Methods Introduction The ACFI Review Project comprised a number of components. The review methods were focused around the two major project aspects: A review of the ACFI system covering suggestions for change and analysis of the changes using existing data. The rationale for and possible options if an external assessment model was to be considered for the resident funding determination. provides an overview of the ACFI Review Project tasks and methods. Subsequent sections provide more detailed information on the project activities. Table 2.1: ACFI Review Framework & Methods Tasks Identify ACFI Issues Practical modification Develop modified ACFI External Assessment Review assessment tools used in Australian health and aged care sector, including validated contemporary care practices (e.g. restorative care, reablement, dementia care, CDC) Identify alternative validated assessment tools Stakeholder interviews Consider use of Australian aged care tools and contemporary care practices Consider how to fit external assessment with Australian aged care sector Targeted review of international (USA, Canada, UK and NZ residential care environments) approaches to needs assessment and external assessment Dept. document review. Targeted literature search and personal communication on external assessments Stakeholder interviews Consider international approaches & tools when modifying ACFI Consider international approaches to external assessment A review of the current ACFI funding model and guidelines to better discriminate care needs and support contemporary care practices Stakeholder interviews Stakeholder interviews AACS analysis Stakeholder interviews A review of the ACFI User Guide and other operational documents to clarify areas of inconsistency ACFI User Guide; Data analysis, industry stakeholder feedback written and verbal, department officials & reports Stakeholder interviews Improve supporting documentation No assessments noted Analyses of the benefits, disadvantages, system adjustments, and viable options for initial and re-appraisal assessments in the context of external assessment No issues identified Stakeholder interviews. Data analysis No modifications noted Options for External Assessment (fully external, partially external model etc.) Statistical analysis of the ACFI questions, domains, weightings and re-calibrations No issues identified No modifications noted Modified ACFI to better discriminate care needs No assessments noted
Table 4.5: 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. Staff standing by for occasional or episodic assistance. Provision of modified textured food and drinks. Setting up activities e.g. taking lids off, cut up food, specialised plates and cutlery, special diets, placing food in front of resident. 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 for standard care. R-ACFI Q1: MNA Short (completed within last 3 months of appraisal) Supporting Evidence Not required for standard care. Not required for monitoring. 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 4.5a: 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). Standing by for occasional or episodic assistance. Transfer Setting up activities e.g. preparing or providing wheelchair or other transfer aid. Locomotion Setting up activities e.g. handing the resident the mobility aid. 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 for standard care. R-ACFI Q2: PMS & FRAT items (completed within last 3 months of appraisal) Supporting Evidence Not required for standard care. 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 for standard care. Moderate cognitive impairment, requires staff to initiate the activity. Evidence: Cognition Assessment (SMMSE), clinical report, NSAF, Severe cognitive impairment e.g. does not participate in the activity. Evidence: Cognition Assessment (SMMSE), clinical report, NSAF, Evidence: Physiotherapy Assessment, NSAF, MP notes, diagnoses
Table 4.7: Summary of ADL Recommendations Item Change Assessments, Checklists, Ratings Audit system Items noted below Changes noted below Mandated Validated assessment Standardised information Contemporary Outcomes Fit to External Assessment Fit to RAC workforce Fit to Gateway Clarifies Improves reviews Assessments (Ax) Rules NR NR NR NR Currency improved (3/12) NR RN/AHP sign off NR Professional Accountability Claim requires a new Ax Nutrition Assessment MNA-Short YES YES & objective YES BMI, nutritional status YES In NATFRAME In NSAF Objective outcomes Objective evidence Nutrition Checklist NR NR NR NR Reduced to one checklist. NR NR NR Standard Care- removed Readiness to Eat (vitamised food, cutting up food) Uses the Ax outcomes Nutrition Rating NR NR NR Monitoring of nutritional needs Standard care; Monitoring; Moderate Assist; Full Assistance NR NR NR NR Uses the Ax outcomes Mobility Assessment PMS YES, for PT, fit for nurses YES & objective NR Transfers, mobility YES In NATFRAME Add to NSAF Guidelines Objective evidence Mobility Assessment FRAT YES, for nurses, fit for PT YES NR NR YES In NATFRAME Add to NSAF Guidelines Objective evidence Personal Hygiene Checklist NR NR NR Based on Statistical analysis Grooming removed NR NR NR NR Redundant Continence Evidence Continence Ax Form and Care Plan OR Diagnosis NR YES Comprehensive assessment supported More than frequency and Ax if tool completed YES- use a subset of Qs Designed for Add to NSAF NR Objective evidence Continence Checklists NR NR NR NR Minor changes to frequency NR NR NR NR NR ADL (R-ACFI 2-4) Rating scale NR NR NR NR Standard Care; Moderate assist; Full assist; Mechanical lifting NR NR NR STANDARD CARE: verbal assist, setting up, occasional or episodic Clarifies the assistance type and resources used. ADL (R-ACFI 1-4) Reason for assistance (new) NR NR YES & requests evidence NR Physical; Sensory; Cognitive; Behavioural YES NR Yes- Map from NSAF NR YES- improves evidence
Table 5.9: Summary of BEH Recommendations Item Changes Assessments, Checklists, Ratings Audit system Items noted below Changes noted below Mandated Validated assessment Standardised information Contemporary Outcomes Fit to External Assessment Fit to RAC workforce Fit to Gateway Clarifies Improves reviews Assessments (ax) Rules NR NR NR NR Currency improved (3/12) NR RN/AHP sign off NR Professional Accountability Claim requires a new ax Cognition Assessment SMMSE YES Fits to Checklist YES Cognitive score YES MMSE NATframe In NSAF NR Shared evidence Cognition Checklist YES NR Updated NR Updated to fit SMMSE scores NR NR NR Requires evidence if no assessment used NR Behaviour Frequency YES-ACFI Behaviour Record NR NR NR 1 = Not at all or less than daily; 2 = Daily; 3= 2 times per day everyday; 4 = > 2 times per day everyday No assessment No change In NSAF, as a rating NR NR Behaviour Verbal refusal & constantly agitated NR NR NR NR Removed NR NR NR Behaviour types NR Behaviour Description YES- Behaviour description ABC approach is widely used NR IPA recommends Behaviour description in ABC approach Individualised description of the behaviour- for clear communication about the behaviour YES- ask an informant Previously expected, not a new concept Add to NSAF The behaviour contex - what is heard/seen for the individual Improves mapping the behaviour to resident documents Behaviour Disruptiveness YES- Disruptiveness rating with contextual information scale used in other assessments YES NR Not at all/Mildly; Moderately; Severely; Extremely For care planning and evaluation YES- ask an informant Minor training/ support required to implement Add to NSAF How disruptive the behaviour is, the level of staff input Disruptive behaviour should be documented in notes for feedback on strategies. Informants will have better recall of disruptive events. Behaviour Checklist NR NR YES NR Matrix of frequency and disruptiveness NR NR NR Severity of behaviour and intensity of interventions NR
3 Complex management of oedema, when the management plan includes the use of compression therapy that includes (bandages/ hosiery/ garment) applied at least weekly for oedema due to one of the following medical conditions as diagnosed by the medical practitioner: chronic venous insufficiency lymphoedema acute (ongoing) DVT (lower leg) The compression garments must be selected correctly to apply the degree of compression required by the individual resident, as evidenced in the diagnosis, assessment and directive. It is expected that the Health Professional providing the directive for treatment would have the clinical expertise to identify the appropriate garments for treating these complex health care conditions. Diagnosis (documented by a Medical Practitioner) AND Directive [registered nurse or medical practitioner or allied health professional]. The Directive is to contain the assessment outcomes, goals of treatment and treatment plan, covering: Aim of the compression therapy Type/description of the bandage/hosiery/garment Objective measurements e.g. calf size, ankle size, Doppler ankle brachial pressure index [ABPI] etc. Compression mmHg Application directions (e.g. frequency of application, who is to apply the therapy). Review details. AND 3. Record of Treatment 7 3 Depression Diagnosis of Major Depressive Disorder AND Directive [registered nurse or medical practitioner] AND Depression Assessment (recommend CSD, GDS, K-10) 8 3 Medications 1- Weekly patches, suppositories or enemas, Daily Medication Assistance. Medication Directive/Chart [medical practitioner] 9a OR 6 Medications 2- Daily administration of injections (Subcutaneous, intramuscular, intravenous). Can only claim one item- either 9a or 9b. Medication Directive/Chart [medical practitioner] 9b 6 Management of chronic infectious conditions Antibiotic resistant bacterial infections Tuberculosis AIDS and other immune-deficiency conditions Infectious hepatitis 1. Diagnosis AND 2. Directive [registered nurse or medical practitioner] 10
Table 6.8: Summary of CHC Recommendations Change Detail Assessments, Checklists, Ratings Audit system Changes noted below Details noted below Mandate/ Recommend Validated assessment Standardised information Contemporary Outcomes Fit to External Assessment Fit to RAC workforce Fit to Gateway Clarifies Improves reviews Assessm’t (Ax) Comprehensive Health Assessment Recommend 3-monthly CHA tool YES NR NR Currency (3/12) For all CHC claims No assessment RN/AHP sign off NR Professional Accountability Claim requires a new Ax Assessm’t Depression Assessments for Depression item Recommend CSD, GDS & K-10 YES NR YES CSD GDS K-10 YES CSD GDS & K-10 in NSAF Information is for care planning, score not used Shared evidence Assessm’t Palliative Care needs Ax Palliative toolkit in Residential Aged Care NR YES YES Description of end stage YES No change- in current ACFI User Guide NR NR Definition clarity Assessm’t Pain Ax for Palliative item Pain Management Guidelines (PMG) kit YES NR YES R-ACFI 8. 15 Scores 15 YES No change- in current ACFI User Guide NR NR NR Items removed BP; Vital signs NR NR NR NR Not complex No assessment NR NR Complexity NR Items re-scored BGL ; Oxygen Therapy NR NR NR NR R-ACFI 8 Q2 R-ACFI 8 Q3 (scores reduced from 3 to 1) YES No change NR Low complexity NR Item relocated Pain mgmt. items; Pain Mgmt Guidelines (PMG) kit NR NR YES- broader therapy choice Moved into Therapy Program Broad need No ax changes NR NR As set out in Therapy Program Item relocated Management of arthritic joints/oedema NR NR NR NR Covered in R-ACFI 3 No assessment No practice change NR Standard care Reduces requirements Item relocated Suppositories & enemas NR NR NR Following best practice Included in Medication R-ACFI 8. Q9a YES No change NR NR NR Item clarified Mgmt. of oedema Assessment NR NR Following best practice R-ACFI Q8.7 YES YES NR NR Objective Directive Items added Medication - 2 levels NR NR NR NR R-ACFI 8 Q9a (scores 3) R-ACFI 8 Q9b (scores 6) YES No change NR NR NR Items added Depression NR YES Major Depression Broader ax choice R-ACFI 8 Q8 (scores 3) YES Broader ax choice NR NR Stronger Diagnosis
The consumer should be involved in: Consenting to program participation. The selection of program options. The design of resident determined goals (e.g. by using SMART Goals – refer below). Signing off on the Therapy Care Plan. Consumer feedback as part of the evaluation. SMART goals provide a guide for the health professional on how to develop (resident informed) goals and outcomes that will fit into a quality improvement approach, ensuring that the collected information is functional and fit for multiple purposes. SMART goals describe what the resident wants out of the Therapy Program, and will also be capable of forming part of an objective outcome measure. Recommendation: Information on SMART goals be inserted into the R-ACFI Assessment Pack. SMART goals (Project Smart, 2017) are an example of a standardised approach to goal setting with measurable outcomes. The acronym SMART stands for: Specific – they provide clarity, focus and direction. A specific goal identifies exactly what is intended to be achieved, not just a general intention. Measurable – objective measures are used to demonstrate the effectiveness of the goal. These are things you can ‘measure’ as improvements rather than just having a hunch that things are improving. Action-oriented – the actions provide a strategy to achieve the goals, and are part of the Care Plan. Realistic – they are to be achievable. Failure to achieve goals can impact on the resident’s motivation, interest and participation. The goal must match with the known situation. They should be realistic. Achievement of small goals can provide motivation and pleasure. Time-based – they should be current for a specific period of time. These goals can be measured at intervals, and re-evaluated on an ongoing basis. Goals need to have a time frame to determine the timing of the evaluation. Therapy Program and an Accountability Framework Does a Therapy Program belong under the accreditation standards or should it be audited with ACFI validation? The quality of a Therapy Program could be audited by both the Quality Agency and, for funding accountability purposes, via the ACFI RO validation activities. Audit criteria for the Therapy Program could include evidence of: Evidence-based assessments. Consumer involvement. Documented program delivery. Documented individualised Therapy Programs. Clearly defined and measurable goals. Documented regular evaluations of the program effectiveness (including resident and family feedback).
Table 8.17: R-ACFI Payment Groups Compared with the Current ACFI Item Number Complex Health Care procedures R-ACFI weighting 1 Management of ongoing stoma care 1 2 Blood glucose measurement 1 3 Oxygen therapy not self-managed 1 4 Complex skin integrity management 3 5 Management of special feeding undertaken by RN 3 6 Catheter care program 3 7 Complex management of oedema 3 8 Major Depression 3 9a Medications 1- Weekly patches, suppositories or enemas, Daily Medication Assistance 3 9b Medications 2- Daily administration of injections. Can only claim one item- either 9a or 9b. 6 10 Management of chronic infectious conditions 6 11 Management of chronic wounds, including varicose and pressure ulcers, and diabetic foot ulcers 6 12 Management of ongoing administration of intravenous fluids, hypodermoclysis, syringe drivers and dialysis. 6 13 Suctioning airways, tracheostomy care 6 14 Management of ongoing tube feeding 6 15 Palliative Care Program 15 Table 8.18: R-ACFI Payment Groups Compared with the Current ACFI Funding Bands1 Number in Bands Average funding in band (Current ACFI Subsidy) Average funding in band (Current ACFI Re-Scale) Average funding in band (R-ACFI Subsidy) 1 3507 10.61 8.38 16.94 2 3507 8.91 7.03 33.11 3 3507 16.37 12.92 33.11 4 3507 16.37 12.92 33.11 5 3507 16.37 12.92 33.11 6 3508 43.31 34.19 33.11 7 3507 46.62 36.81 33.11 8 3507 46.62 36.81 33.11 9 3507 48.67 38.43 33.11 10 3507 67.32 53.15 33.11 11 3508 67.32 53.15 33.11 12 3507 57.33 45.26 33.11 13 3507 37.22 29.38 38.50 14 3507 16.37 12.92 44.15 15 3507 16.37 12.92 44.15
Table 10.1: Most Relevant International Residential Care Systems – New Zealand Country Payment level determination Mandated Care funding tool Care Classification levels Review of needs Auditing of Funding Claims New Zealand Pre-entry – External Assessor DHBs fund residential care. DHBs determine the level of care needed by having NASC teams conducting assessments using the community inter-RAI. (Valid for This model provides a transparent and consistent assessment approach. Assessments and judgement by NASC teams assigns resident to one of four care levels. Each care level attracts one flat payment amount. None interRAI is done pre and post entry. interRAI used for MDS and to promote care planning not used for funding. Considering using the facility completed interRAI – RUGs ADL but concerned it may increase payments due to inflated ratings Considering moving to interRAI and RUGs for not only needs but funding assessment. Providers have indicated that the length of time to complete the interRAI assessments and the efforts to regularity repeat the assessments is a significant resource demand. Four facility classifications and related funding types. Rest home. Hospital care. Specialist dementia care with locked unit accommodation. Psychogeriatric care associated with hospital care. interRAI completed and DHB has access to all data. External Assessor Facility must complete NH inter-RAI within 21 days post admission and facility can dispute the allocated home type level. Visit from an External Assessor determines decision. Facility asks for home type review using interRAI & NASC determines outcome, may require visit. The decision to move to a higher-level care facility is made in consultation with facility staff. Higher care facilities are often on the same campus as lower level options. None Facility assessor requests review if resident has higher care need than facility type can manage. Local Health Body (DHB) - NASC assessor determines if move approved.
Table 10.2: Most Relevant International Residential Care Systems – Canada Country Payment level determination Mandated Care funding tool Care Classification levels Review of needs Auditing of Funding Claims Canada (Varies across provinces) Example based on Ontario. Internal – Facility Assessor Post-entry The Ministry of Health and local health care authority manage waiting lists and determine who is admitted to a facility. Clients on wait list must take first offer (could be 50km away) or go to the bottom of the list. When a place becomes available at a facility nearer their home/family, a further move can be approved. There are significant issues regarding the waiting times. The median waiting time is around 4 months, while those in hospital needing placement wait around 3 months. Getting timely access to residential care has become a system issue which is being addressed by a new ‘home first’ program. RUGs groupings result from the case mix classification system. The groups are determined by the coding of specific interRAI MDS items related to the intensity of assistance the resident received with ADLs plus selected treatments, health conditions, diagnoses, behaviour and cognitive status. While the Aged Care Provider determines their overall funding post-entry via regular individual resident RUGs ADL determinations, the provider is not paid on a resident by resident basis. Payment is based on an annualised Casemix average (case mix index – CMI). interRAI – case mix results in RUGs used to determine funding group. Algorithms vary across provinces. RUGs-ADL 44 Groupings Case Mix Design Yearly adjustments based on historical average yearly Casemix index. ADLs are the biggest driver of funding. Therapy minutes based on care provided, not outcomes. Therapy question under review due to inability to audit and lack of linkage to outcomes. Facility Assessors Facility assessors complete the interRAI quarterly on each resident to determine care needs. The funding groupings for each quarter are then averaged annually, to determine the Casemix average or index (CMI). The funding is then related to the variations in resident care needs and by implication resources, via these updated groupings. Data checks and audit visits are undertaken to assess the accuracy of the RUGs MDS. Facility case managers need to account for claims and accuracy. Penalties apply for inaccurate claiming patterns.
Table 11.2: Option 1. Provider Self-Assessment and Modified Department Audit Model Summary Audit Approach Appraisal Types Entry Funding Appraisal / Mandatory 6-month re-appraisal One category re-appraisal / Two category major re-appraisal Review Outcomes Agree Review Outcomes Disagree New Resident Provider completes R-ACFI and submits to Medicare (current rules apply) NA NA Validation Approach Three tiered Can only be applied for a period of 12 months. R-ACFIs not reviewed are automatically approved. From most recent of: R-ACFI appraisal start date or R-ACFI submission to Medicare. NA NA Validation Level 1 Data Matching & Algorithm Audits Time requirement computer program Basic data validation check Data algorithm check checks facility R-ACFI against ACAT completed NSAF R-ACFI (new residents) applies current data modelling analytics and historical data to predict likely changes since NSAF R-ACFI was completed. Funding Approved Downgrade OR Go to Validation Level 2/3 Validation Level 2 e-Review (medium to longer term possibility) ROs use remote access to provider electronic clinical software system ‘partitioned sections’ to conduct e-Review. ROs document their findings and provide a report for providers which provides the rationale for their decisions Funding Approved Downgrade OR Possible Level 3 Validation Level 3 RO visit New guidelines need to be developed for site reviews (assessed care need vs care provided and relevance to a review decision) to clarify: the ROs R-ACFI review protocols compliance aspects of the RO role. A visit program may include: review of residents’ records observations of residents interviews with residents, staff, and families. Incongruences noted during direct observation of the resident should be used as a flag for further investigations to check the accuracy of the assessed care need. Interviews with informants (residents, families, staff, AHPs, GPs) could be used to inform on the accuracy of the assessed need. Funding Approved Downgrade Appeals Provider can appeal as per current process to review outcome.