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Plans for the great unknown

In part one of a two-part series, Benetas chief executive Sandra Hills and project manager Helen Brightman ask the question that many aged care providers are not yet prepared to confront  – when will we be ready for consumer-directed care in Australian aged care facilities?

Regardless of the support service industry in Australia, consumer-directed care (CDC) means just what it says – individuals get to choose the design and delivery of their own care services.

While there is no one definition of CDC, its objective is to give the individual greater control over their lives by giving them that option, if that’s what they wish. This can be done by allowing the individual to choose the type of care services they access and the delivery of those services, including who will deliver them and when. CDC is about having the choice to exercise choice. It is a philosophy – the right to choice and access to a range of options to enable that choice.

In the disability sector, the National Disability Insurance Scheme has already moved providers down the road of CDC. For aged care, all new in-home care packages are already required to be delivered on CDC, and from July 2015, all packages will operate on a CDC basis.

At Benetas we recently trialled a CDC program for in-home services. A case study from this trial involved Mrs S who is the primary caregiver for her husband who has dementia. Throughout the trial, she managed the CDC home care package on his behalf. Due to this high level of self-management, more funds were allocated to the weekly budget, with Mrs S choosing her funds to go towards additional services.

For the disability sector and in-home aged care, CDC means that the consumer has much more control over their package and can choose their level of involvement. One person may coordinate all their own services and care, with minimal case management, while their neighbour may choose to pay for a case manager to co-ordinate their whole package. It is flexible and entirely dependent on the individual and we know, broadly, how it will work.

What we don’t know is how this will look in residential aged care. There is a clear path for providers to move towards CDC in residential, but as yet the government has not  set a date for implementation.

CDC could be like staying in a hotel. As a guest, you can order what you like from the room service or restaurant menu. You can eat at whatever time you want. You can have a newspaper delivered. You can choose to use the hotel’s facilities. You can ask for your clothes to be dry-cleaned. You can have a massage in your room or visit the day spa. All you do is sign for whatever services you order during your stay, and it’s all billed to your credit card.

So far, CDC in residential aged care facilities is the great unknown. The more comfortable aged care providers become with the federal government’s Living Longer, Living Better (LLLB) reforms, the clearer the future becomes. We are starting to work out the kinks and creases of the reforms, and our service offerings for the future are becoming more clearly defined. Yet with CDC in residential, we are still very much in the dark.

The only innovations happening in this area of which I am aware are other residential care providers offering packages of services for a fee, similar to the extra services concept. Homes are already offering extra services such as newspapers or wine with dinner or special lifestyle activities, at a cost to the client, but not care, as far as I am aware. This is moving towards CDC, but there is still a long way to go.

The concept of CDC, to me, does not involve offering any particular service, but offering access to all services. It is about asking an individual what they want and bringing in the services they chose. Currently we promote the services we offer and people generally choose our facilities based on this offering. CDC is the complete opposite. In the future, under a CDC regime, if someone asks us what we can offer them, we will say: “Choice. Let’s talk about what you might need and see if we can get it in for you.”

Changing to this type of service delivery in residential care means a complete shift in culture. Staff will be more focused on providing customer service than traditional care. Providers will still have a duty of care, but will not choose the care. The client will need to agree to what support we provide them with to meet their care needs. Providers will need to be much more innovative and flexible in the type of services they offer, as the client will be much more in control and will expect to have a choice. For example, how will staff cope if residents say they only want three or four showers a week instead of one a day.

We need to think about how we charge for any additional service a client may choose to access. And how our staff then carry out our clients’ wishes. This will require a much more flexible staffing model to meet the demands of our residents. For example, our kitchen will need to be open at all hours, so that we can serve food and drink as requested. This is a real change to current service provision.

The reality of residential aged care planning has been, rightly or wrongly, that providers write a business plan, design a new facility and then think about attracting clients. Implementing CDC will turn that process on its head – and we are already seeing a shift in this area. Providers need to think about how their clients might want to live, what services they might want access to, how they may be able to pay for it, how they want to spend their time and then they will write a business case. It will be 100 per cent about the individual.

And this is how it should be. Right now, as individuals living independently in our own homes, we choose when we have dinner, who we spend our time with, which health practitioner we go to – we make multiple choices every single day. So why should these choices stop simply because we move into a residential aged care facility? The harsh reality of aged care in Australia is that it is about providing a cost effective service model. With CDC we must move to a lifestyle model.

So how do we, as highly regulated aged care providers, make this work?

Implementing CDC in residential aged care will move the current system from compliance heavy to market-driven. One of the biggest questions for aged care providers will be about  how we respond to government legislation, ensure we meet all accreditation standards and provide our clients with the level of choice they desire. And who will pay?

We could use disability service providers as an example of how this might look in our residential setting. Our risk profile as service providers doesn’t match our goals for the future, based on the current legislative restrictions. We are a risk-averse business; we deal with people’s lives so we have to be.

But what if someone moves into one of our homes and wants to go swimming in the ocean every day of the year, because that is what they have always done, and they need a carer to go with them? Or someone wants to go interstate once a year to see their family? How do we eliminate the risk in these activities if the individual is willing to pay?

One way would be by embracing the concept of dignity of risk and the right of individuals to choose to take some risk in engaging in life experiences. Dignity of risk places an emphasis on personal choice and self-determination, two concepts that are also central to CDC. Currently the barriers we face to that – fear, systems, time and environment – stop us from allowing individuals the dignity of risk.

How do we work within government regulations to provide the lifestyle model we, and the community, desire while still providing safe and responsible care to all our clients?

We may be able to follow the model of other industries as a guide to implement CDC effectively. One example of this could be the hospitality business model. This model has the host/guest transaction at its centre. The interaction between the hotel staff and guest is the most important part of the transaction – in other words, customer service. A whole lot of different elements rest on this, including commerce and law, all of which result in a two-way process. CDC in residential aged care could, potentially, function exactly the same way as a hotel – people access their care based on their budget, interest and health needs and they pay accordingly.

Another model we could follow is car manufacturing. Car manufacturers have to research what type of vehicle people want to buy and then put a large amount of capital into an assembly plant to produce the product. It takes a huge cost to alter the assembly plant to get the product right for the market. Similarly in aged care we can research people’s interests, put capital into design and building, and then offer the product to the market. Because of this capital investment we need to make sure we have the right product before we take it to the market, rather than the other way around.

Implementing CDC at residential facilities is the way of the future for aged care in Australia. There are no ifs; it is simply a matter of when. The LLLB reforms are already pushing providers in that direction. Other sectors are working towards a CDC model, and aged care must follow if it is to meet the changing needs of our ageing population. The biggest question for aged care providers is how.

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