the following sources: Glendinning 2008, Hardy 2008, Kodner 2003, Lundsgaard 2005, Productivity Commission 2011, Tilly, Wiener and Evans Cuellar 2000. The literature indicates that CDC programs based on direct payment models are also operating in Israel, Japan, Korea, Luxembourg and Norway, but insufficient descriptive information was identified to include them in this summary. Table A2: Comparison of various CDC models – evaluated outcomes Jurisdiction Evaluation details Consumer outcomes Carer outcomes Cost effectiveness Areas to improve Australia (Victoria) Direct payments trial (2007) High satisfaction - - - UCCO CDC trial (2009) High satisfaction Variable satisfaction (felt isolated over time) - Social inclusion of carers Australia (WA) LAC review (2003) High satisfaction (but lower for CALD/ - Cost effective compared to agency Tailoring for CALD and Indigenous
ATSI) direction clients Austria LTC review (1998) - - - - Canada CSIL review (2008) High satisfaction High satisfaction - - France - - - Cost effective compared to agency direction Germany (2008) Higher satisfaction than for agency directed consumers Increased paid care hours - - - Netherlands (1996, 1998) Higher satisfaction than for agency directed consumers Quality of care equal to agency directed care - - Use of fiscal agents to prevent abuse (not relevant to Australian CDC model) United Kingdom (England) Individual budgets pilot (2007) Satisfaction higher than for agency directed consumers Lower psychological wellbeing for older consumers Positive impact on quality of life and social outcomes Satisfaction with care planning a predictor of outcomes - Safeguarding and quality control of paid carers (not relevant to Australian CDC model) United States Cash and counselling demonstrations (2007) Higher satisfaction than for agency directed consumers Reduced unmet demand Reduced nursing home use Quality of care equal to agency directed care Higher satisfaction than carers - Use of fiscal agents to prevent abuse (not relevant to Australian CDC model) Information in this table has been primarily drawn from the following sources: Arntz 2008, Dale and Brown 2006, Foster, Disability Services Commission 2003, Glendinning 2008, LDC 2007, Ottmann, Laragcy and Haddon 2009, Phillips 2003 and Tilly and Bectal 1999
Not applicable to me 1% Multiple response 1% Blank / No response 2% Table B11: My planning provider helped me to make decisions regarding the types of services I could choose Question / response CDC Strongly disagree 1% Disagree 1% Neither agree nor disagree 2% Agree 60% Strongly agree 31% Don’t know 1% Not applicable to me 1% Multiple response 1% Blank / No response 2% Table B12: I was satisfied with the help I received from my planning provider Question / response CDC Strongly disagree 0% Disagree 2% Neither agree nor disagree 2% Agree 54% Strongly agree 37% Don’t know 0% Not applicable to me 1% Multiple response 2% Blank / No response 2% Table B13: I was satisfied with the range of services that I could choose Question / response CDC Comparison
activities 10 Nursing care 96 1% 10 Support for care recipients with cognitive impairment 165 1% Total hours* 8326 Total hours* 12547 *Excludes supports that were not measured in hours, and on-call access Table C14: Top 10 service types accessed – by number of participants accessing each service type, CDCL April-June No. of participants of total participants No. of participants of total participants 1 Domestic assistance 147 79% 1 Domestic assistance 119 64% 2 Activities of daily living 88 47% 2 Activities of daily living 84 45% 3 Social support 69 37% 3 Social support 56 30% 4 On-call access 41 22% 4 Nutrition, hydration and meal preparation 42 23% 5 Nutrition, hydration and meal preparation 36 19% 5 Emotional support 33 18% 6 Leisure, interests and activities 32 17% 6 Home maintenance 33 18% 7 Home maintenance 32 17% 7 Leisure, interests and activities 22 12% 8 Emotional support 32 17% 8 Home safety 16 9% 9 Home safety 28 15% 9 Mobility and dexterity 16 9% 10 Allied health 18 10% 10 Informal services 14 8% Total participants 186 Total participants 186 Table C15: Top 10 services types accessed – by expenditure, CDCL
9 Leisure, interests and activities 27 27% 9 Continence management 22 17% 10 Allied health 25 25% 10 Management of skin integrity 21 17% Total participants 101 Total participants 126 Table C18: Top 10 service types accessed – by expenditure, CDCH April-June Expenditure % of total expenditure Expenditure % of total expenditure 1 Activities of daily living $125,528 32% 1 Activities of daily living $163,499 36% 2 Leisure, interests and activities $62,352 16% 2 Social support $60,931 13% 3 Domestic assistance $45,540 12% 3 Domestic assistance $52,296 11% 4 Social support $23,614 6% 4 Nutrition, hydration and meal preparation $31,760 7% 5 Equipment $19,468 5% 5 Nursing care $20,081 4% 6 Nutrition, hydration and meal preparation $16,370 4% 6 Continence management $17,630 4% 7 Informal services $13,093 3% 7 Leisure, interests and activities $15,713 3% 8 Home modification $13,046 3% 8 Equipment $14,921 3% 9 Continence management $12,274 3% 9 Support for care recipients with cognitive impairment $14,547 3% 10 Mobility and dexterity $12,175 3% Clinical care $14,479 3% Total expenditure* $395,622 Total expenditure* $459,767
5 Clinical care 15 31% 5 Clinical care 11 20% 6 Social support 14 29% 6 Allied health 10 19% 7 Nursing care 13 27% 7 Support for care recipients with cognitive impairment 10 19% 8 Support for care recipients with cognitive impairment 13 27% 8 Continence management 9 17% 9 Emotional support 11 23% 9 Emotional support 8 15% 10 Allied health 10 21% 10 Leisure, interests and activities 8 15% Total participants 48 Total participants 54 Table C21: Top 10 service types accessed – by expenditure, CDCHD April-June Expenditure % of total expenditure Expenditure % of total expenditure 1 Activities of daily living $50,474 24% 1 Activities of daily living $80,948 32% 2 Leisure, interests and activities $41,605 19% 2 Support for care recipients with cognitive impairment $42,451 17% 3 Domestic assistance $21,568 10% 3 Social support $32,786 13% 4 Social support $14,501 7% 4 Leisure, interests and activities $27,305 11% 5 Equipment $13,343 6% 5 Domestic assistance $18,876 7% 6 Support for care recipients with $12,340 6% 6 Continence management $8,860 3%
respite 8 Domestic assistance 30 17% 8 Commonwealth funded residential respite 18 9% 9 Individualised respite 29 17% 9 Social support 14 7% Education/training 26 15% Community residential respite 12 6% Table C34: Top 10 service types accessed – by expenditure, CDRC April-June % of total July-September % of total 1 In home respite 104682 31% 1 In home respite 44053 23% 2 Regular respite care 31190 9% 2 Regular respite care 26410 14% 3 Individualised respite 25496 8% 3 Individualised respite 14038 7% 4 funded residential respite 22740 7% 4 Commonwealth funded residential respite 12528 7% 5 Provision of goods and equipment 22689 7% 5 Assessment 11443 6% 6 Personal care 18560 5% 6 counselling 10791 6% 7 Community respite 14784 4% 7 Provision of goods and equipment 9763 5% 8 Home maintenance 13051 4% 8 Community residential respite 9595 5% 9 Domestic assistance 12511 4% 9 Social support 9247 5% Home modification 11943 4% Information provision 9025 5%
Table C39: Set-up costs reported by CDRC providers – 2010-11 Total costs reported Staffing Total costs reported Total costs reported Total Average cost per package allocated* Staffing Average cost per package allocated* Average cost per package allocated* Total Planning $41,767 $820 $42,587 $246 $5 $251 Development or modification of systems (eg IT systems) and processes $11,996 $3,414 $15,410 $71 $20 $91 Development of information and other resources $21,496 $3,444 $24,940 $126 $20 $147 Participant recruitment $28,833 $1,978 $30,811 $170 $12 $181 Training and skills development $13,981 $8,474 $22,455 $82 $50 $132 Other $41,219 $9,278 $50,497 $242 $55 $297 Total $159,292 $27,408 $186,700 $937 $161 $1,098 *Average cost per package is based on 441 packages, which is the number of packages allocated to those providers who submitted data as part of the April-June provider data collection. Note not all of these packages had been allocated to participants. Source: April-June provider data collection Table C40: Ongoing costs reported by CDRC providers Total costs reported Staffing Total costs reported Total costs reported Total Average cost per package allocated Staffing Average cost per package allocated Average cost per package allocated Total Management and administration Management $13,328 $76 $13,404 $284 $2 $285 Administration $12,284 $2,644 $14,928 $261 $56 $318 Finance and IT support $9,482 $3,534 $13,016 $202 $75 $277 Other $20,569 $5,528 $26,097 $438 $118 $555