residents; and the volatility of the RCS, including its susceptibility to manipulation and the potential for residents with similar care needs to be classified into different categories.” An integrated residential care system with the full spread of resident dependencies included in the RCS funding model, also meant that the number of residents for whom higher levels of funding could be claimed increased significantly. The RCS Review Audit program was expanded to address this issue, as without controls to prevent the documentation of ever rising care needs, systematic increases in RCS claims had the potential to significantly increase government expenditure. Over time, RCS claims did rise significantly with the majority of aged care residents being classified as needing the highest levels of funding (RCS 1 and 2), outcomes which significantly impacted on the relativities in the original scale design and government expenditure, which increased beyond budget projections. Claims also became harder to audit effectively with a high proportion of Departmental review decisions being challenged. For example, during 2008-09, 12,548 reviews of RCS appraisals were completed. Of those reviews, 3,749 or 30 per cent resulted in reductions of funding, of which 350 or 9.3 per cent were appealed by providers. In approximately 43.7 per cent of appealed cases, the original by the home was reinstated (Commonwealth of Australia 2009). 2005-2008: Development of the ACFI In response to concerns about the perceived burden resulting from the administrative and documentation requirements of the RCS assessment tool and a financial growth at a higher level than expected by Government, four reviews were undertaken and culminated in a project (starting in 2005) to develop and implement the Aged Care Funding Instrument (ACFI). The ACFI and Assessed Care Needs Resulting from the learnings associated with the RCS operation it was deemed more appropriate to build future funding systems around assessed care need as: It would provide for a standardised basis for funding system determinations wherever a person was supported, including community care. Providers could build flexible care models to address the assessed care needs without having the care provided aspect dictated by a funding mechanism. It would allow more flexible ‘care provided’ responses by providers to resident desires and preferences (promotes consumer directed care). Care provided is a quality of care matter that is better covered separately by the Specified Care and Services requirements and the Quality Agency. It allowed for the introduction of an External Assessment model and funding determination if required at a future time .
Summary of assistance needed provisions for R-ACFI 1 to 4 Table 1: R-ACFI ADL rating (Nutrition) Requirements 0 Standard Care 1 Monitoring 2 Moderate assistance 3 Full assistance Nutrition Nutrition Standard Care: Independent during the EATING activity; OR Staff standing by for occasional or episodic assistance; OR Provision of modified textured food and drinks; OR Setting up activities e.g. taking lids off, cut up food, specialised plates and cutlery, special diets, placing food in front of resident; OR Providing verbal assistance (e.g. prompting, cueing). Needs general monitoring for an assessed nutritional need using the mandated assessment. Always providing physical assistance, on a one-to-one basis, for part of the EATING activity, whenever the activity is needed, due to a swallowing issue or other impairment. Always providing physical assistance, on a one-to-one basis, throughout the entire activity, whenever the activity is needed. Mandated Evidence Not required R-ACFI Q1: MNA Short (completed within last 3 months of appraisal) Supporting Evidence Not required Not required Swallowing impairment: Evidence- Speech Pathologist report Physical/ sensory impairment: Evidence- NSAF, MP notes, diagnoses. Moderate Cognitive Impairment- requires staff to initiate or complete the activity. Evidence: Cognition Assessment (SMMSE), clinical report, NSAF, MP notes, diagnoses. Swallowing impairment: Evidence- Speech Pathologist report Physical/ sensory impairment: Evidence - NSAF, MP notes, diagnoses. Severe Cognitive Impairment: e.g. does not participate in the activity Evidence: Cognition Assessment (SMMSE), clinical report, NSAF, MP notes, diagnoses.
Table 2: R-ACFI ADL rating (Mobility) Requirements 0 Standard Care 1 Moderate assistance 2 Full assistance 3 Mechanical Lifting Mobility Transfers Locomotion Independent (with or without aids); OR Standing by for occasional or episodic assistance; OR Transfer Setting up activities e.g. preparing or providing wheelchair or other transfer aid; OR Locomotion Setting up activities e.g. handing the resident the mobility aid; OR Verbal assistance, prompting, cuing. Always providing physical assistance, on a one-to-one basis, for at least part of the activity, whenever the activity is needed. Always providing physical assistance, by at least two staff, throughout the entire activity, whenever the activity is needed. Use of Mechanical Lifting device for Transfers: Always providing physical assistance by the use of mechanical lifting equipment, throughout the entire transfer activity, whenever the activity is needed. Mandated Evidence Not required R-ACFI Q2: PMS & FRAT items (completed within last 3 months of appraisal) Supporting Evidence Not required Sensory Impairment: Evidence: NSAF, MP notes, diagnoses Behavioural Issues: Evidence- clinical report, NSAF, MP notes. Physical impairment e.g. gait, balance. Evidence: Functional Assessment (PMS), Physiotherapy report, NSAF, MP notes, diagnoses. Supporting Evidence Not required Moderate cognitive impairment, requires staff to initiate the activity. Evidence: Cognition Assessment (SMMSE), clinical report, NSAF, MP notes. Severe cognitive impairment e.g. does not participate in the activity. Evidence: Cognition Assessment (SMMSE), clinical report, NSAF, MP notes, diagnoses Evidence: Physiotherapy Assessment, NSAF, MP notes, diagnoses
6 Management of chronic wounds, including varicose and pressure ulcers, and diabetic foot ulcers. 1. Diagnosis AND 2. Directive [registered nurse or medical practitioner or allied health professional] AND 3. Wound Assessment AND On request: record 11 6 Management of ongoing administration of intravenous fluids, hypodermoclysis, syringe drivers and dialysis. 1. Directive/prescription [authorised nurse practitioner or medical practitioner] 12 6 Suctioning airways, tracheostomy care. 1. Diagnosis AND 2. Directive [registered nurse or medical practitioner] 13 6 Management of ongoing tube feeding. 1. Diagnosis AND 2. Directive [registered nurse or medical practitioner or allied health professional] 14 15 Palliative Care Program involving End of Life care where ongoing care will involve intensive clinical nursing and/or complex pain management in the residential care setting. End-of-life (terminal) care definition This description is similar to and modified from the end-of-life description found in page 6 of the 2017 ACFI User Guide. “… palliative care is appropriate when the resident is in the final days or weeks of life and care decisions may need to be reviewed more frequently.” (Australian Palliative Residential Aged Care Project, 2006, p. 38) 1. Directive by [CNC/CNS in pain or palliative care or medical practitioner] AND 2. Pain Assessment (as per Pain Management Guidelines (PMG) kit) AND 3. Assess the resident using the Palliative Approach Toolkit in Residential Aged Care Facilities. *Note: a Palliative Care claim will require a mandatory re-appraisal in 6 months. 15 Table 7: R-ACFI Complex Health Assessment Tools Recommendations Complex Health Care (CHC) Mandatory Recommended Source Comprehensive Health Assessment (CHA) Regular, ongoing, documented 3 monthly, comprehensive health assessment, undertaken and signed off by a Comprehensive Health Assessment for Older People: Documentation Template. (CHAOP) La Trobe University (ACEBAC) research team: Dr Deirdre Fetherstonhaugh, Dr Margaret Winbolt, Dr Michael Bauer, Professor Rhonda Nay. This project was supported with funding from Victorian Department of Health, Wellbeing, Integrated Care and Ageing Division and from the Home and Community Care Program which is
Assessments for the physical therapy program Evidence-based assessments must be used that produce measurable objective outcomes. Recommendations have been made for Functional assessments (PMS, MMT, BBS, Boomer and Short Physical Performance Battery); and Pain assessments (M-RVBIP, PAINAD, ABBEY Pain scale, uni-dimensional pain intensity tools). Who can do assessments for the physical therapy program? R-ACFI User Guide Health Professionals under AHPRA: will include RN, MP, AHP (OT, Physio). AHP self-regulated professional body: Dietitian, SP, Exercise Physiologist. Who will qualify for the Therapy Program? The Therapy Program will be available for all residents at any level of care need. The only requirements will be that: The resident wants to participate in the program on an ongoing basis and it can be delivered; It is likely to be beneficial for the resident and the benefits are evaluated and reported in documentation on a three-monthly basis; and There is evidence that there is regular multi-disciplinary input into the development and modification of the program. How are residents and families included? The Therapy Program has a consumer focus included in the design of the therapy care plan, including goals and desired outcomes. Consent for program participation from resident/family or advocate. Selection of program options. Design of resident focussed goals. Sign off on Therapy Care Plan. Providing feedback for the 3-monthly evaluations. Consideration should be given to the communication method between the therapist and the person consenting – i.e. personalised flyers, inviting family to observe a group in action and to talk to the therapist. Information to be provided about SMART goals that will assist the therapist to develop consumer identified goals that can be measured and evaluated.
Therapy Program Available for all residents at any level of care need. Consumer involvement – consent, developing goals and therapy options, sign off on Therapy Care Plan, evaluation feedback. Therapy service: delivered for 60, 140 or 180 minutes per week on three to four days of the week. Time depends on mix of mode. Therapy service mode: One-to-one or small group (max of 5 residents). Evidence-based assessment tools by defined list of HP Therapy Care Plan developed by defined list of AHP Directive: developed by defined list of AHP lists the activities to achieve the goals, what is to be delivered, resources needed, who delivers it (by defined list of AHP) and the program timelines. Record of Treatment is maintained three monthly evaluation of measurable outcomes, observed outcomes and resident goals. Activities of Daily Living Domain No. Question Appraisal Evidence Requirements 1 Nutrition Care need: Eating activities. Assistance level equals Standard Care OR Monitoring OR Moderate Assistance OR Full Assistance. Mini Nutritional Assessment Nutrition Assessment Summary Nutrition Checklist 2 Mobility Care needs: Transfers / Locomotion. Assistance level equals Standard Care OR Moderate Assistance OR Full Assistance OR Mechanical lifting. PMS & FRAT Assessment Mobility Assessment Summary Mobility Checklists 3 Personal Hygiene Care needs: Dressing / Washing. Assistance level equals Standard Care OR Moderate Assistance OR Full Assistance. Assessment Personal Hygiene Checklists PMS & FRAT Assessment 4 Toileting Care needs: Use of toilet / Toilet completion. Assistance level equals Standard Care OR Moderate Assistance OR Full Assistance. Assessment Toileting Checklists PMS & FRAT Assessment