Evaluation of the Demonstration Day Respite Pilot in Residential Aged Care Facilities Initiative

Final report on Demonstration Day Respite Pilot in Residential Aged Care Facilities Initiative

Page last updated: 19 September 2011

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Acknowledgements and Evaluation Team
Summary of Key Findings
Executive Summary

Acknowledgements and Evaluation Team

The evaluators would like to thank all of the 31 site providers – their managers, and day respite staff – and carers from these sites, for their input into this evaluation. This has been a two and a half year project requiring significant cooperation in order to obtain information about an innovative pilot program. Although we worked hard to minimise burden on these stakeholders, their contribution has required an investment of time and commitment to the evaluation, and this has been greatly appreciated.

Department of Health and Ageing

We would also like to thank Department of Health and Ageing staff who have managed the evaluation and provided us with ongoing support. In particular, we acknowledge the work of –
  • Mr Erni Rauter, Director, Respite for Carers Section, Office for an Ageing Australia, Ageing Aged Care
  • Ms Kathy Vanduren, Assistant Director, Respite for Carers Section, Office for an Ageing Australia, Ageing Aged Care

Evaluation Team

  • Dr Kate Barnett (Project Manager), Deputy Executive Director, Australian Institute for Social Research
  • Ms Naomi Guiver, Senior Research Fellow, Australian Institute for Social Research
  • Mr Daniel Cox, Director, Evolution Research Pty Ltd
  • Mr Richard Giles, Director, Evolution Research Pty Ltd
  • Ms Anne Markiewicz, Director, Anne Markiewicz and Associates
The Project Team has also received research assistance support from –
  • Dr Natasha Howard, Research Assistant, Australian Institute for Social Research
  • Ms Rachel Katterl, Research Assistant, Australian Institute for Social Research
  • Ms Alicen McNaughton, Research Associate, Australian Institute for Social Research
  • Mr Graeme Tucker, Research Associate, Australian Institute for Social Research Top of page

Summary of Key Findings

Findings About the Service Model

The location of day respite services in residential aged care facilities (RACFs) provides a valuable, and value-adding, component to the broader aged care system when certain conditions are met. Providing the following three factors are addressed, this model enables a synergistic sharing of resources across the organisation, and links service users to a wider range of supports and services than would normally be provided by a day respite program –
    • its implementation is managed carefully
    • it brings with it a design of physical infrastructure that is sensitive, user-friendly and supports flexible, consumer-centred service provision, and
    • it is delivered by an organisation that provides a suite of service types.
Day respite that is located in a RACF setting can also reduce negative perceptions of residentially-delivered care through familiarisation of carers and care recipients with the services that can be available in RACFs, in particular, residential respite care. In such a context, day respite constitutes a bridge that seamlessly links community and residential services, smoothing the transition between both. However, the issue of stigmatisation of the DDR services because of their location can be a deterrent to consumers, albeit one which is overcome for most through familiarisation and satisfaction with services provided.

Findings about Appropriateness

Appropriateness relates to a program’s suitability in terms of achieving its desired effect and being used by its intended participants.
Administrative and Program Guidelines for the National Respite for Carers Program (2004) identify a number of target groups of which the following are relevant to the DDR initiative –
    • people with dementia;
    • people with dementia and challenging behaviour;
    • frail older Australians (65 years or over, or 50 and over if Indigenous).
Consistent with the original intention of the day respite program, according to the SARs almost all of the care recipients attending the program over the past two years were aged over 65 (or over 50 if from an Aboriginal or Torres Strait Islander background). In terms of health and functioning, over half of all care recipients had dementia, around a quarter had dementia with challenging behaviours, and around a quarter had a disability. The characteristics of the carers and care recipients attending the program in 2008/09 and 2009/10 are summarised in Tables 14 and 16 of SAR Report Accompanying Report 9. The results show that –
    • The proportion of carers and care recipients from Aboriginal and/or Torres Strait Islander backgrounds had remained constant at around 3 to 4%.
    • The proportion of carers using the service who were living in rural locations appeared to increase slightly from 15.1% in 2008/09 to 21.6% in 2009/10, due to the increased service delivery of some of the rural-based DDR projects. However the number of carers living in remote locations dropped slightly from 5.5% in 2008/09 to 3.0% in 2009/10.
    • The proportion of carers from financially or socially disadvantaged backgrounds remained steady at 24.5% of carers assisted in 2008/09 and 2009/10.
    • Employed carer numbers reduced slightly from 1 in 3 carers (33.3%) in 2008/09 to 27.5% of carers in 2009/10.
More detailed information on the health and functioning of care recipients was collected in the first round of our Site Data Collection (refer to Accompanying Report 7). That report illustrates that, at assessment –
    • the General health status of nearly half (48.2%) of all care recipients was Fair,
    • the Level of care required was assessed as High for 45.1% of care recipients,
    • the Priority level for entry to the day respite service was assessed as High for nearly half (49.0%) of the care recipients, and
    • Special care needs were reported for 67.6% of the 896 care recipients, of which the most common special care need was Dementia (27.2% of all care recipients).
The Final Site Data Collection identified a change in the profile of carers and recipients by 12 of the 31 sites (38.7%) that included a trend in 2010 towards increasing high care needs and clients from diverse cultural and linguistic backgrounds. Some sites also noted an increase in the number of carers presenting with stress or health issues – see Accompanying Report 8.
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In 2009 the most common reasons cited for ineligibility or exclusion of applicants to the DDR service were High-level care needs (i.e. requiring two staff), cited by almost half of all projects, and High-level challenging behaviours (i.e. abusive, intrusive or inappropriate behaviours), cited by more than a third of projects – see Accompanying Report 7. The final Site Data Collection showed that little had changed in 2010 – the most commonly cited reason for rejecting applicants was an inability to accommodate care recipients with complex and high level care needs, particularly arising from behavioural issues, mobility issues and other health issues requiring one-on-one support. Furthermore, most sites reported that they were rejecting around the same proportion of applicants as they had in the previous 12 months – see Accompanying Report 8. This is a concern as this is one of the NRCP’s key target groups and the burden for their carers is significant.

It is important to note that assessment practices and care recipient characteristics may vary greatly between DDR projects as there is an absence of uniform, nationally consistent assessment (such as would be provided by an ACAT) informing the overall client profile. The evaluators believe that a nationally consistent and recognised assessment process, as is provided by ACAT services, should be required to achieve entry to DDR services. Standardised assessment would allow more reliable quantification of the characteristics of carers, and promote a better understanding the impact of DDR services on entry to permanent residential care (discussed below).

The overall exit rate for the day respite program appears to have remained between 28% and 39% so far, with an exit rate of 27.9% calculated for the period July-December 2009 (first Site Data Collection), and exit rates of 37.3% and 38.9% for the full 2008/09 and 2009/10 financial years respectively (SARs).

Consistent with the reported difficulty in accommodating clients with high care needs, data on exit destination from the first Site Data Collection and from the 2009/10 SARs indicated that approximately one third of all care recipients leaving the day respite service entered high level full time residential care (35.2% from the Site Data and 33.7% from the 2009/10 SARs). According to the SARs, this proportion had increased since 2008/09 (up from 27.4%), with a corresponding decrease in the proportion of care recipients entering low level full time residential care (18.0% in 2008/09 and 13.9% in 2009/10). However the ageing of the care recipients enrolled in the first year of the program may explain this apparent trend.
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It will be important to continue to track exit destination as the DDR program matures and moves towards capacity, in order to determine its true impact on entry to high level residential care. Therefore we recommend that the Department begins to include the exit destination section of the SAR in the usual subset of items that are entered electronically by the Department from the paper SAR forms. (That the Evaluators undertook to enter this data for 2008/09 and 2009/10 specifically to address this issue).

A range of services that are appropriate to day respite care are being provided, with the value-add of access to additional services being provided by the RACF that are not normally available in a day respite service. These include nursing, health monitoring and hygiene supports, as well as residential respite.

Both the literature review and evaluation survey feedback (Accompanying Reports 1 and 4) identify flexibility of day respite delivery as the most important critical success factor for carers, closely followed by responsiveness to consumer need, and the evaluation has found the DDR services as a group to be addressing both of these requirements. Feedback from carers indicates that what they sought from the day respite services (for themselves and the person in their care) has been provided (see following section on ‘Effectiveness’).

Services have also rated well for their accessibility, with the provision of transport, subsidisation of fees and services designed for specific cultural groups - including Indigenous people or those from specific culturally and linguistically diverse (CALD) backgrounds, as well as people living in rural or remote locations - being essential to this outcome. On the whole, carers are satisfied with the amount of respite (88.6% of carers surveyed) and the hours of its delivery (82.5% of carers surveyed), but there are some (3.7%) who are not satisfied with the days or hours provided, often seeking more weekend and public holiday provision (refer to Accompanying Report 4). However, few DDR services offer specialist services for employed carers, and SAR data indicates that the proportion of these carers has reduced slightly from 33.3% in 2008/09 to 27.5% in 2009/10. Some but not all sites offer hours of operation that support carers’ employment.

The research literature is clear in finding that transport plays a key role in making day respite services accessible. Findings from the evaluation confirm that transport is a critical success factor for the DDR service model. According to the most recent Site Data Collection (2010), only three projects do not currently offer any type of transport to their care recipients. It was evident from the Surveys and the Site Data Collections (see Accompanying Reports 4, 7 and 8) that services are tailoring their transport provision to user need, and to local conditions. Transport costs tended to be subsidised by the day respite service to minimise any financial burden on clients, however some sites have experienced difficulty in meeting the demand for transport.

Results from the Surveys and the SARs both indicate that the number of complaints made about the day respite service is low. According to SAR data there were less than 3 complaints per 100 carers/care recipients who used the DDR services, suggesting that the program is operating without any major problems.
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Findings about Effectiveness

Effectiveness concerns the extent to which the program’s objectives are being achieved, or are expected to be achieved, and the benefits for its participants.

The DDR services have received very positive ratings from all four stakeholder groups surveyed regarding their effectiveness and their impact. A range of benefits arising from the program have been identified for carers and the person in their care – indicating that DDR services are being designed and provided with the caring relationship taken into account. Three types of benefits were identified – those relating to the respite provision itself (eg provision of a break for carers, provision of a range of opportunities for care recipients), those relating to carer health and wellbeing (including reduced stress, time to address their own health issues) and those relating to service access and usage (including making carers more confident about using residential respite and increasing carer awareness about available services). However, carers were less likely to see the DDR services as linking them to other services.

Extensive literature reviews have found no reliable experimental evidence that respite care provides significant short or long term benefits to care recipients (Arksey et al, 2004) or that it adversely affects them (Mason et al, 2007), regardless of respite care model – see Accompanying Report 1. Nevertheless, Carers, Care Workers and Care Coordinators surveyed for the evaluation have identified benefits relating to the DDR services’ social impact on care recipients, but less so in relation to improving physical or cognitive functioning.

Less expected have been benefits identified for RACF residents through sharing in DDR services, for RACF staff through exposure to a wider range of clients and services than normal, and for participating RACF organisations in terms of synergies achieved in resource usage and cross-fertilisation across programs. This has been particularly evident when a suite of services and programs can be drawn from, including the DDR service.

Combining Site Data information with that received from our surveys with carers, care workers, care coordinators and service directors and our case studies with selected sites, it would appear that the day respite services are likely to have delayed entry into residential care while facilitating that transition when it was needed. However, this finding should be treated with some caution as it is based on the perceptions of key stakeholders and not on measured, assessment based change (such as an ACAT assessment provided on entry to the DDR service and upon exit from the service). While these perceptions have been triangulated and show agreement across key stakeholder group, without the recognised national measure offered by an ACAT, this cannot be treated as a definitive finding.
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A key mechanism for the transition from community to residential care has been the residential and overnight respite services offered to day respite clients, which carers and care workers report as having demystified residential care. This, combined with the sharing of some services between day respite and residential clients, can be seen as likely to have reduced the fear of entering residential care for many carers and care recipients. Furthermore, Site Data and SAR analysis shows that when DDR care recipients have entered full time residential care, three quarters have been admitted to high level care, which provides a further indicator of their degree of need and by implication, the reduction of demand placed on carers. As discussed, analysis of Site Data and SAR data shows that approximately one third of the care recipients who exited DDR services in 2009/10 entered a high care residential service, whereas less than 15% exited to enter a low care residential service.

Findings about Efficiency

Efficiency is concerned with how economically resources have been utilised, and how inputs (funds, expertise, time, etc.) are converted to results or outputs. The evaluation has collected information about staffing levels and usage (both DDR funded and unfunded) and staff : client ratios, as key input factors and taken as results quantifiable information about hours and days of respite delivered, management of demand levels, carer satisfaction with outcomes and whether or not projects are in deficit or surplus. In addition, evidence of economies of scale and value-adding have been identified as an indicator of effective and efficient use of resources.

However, it should also be noted that is difficult to determine precisely the cost effectiveness of the DDR Initiative as a whole as there are a range of variables to take into account. Relevant variables include location (the more remote the higher many costs will be and the greater will be the difficulty of achieving economies of scale), the level of care provided, the needs of care recipients (for example, those with dementia will require significantly more support), facility size and the capacity to achieve synergies in resource usage. Furthermore, as new initiatives there will be start up costs for DDR services that will reduce over time.

Inputs

The DDR services have been able to achieve economies of scale by sharing staff-related and service provision-related resources. In addition, the RACFs have benefitted from the infrastructure provided through the DDR Initiative, with service users also gaining from the enhanced service provision made possible by day respite focused building design and renovation. Sharing of staff across programs is also exposing staff to wider learning opportunities, and residents as well as care recipients can be expected to benefit from this. In addition, DDR clients are likely to benefit from the value-add of access to services available in the RACF. The two most commonly cited services were nursing services and referral to other RACF health and support services (27 sites), followed by use of residential respite (26 sites), RACF allied health services (24 sites), health monitoring (22 sites) and hygiene services (21 sites) – refer to Accompanying Report 7.
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According to Site Data submitted for July-December 2009, for every FTE day respite staff member (regardless of role) there were on average 7.7 day respite places used per week. In terms of staff providing direct care to care recipients, there was on average one direct care staff member per 12 places. However, within this range there was substantial variation between projects, perhaps reflecting operational characteristics such as the specialist focus of each service (for example, dementia-specific) and the implications of that focus on staff : care recipient ratios.

In addition, most of the sites indicated that operating their DDR service involved the use of additional unfunded staffing from the RACF. Most commonly, this involved Managers, Nursing staff, particularly RNs, and Domestic staff. While this has entailed a small amount of time per week per site, when considered across the DDR program as a whole it represented the equivalent of over 30 full time staff per week (30.5 FTE) in total, an average of 1.1 full time staff members per project (based on detailed data provided in the first Site Data Collection). This is not necessarily an efficiency indicator for individual projects, but from a program perspective is a further value-add for overall respite resource provision.

Outputs

Based on information gathered in the first Site Data Collection regarding the number of day respite places offered by each site in July-December 2009 (refer to Accompanying Report 7), it was estimated that more than 1,400 day respite places were being offered per week under the DDR scheme. Therefore, if each carer were to receive one occasion of respite each week (i.e. the average indicated by the detailed Site Data collected on individual care recipients), more than 1,400 carers could use the service each year.

This is consistent with information from the Service Activity Reports (SARs) regarding the number of carers actually receiving a service – 1,262 in 2008/09 and 1,427 in 2009/10, an increase of 13.1% (refer to Accompanying Report 91). If each of these carers used the service once per week (as is the average indicated by data from the first Site Data Collection), this would mean that the original Budget estimate for the DDR Initiative quoted by the Department, which estimated that the measure would help carers of frail older people at a rate of 1,200 per week, had been met.

Based on the sites’ operating days and hours as at December 2009, the DDR Pilot offered over 73,000 days of respite per annum and over 700,000 hours of respite per annum. Operating days and hours remained unchanged at most of the sites in 2010 (final Site Data Collection round – refer to Accompanying Report 8). While the number of days offered exceeds the original target set for the DDR Initiative (62,400 days of respite for carers of frail older people), according to the Service Activity Reports (SARs) few sites had actually reached full capacity by the end of 2009/10. The total number of hours of respite actually delivered per annum had increased by 33.8% from 252,788 hours in 2008/09 to 338,302 hours in 2009/10. However, this still only represented around half of the total capacity of the program in terms of the fundedhours reported in the SARs and the operating hours reported in the Site Data Collection.
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According to the SARs the number of respite hours delivered per annum per carer (i.e. the total number of hours delivered divided by total number of carers) increased from 200 hours in 2008/09 to 237 hours in 2009/10, an increase of 18.5%. This equates to an average of 3.9 hours per carer per week in 2008/09 and 4.6 hours per carer per week in 2009/10. However, it should be noted that there can be a very broad range of service use patterns, with some carers using the day respite service only occasionally, others using it weekly, and others using it up to 7 days per week. Some sites limit the amount of respite offered to individual carers, whereas other sites offer almost unlimited use. Therefore a slightly different picture of the average number of hours delivered per carer will be generated when using data based on individual care recipients, as was collected for the period July-December 2009 (see Accompanying Report 7). Statistics calculated using these data showed that the average (mean) number of hours that each care recipient attended day respite during that period was just over 6 hours per week, higher than the figure based on SARs data, due to the very high usage of care recipients at some services (e.g. 7 days per week).

Cost of DDR services

The cost (expenditure) per hour of respite funded, the cost per hour of respite actually delivered and the cost per carer was calculated for the Demonstration Day Respite program as a whole and for individual projects, by combining data from Service Activity Reports (SARs) with expenditure data from the Financial Accountability Reports (FARs). A summary of that information is presented below – refer to Accompanying Report 10 for further details.

The cost per hour of respite delivered for the program as a whole appears to have decreased over the last two financial years, from $35.75 in 2008/09 to $30.37 in 2009/10. In comparison, the cost per hour delivered across 138 NRCP Day Care projects in 2008/9 (provided by the Department for comparison purposes) was $17.28. There is potential for DDR service delivery costs to decrease to this level over time as the program moves further towards service capacity and thereby towards equivalence with the cost of DDR hours funded ($16.92 in 2009/10, based on additional data extracted from hardcopy SAR forms for the purpose of the evaluation). The annual cost of respite delivered per carer had remained steady at around $7,000 ($7,161 in 2008/09 and $6,940 in 2009/10) – refer to Accompanying Report 10 for details).

The FAR data showed that the DDR program as a whole was operating with a modest surplus. More than half of the individual projects reported a surplus rather than a deficit in both 2008/09 and 2009/10, and most of the projects which had reported a surplus for 2008/09 also reported a surplus for 2009/10. The average surplus/deficit reported by individual projects had reduced from just under $25,000 in 2008/09 to just over $14,000 in 2009/10.

This can be seen as an indicator of efficient use of resources. Apart from avoiding a deficit situation, a modest surplus as opposed to a significant surplus, indicates a maximising of available resources to meet consumer need.
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Demand and unmet need

In reviewing demand levels, the evaluators extracted additional data from hardcopy SAR forms pertaining to the number of hours of respite funded (rather than hours actually delivered) and the reasons given by projects for any difference between the hours funded and hours actually delivered. Those data items are not normally entered into the Department’s spreadsheets.

Each project receives an agreed amount of funding each financial year to cover the delivery of a certain number of respite hours. The difference between the number of funded respite hours and the number of respite hours actually delivered can be seen as a measure of unused (or over-used) capacity in a service. An indicator of unused/overused capacity was defined as the proportion of funded respite hours that were actually delivered, i.e. calculated as hours delivered as a proportion of hours funded
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For the program as a whole, the proportion of funded hours that were actually delivered rose from 38% in 2008/09 to 51% in 2009/10. This suggests that while the number of respite hours delivered increased by about a third between 2008/09 and 2009/10, it appears that around 49% of the stated capacity is still unused and therefore there is scope for substantial growth in the program (see Section 3.3 of Accompanying Report 9).

It is also important to note that almost all of the individual projects, including two of the projects identified as showing the greatest underuse, did demonstrate growth between 2008/09 and 2009/10 in terms of the proportion of funded hours that they actually delivered. While many projects clearly faced unexpected challenges in establishing and running their service, it appears that over time these issues are being addressed.

These findings are further explained by information from the Site Data Collections which indicated that in an attempt to better meet actual demand, more than half of the projects had changed their operating days/hours from those originally proposed, and that these variations had mostly continued through 2010. Reasons given indicated that demand levels had not been accurately forecast prior to opening the service. This issue was also acknowledged by many sites when giving reasons in their SARs for significant variations between their funded respite hours and the actual respite hours delivered.
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Demand is also reflected in vacancy rates (ie the average number of vacant places per week as a percentage of the average number of places offered per week, as collected in the first Site Data Collection), and waiting lists (collected by the SARs). These showed that –
  • The vacancy rate varied greatly across projects – ranging from a high of 67.0% to zero vacancies (i.e. operating at capacity). The overall vacancy rate during the period July-December 2009 was 32%, representing over 400 vacant places per week in total. Furthermore, 81% of these vacancies were mainly due to lack of demand. This information raises concerns about methods used to determine demand levels.
  • At 30 June 2009 there were only 28 carers on waiting lists for the program as a whole. By 30 June 2010 this had more than doubled to 67 carers – an increase of 139.3%. Only six projects reported a waiting list at 30 June 2009, however, at 30 June 2010 ten projects had a waiting list. As the DDR services become more established it can be expected that waiting lists will increase and these rates need to be plotted over time.
It was not possible to benchmark these rates against other NRCP funded day respite services due to a lack of available comparable data.

In order to accurately assess which services had the greatest unmet need, the SAR data on waiting lists was combined with the SAR data on service capacity (see Accompanying Report 9). In 2009/10 six projects were delivering 100% or more of the respite hours for which they had been funded, and had a waiting list, indicating clear unmet need for those services. Other projects with a waiting list in 2009/10 had delivered less than 70% of their funded respite hours, which reflected situations where the particular days or times requested by carers were unavailable rather than overall lack of capacity.

For those projects where unmet need is clearly evident, should ongoing funding be sought, it would be important to identify other day respite services in or near the same location as part of the process of determining the most efficient way to meet demand.

Future funding model

Should the DDR services be continued as an ongoing component of the aged care respite service system, it is highly unlikely from the evaluation findings that they will be able to rely on a user pays model (if they are to be equitable and accessible). This means that funding will need to be recurrent, but based on meeting a set of required deliverables that reflect the purpose of the program and its service model.
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The grants based funding provided for the DDR pilots has been effective not only in meeting service costs but for a number of other reasons –
    • Its four year timeframe, as opposed to a one year timeframe, has enabled issues associated with service establishment to be addressed and lessons learned from the path-finding nature of these pilots to be identified and absorbed.
    • The long timeframe has also supported services to be innovative and flexible, which would have been far less likely if funding had been provided on an annual basis.
    • It is very important for carers and care recipients to have a guarantee of service continuation.

      At the same time, the provision of a service for four years will have raised expectations among service users of the continuation of DDR services and if the Program is not continued or absorbed into the NRCP, the negative impact on them will be significant (based on the positive feedback that the evaluation has identified).
There is inconclusive evidence about whether the amount of funding provided has inhibited or enhanced the services provided. However, it is more likely that the guarantee of four years of funding support has been deemed by providers to be worth investing RACF time and resources in developing DDR services.

Executive Summary

(This Executive Summary is designed to be a stand-alone document, hence it has more detail than would normally be provided in this part of the report.)

Introduction

The Demonstration Sites for Day Respite in Residential Aged Care Facilities (DDR) Initiative was announced as part of the 2007/2008 Federal Budget with $41.2 million provided over four years by the National Respite for Carers Program (NRCP) to establish demonstration sites for day respite care in aged care facilities. Thirty providers from metropolitan and rural and remote areas across Australia were offered funding. (One of these providers operates its services over two sites, and asked the evaluators to treat the sites separately, so for the purpose of the evaluation, there have been 31 sites, representing 30 projects.)

Evaluation requirements

The evaluation of the Demonstration Sites for Day Respite in Residential Aged Care Facilities Initiative is to investigate and report on the following 9 factors:
  1. The efficiency, effectiveness and appropriateness of funding DDR services in residential aged care facilities.
  2. The benefits to the carer and care recipient of accessing DDR services, including the extent to which this model of respite care supports home-based care, the caring relationship and the well-being of the carer and the care recipient.
  3. Any unintended effects of the Initiative, including adverse consequences for the carer or care recipient.
  4. The impact of accessing DDR services on the care recipient’s entry to permanent residential care, including the extent to which the receipt of day respite delays or else facilitates entry into full-time residential care.
  5. The effects of providing DDR services on the operations of residential aged care facilities in providing care to full time residents.
  6. The demand for DDR services in residential aged care facilities.
  7. The costs of delivering DDR services, taking into account relevant variables including: locality, level of care provided, needs of care recipients, facility size etc.
  8. Appropriate levels of user fees for DDR services.
  9. Appropriate options for future funding of this type of respite, such as a day respite subsidy and/or grant funding.

Evaluation methodology

A methodology involving both quantitative and qualitative approaches was designed, involving –
  • A review of Australian and international research relating to day respite (A Discussion Paper presenting its findings is available in Accompanying Report 1).
  • A Monitoring and Evaluation Framework was developed to guide the evaluation (A copy of the Framework is presented in Accompanying Report 2).
  • From June to October 2009, the evaluators visited 13 of the sites in order to undertake in depth qualitative analysis which was reported in the form of individual Case Studies, brought together in a single report that also identified trends and differences across the sites studied. Case Study sites were selected to yield rich qualitative information and provided a range of locations (metropolitan, regional and rural), auspice types, States and Territory, size (small, medium, large) and a culturally-specific or Indigenous-specific focus. (A copy of the Case Study report can be found in Accompanying Report 3).
  • In late 2009, the evaluators distributed four surveys – one for CEOs and Service Directors, one for Care Coordinators/Managers, one for Day Respite Care Workers, and one for Carers – to collect information on the experiences and opinions of those stakeholders regarding the appropriateness, effectiveness and impact of the DDR service. (A copy of the Survey Report can be found in Accompanying Report 4).
  • Based on initial interviews with DDR Site Managers and a survey of existing project data collection, a Site Data Collection tool was developed to extend and complement data provided by sites through the Financial Accountability Report (FAR) and Service Activity Report (SAR) processes. The Site Data Collection was undertaken twice. The first round related to the period 1/7/09 to 31/12/09 and collected detailed information on operations, service delivery and staffing. The second round, in late 2010, identified any changes that had occurred since 2009, so that an up to date picture could be obtained. (The first Site Data report can be found in Accompanying Report 7 and the final Site Data report in Accompanying Report 8).
  • In 2010, analysis was undertaken of available Financial Accountability Reports (FARs) for the financial years 2008/09 and 2009/10 and Service Activity Reports (SARs) for 2007/08, 2008/09 and 2009/10. A preliminary analysis (Accompanying Reports 5 and 6) was superseded by a final analysis of 2008/09 and 2009/10 data (Accompanying Reports 9 and 10) using cleaned and updated datasets.
  • The evaluators facilitated a Workshop in Melbourne in May 2009, with multiple representatives from all sites and from the Department. The Workshop presented the draft Monitoring and Evaluation Framework and the Site Data Collection tool, and provided an early opportunity for the evaluators to meet all site representatives, and for those representatives to meet each other.
  • Synthesis and analysis of findings from these different evaluation activities has been designed to enable triangulation of results.
  • Reporting has been continuous, with individual reports for each major evaluation activity being provided, together with four Progress Reports.

Findings about the model of service

The provision of DDR services usually occurs in a community rather than a residential care setting, and this is the distinguishing feature of the DDR model – its location. From this base several other differentiating features are evident –
  • Co-location of day respite in a RACF brings together residential and community care staff, offering scope for the development of enhanced knowledge and skills on the part of both groups of staff, and can provide the day respite service with access to staff they may not normally be expected to work with (eg Lifestyle Coordinators). It can also mean that activities are designed with the support of specialist RACF staff not always available in day respite programs – for example, a dedicated Activities Officer or Recreation Coordinator. However, if the transition of the implementation of the day respite service is not managed effectively, with RACF staff being consulted, informed and so on, there can be resentment on the part of residential staff which takes months to overcome.
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  • Co-location also offers the opportunity for residential and DDR service recipients to share in activities, broadening the range otherwise possible. In smaller communities (eg rural or culturally specific) many of the residents are known to day respite users and given the opportunity to re-connect. However, the sharing of activities and facilities requires sensitive management. It is important that residents do not feel ‘overtaken’ and it is important that individual user needs are taken into account when bringing both groups together.
  • Co-location brings the risk that the stigma associated with a residential care setting will deter carers and care recipients from accessing the DDR service. Fortunately, the DDR Initiative has offered funding for infrastructure that enables RACFs to provide a separate day respite centre or renovations designed to support flexible service provision and to create a homelike setting. A critical factor in the application of the model is sensitive infrastructure design. It has also been evident from the evaluation that stigmatisation has generally been an initial rather than an ongoing issue as familiarisation with the RACF and the day respite service increases over time.
  • Co-location and the familiarisation involved also means that many carers and care recipients can more easily access residential respite, and that if the care recipients’ needs change and they require long term residential care, this is less threatening. The evaluation has not found that the service model encourages premature entry to residential care, but rather, that it delays admission and eases the transition when it does occur.
  • For all of the above reasons, the DDR model can be seen as building a bridge between community and residential care, providing an important component of the care continuum and easing the carer and care recipient journey in the process.

What did carers seek from the DDR service?

Based on survey findings, the main reasons given by carers for using DDR services reflected a duality of need, with the two most commonly cited reasons being to provide the care recipient with an opportunity to socialise (77.4%) and giving the carer a break (68.4%). In addition, information provided by carers about their health showed that–
  • nearly one third of carers (32.0%) reported that they had no disabilities and no chronic health conditions;
  • 39.0% reported one or two disabilities and/or chronic health conditions; and
  • 16.5% reported three or more disabilities/conditions. Refer to Accompanying Report 4.
This information points to the important role played by day respite services providing a specialist focus on carer health and wellbeing, as occurs with the Healthy Ageing Centre at Rooty Hill (one of the sites case-studied for the evaluation – details in Accompanying Report 3).
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Did the DDR service provide what carers were seeking?

It is of paramount importance that any new respite care service actually provides what carers want and need. Consumers usually make a clear choice between care in the community and care in a residential facility, but the DDR model blurs this distinction and carries the risk that people seeking a service that is essentially at the community end of the care spectrum will find the residential location to be a deterrent. The stigma associated with residential services has been significant for some, but certainly not the majority.

It is evident from the literature review (Accompanying Report 1) undertaken for the evaluation that it is not the model per se of respite care but how it is delivered that affects carer and care recipient preferences (Mason et al, 2007: 3). In particular, the flexibility and responsiveness to individual need emerge as the most consistent themes in the preferences of carers identified by researchers, as well as the provision of quality services that enable the carer to entrust the person in their care to those services (Pollock et al: 2007). The survey feedback provided by carers for this evaluation has reinforced the accuracy of these findings, and the DDR model has been rated by them as achieving the key requirements of flexibility and quality care and support.

The survey of carers sought a rating from ‘1’(most negative) to ‘5’ (most positive) about a number of features of the DDR service. The 297 carers in the sample indicated that the service was meeting their needs, however, their ratings – while high – were slightly lower than those of Care Workers and Coordinators/Managers on most dimensions. The table below summarises what carers were seeking from the DDR service, and how well it was rated by them in achieving these goals.

Carers’ reasons for using the DDR service against average ratings applied by carers

Reason

DDR capacity to meet this need (Average rating)

To provide the care recipient with an opportunity to socialise more*
4.5
To give the carer 'time out' / a break*
4.4
To give the carer time for their other responsibilities
To provide the care recipient with an opportunity to participate in activities that help with their condition*
4.3
To delay the need to place the care recipient in full time care*
4.1
The carer's own health issues – positive impact of service on carer health and well-being*
3.9
Positive impact of service on carer mental health/stress management*
4.3

*Carers’ ratings on these dimensions were significantly lower (p<.05) than those applied by care workers and care coordinators, indicating that staff and managers hold a more positive view of the DDR Pilot that needs to be ‘reality checked’ against carer perceptions.


Against these very positive findings, there are a relatively small number of service provision features that were rated significantly less positively by carers. These relate to the DDR service’s capacity to –
    • Improve their own health and well being (3.9)
    • Improve the physical functioning (3.8) and cognitive functioning (3.7) of care recipients
    • Reduce carer anxiety about the care recipient needing to enter full time residential care (3.8)
    • Link carers to services that they would not otherwise have known about (3.7).

Diversity and specialisation in applying the DDR model

There is significant diversity across the sites in the application of the model, indicating that a range of carer needs is being met, and that the model has the capacity to be applied to a range of settings and diverse needs. The evaluation has identified diversity in relation to:
  • The level of integration with the residential care service, ranging from full integration to quite distinct services which do not ‘cross over’ with the residential service, and from complete physical separation to complete integration.
  • The range of services offered – including the balance of on- and off-site activities, and the way in which transport is provided (which is highly flexible being adapted to local conditions and user needs).
  • Service intensity, including operating hours and the number of carers assisted. Also, the number of days of service available to individuals ranges from occasionally to fortnightly, weekly or daily, and sometimes includes weekend provision.
  • Focus of the service – for example, some sites offer a traditional ‘drop off’ respite program, while others have adopted more innovative approaches including on-site carer programs some of which involve the care recipient simultaneously, carer health and well being programs and a one stop shop providing seamless linkage to a range of services, including primary health care. Some provide culturally specific and holistic services tailored to local need (particularly evident in Indigenous specific services located in remote areas, the So Wai service for Chinese people and the Stepping Out service for Jewish people). Refer to Accompanying Report 3 (Case Studies) and Accompanying Reports 7 and 8 (Site Data Analysis).

Innovation in the DDR model

Evaluation feedback from the surveys and case studies indicates that the DDR model is supporting innovation in day respite provision. In part this stems from co-location with residential care services which is requiring both day respite and residential care staff to think and operate outside of their usual paradigms. In addition, the Pilot has encouraged services to trial different approaches to providing day respite and approaches that place the carer and care recipient at the centre of service delivery.
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Across all projects, site data analysis identified that approximately 30% of total activity hours per week were shared with residential care recipients. All projects gave day respite clients access to some type of additional service provided by the RACF and these represent value-add services that would not normally be accessible in community-delivered day respite care.

Sharing of resources between the RACF’s other programs and the day respite services was also evident in relation to staffing. Site Data show that many DDR staff members were also employed part time by other areas of their organisation. Almost half (49%) of all DDR staff also worked in their RACF’s Residential care service but this practice varied greatly across project sites. This means that DDR and RACF staff are being exposed to a wider than normal range of work experience, which can be seen as beneficial for them and therefore, for their clients. (This was also the view of staff surveyed by the evaluators in our surveys of care workers, care coordinators and service directors.)

Impact on use of residential respite services

Guiding Evaluation Question

What has been the impact of accessing DDR services on the care recipient’s use of residential respite, including the extent to which the receipt of day respite either discourages or facilitates use of residential respite?

The DDR model is seen as enabling carers’ access to overnight or residential respite and providing a seamless link between day and residential respite services. Site Data Analysis identified a total of 1,004 nights of residential respite used by carers during July to December 2009 (the six month period studied in detail as part of the first Site Data Collection), at an average of 2.0 nights per care recipient. Case study findings indicated a trend for access to residential respite to be enhanced.
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Impact on entry to residential care

Guiding Evaluation Question

What has been the impact of accessing DDR services on the care recipient’s entry to permanent residential care, including the extent to which the receipt of day respite either delays or facilitates appropriate entry into full-time residential care?

A concern that has been expressed by some is that locating day respite services in a RACF could work against the objective of keeping care recipients in the community for as long as possible. Apart from the fact that this overlooks the gate-keeping role played by Aged Care Assessment Teams, the evaluation evidence does not support this concern.

In their comprehensive review of the literature, Mason et al (2007) found no widespread reliable evidence that respite (regardless of setting) can delay entry to residential care. This is due largely to the difficulty of separating the impact of other factors (DoHA: 2002), including the care recipient’s own need for care, the carer’s capacity to manage, and the confounding effect of the existence of other services being provided at the same time as respite, making it difficult to isolate the specific effect of respite care on delayed entry to residential aged care (Keefe & Manning, 2005: 10).

However, more recent pathway analysis by the Australian Institute of Health and Welfare (2006: 1, 12) has found that the use of community care services by residential care clients appears to delay entry into permanent residential care. Their study found that although a ‘substantial proportion’ of people using residential respite care enter permanent residential care, the use of the residential respite was not a ‘necessary precursor’ into permanent residential care.

Combining Site Data and SARs data with perceptions of stakeholders from surveys of carers, care workers, care coordinators and service directors and our case studies with selected sites, it would appear that the use of day respite services can delay entry into full time residential care and can facilitate that transition when it is needed. The stakeholders clearly indicated that the DDR service enabled carers to continue in their caring role, allowing the care recipient to remain in the community and thereby delaying entry to residential care. The Site Data demonstrated the significant levels of need of care recipients, and therefore the need for significant levels of support and assistance to carers to enable them to continue to provide care at home. According to the both the Site Data and the SARs, around half of the care recipients leaving the DDR service entered some form of full time residential care, with three quarters of those entering high level care. It therefore seems reasonable to conclude that DDR services may have assisted in delaying entry to full time residential care until care recipient needs become quite high.
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However, without data on the pathways of carers who did not use the DDR service, and without formal assessments of individual change over time (such as an ACAT assessment provided on entry to the DDR service and upon exit from the service), it is difficult to draw direct causal links regarding the effect of the DDR service on entry to permanent residential care.

The evaluators will be conducting a separate client pathway analysis as a supplement to this evaluation, and it is expected that this will provide additional information about the carer and care recipient journey and the role played by day respite services.

A key mechanism for the transition from community to residential care has been the residential and overnight respite services offered to day respite clients, which carers and care workers report as having demystified residential care. This, combined with the sharing of some services between day respite and residential clients, can be seen as likely to have reduced the fear of entering residential care for many carers and care recipients. Survey findings (see Accompanying Report 4) confirm this finding.
      ‘Carers and care recipients become more receptive to nursing home care. The day respite centre is co-located with the nursing home. Carers visit the nursing home frequently and understand the nursing care services much better, thus removing the stigma and concern related to the service.’ (care coordinator)

Challenges associated with implementing the DDR model

The two most commonly identified challenges related to countering stigmatisation associated with residential care provision and ensuring that this did not deter potential consumers, and managing the (initially) negative reactions by some RACF staff to the day respite service.

Apart from the combined positive impact of time, increasing knowledge and understanding of the day respite service and its associated model and seeing the benefits that can arise from co-location, it is clear that the management of the DDR service’s implementation and integration into RACF programs is crucial. Preparing staff and developing specific processes for communication and coordination of staff have emerged from interviews and open-ended feedback as important strategies for smoothing the integration process.

Stigma

Feedback from carers surveyed for the evaluation shows that some were initially deterred and that some of these continued to be uncomfortable with the setting for the day respite service. However, most could see advantages associated with the co-location, including the provision of a wider range of activities for care recipients, familiarisation and therefore greater access to residential respite services, and reduced anxiety about the person in their care entering long term residential services should this be needed. Refer to Accompanying Report 4 which details these survey findings.
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It was common for DDR staff at the sites case-studied to report that the stigma held by many service users about residential aged care, while initially acting as a deterrent for some to access the day respite service, was reduced through familiarisation when using the day respite service. This was seen by some as making residential care a choice when once it would not have been considered.

It was also evident that the issue of stigmatisation was less apparent when the service was culturally-specific or Indigenous-specific, and regarded by the target community as a trusted and culturally-relevant form of support – regardless of co-location in a RACF. Further information can be obtained in Accompanying Report 3 which provides case study detail.

Synergies generated by the DDR model

DDR providers reported significant economies of scale due to sharing and consolidating resources with their auspicing RACF. These can be seen as beneficial for both residents and day respite users, and as bringing benefits to the RACF that range from the tangible (sharing of staff resources, staff training, equipment, purchasing of goods and stores, meals preparation, laundry services, transport services) to the intangible (raised profile in the local community, increased staff experience across programs).

At the same time, RACFs were found to be providing an unfunded contribution in terms of staff time (FTE) that equated to an average of 1.1 full time staff members per project (see the first Site Data Report, Accompanying Report 7.) In terms of time, most of this contribution came from Care/support workers, Domestic staff and Managers. The final Site Data Analysis for the year 2010 found that unfunded contributions had continued to be a feature of the service model – see Accompanying Report 8.

Findings relating to the Appropriateness of the DDR model

Guiding Evaluation Question

To what extent has the model of respite care supported home-based care, the caring relationship and the well-being of the carer and the care recipient?

Appropriateness relates to a program’s suitability in terms of achieving its desired effect and being used by its intended participants.
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Administrative and Program Guidelines for the National Respite for Carers Program (2004) identify a number of target groups of which the following are relevant to the DDR initiative –
    • people with dementia;
    • people with dementia and challenging behaviour;
    • frail older Australians (65 years or over, or 50 and over if Indigenous).
Consistent with the original intention of the day respite program, according to the SARs almost all of the care recipients attending the program over the past two years were aged over 65 (or over 50 if from an Aboriginal or Torres Strait Islander background). In terms of health and functioning, over half of all care recipients had dementia, around a quarter had dementia with challenging behaviours, and around a quarter had a disability. The characteristics of the carers and care recipients attending the program in 2008/09 and 2009/10 are summarised in Tables 14 and 16 of SAR Report Accompanying Report 9. The results show that –
    • The proportion of care recipients from Aboriginal and/or Torres Strait Islander backgrounds had remained constant at around 3 to 4% of all carers and care recipients.
    • Approximately one in five care recipients were from culturally and linguistically diverse (CALD) backgrounds.
    • Those with dementia represented around 57% of all care recipients, while those with dementia and challenging behaviour represented around 23% of all care recipients.
    • The proportion of care recipients with a disability had increased slightly from 23.2% in 2008/09 to27.7% in 2009/10.
    • The proportion of carers using the service who were living in rural locations appeared to increase slightly from 15.1% in 2008/09 to 21.6% in 2009/10, due to the increased service delivery of some of the rural-based DDR projects. However the number of carers living in remote locations dropped slightly from 5.5% in 2008/09 to 3.0% in 2009/10.
    • The proportion of carers from financially or socially disadvantaged backgrounds remained steady at 24.5%.
    • Employed carer numbers reduced slightly from 1 in 3 carers (33.3%) in 2008/09 to 27.5% of carers in 2009/10.
More detailed information on the health and functioning of care recipients was collected in the first round of our Site Data Collection (refer to Accompanying Report 7). That report illustrates that, at assessment –
    • the General health status of nearly half (48.2%) of all care recipients was Fair,
    • the Level of care required was assessed as High for 45.1% of care recipients,
    • the Priority level for entry to the day respite service was assessed as High for nearly half (49.0%) of the care recipients, and
    • Special care needs were reported for 67.6% of the 896 care recipients, of which the most common special care need was Dementia (27.2% of all care recipients).
The Final Site Data Collection identified a change in the profile of carers and recipients by 12 of the 31 sites (38.7%) that included a trend in 2010 towards increasing high care needs and clients from diverse cultural and linguistic backgrounds. Some sites also noted an increase in the number of carers presenting with stress or health issues – see Accompanying Report 8.

The evaluators note that almost half of all projects reported High-level care needs (i.e. requiring two staff) as a reason for ineligibility or exclusion of applicants. The second most frequently cited reason for ineligibility or exclusion, reported by more than a third of projects, was high-level challenging behaviours, that is, abusive, intrusive or inappropriate behaviours – see the Site Data Reports. This is a concern as this is one of the NRCP’s key target groups and the burden for their carers is significant.

According to the both the Site Data and the SARs, around half of the care recipients leaving the DDR service entered some form of full time residential care, with three quarters of those entering high level care. It therefore seems reasonable to conclude that DDR services may have assisted in delaying entry to full time residential care until care recipient needs become quite high.

However, despite the number of people excluded because of their level or complexity of need, Site Data and SAR data regarding the destination of those exiting the DDR service indicate that over 60% of DDR care recipients had significant levels of need, with exit occurring due to acceptance into full-time residential care or due to death. Level of need is further reflected in the proportion who were admitted to high level residential care – three quarters of all clients entering full time residential care.
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It is important to note that assessment practices and care recipient characteristics may vary greatly between DDR projects as there is an absence of uniform, nationally consistent assessment (such as would be provided by an ACAT) informing the overall client profile. The evaluators believe that a nationally consistent and recognised assessment process, as is provided by ACAT services, should be required to achieve entry to DDR services. Standardised assessment would allow more reliable quantification of the characteristics of carers, and promote a better understanding the impact of DDR services on entry to permanent residential care.

The surveys of Carers, Care Workers and Coordinators/Managers contained common questions about the features of the day respite service model and its appropriateness. Specifically, they were asked to rate their day respite service on these eight key features –
  • its flexibility in adapting to their needs, and to the needs of care recipients,
  • the appropriateness of the service for the needs of carers and care recipients,
  • the quality of the care and support provided to carers and care recipients,
  • the provision of a safe environment for care recipients,
  • the degree to which sufficient staff were being employed.
Comparative analysis showed that there were strong levels of agreement (expressed in average ratings of 4.4 to 4.7, where the lowest possible rating was 1 and the highest possible rating was 5) that all but one of these features was being achieved. The only exception to this trend related to the lowest rating given by all three groups regarding the appropriateness of care worker to service user ratios. Given the survey has identified from staff that individualised care, rated as a key success factor for day respite, is dependent on an appropriate care worker to care recipient ratio this can be interpreted as an area of concern.

Carers surveyed have provided positive ratings of the quality of day respite services they received. However, their ratings while high (average 4.6) were slightly lower than those of care workers and care coordinators (average 4.7) in assessing the quality of care provided to care recipients. They were significantly less positive (p<.05) in rating the quality of support offered to carers (4.4 as opposed to 4.6). This then is an area in which DDR services can seek improvement.
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Managing cultural diversity

Although carers surveyed gave very positive ratings (average 4.6) about their DDR service’s ability to meet their language and cultural needs, day respite staff in culturally generic DDR services were much less positive in rating their services’ capacity to provide culturally appropriate services for Indigenous and for CALD background people, and for providing sufficient training and development opportunities to care workers. These findings suggest areas for potential improvement by services not offering a program with a specific cultural focus. The evaluators understand the pressures faced by day respite services in stretching finite resources, but note that investment in cross cultural awareness raising and the management of cultural diversity (for those services that are not culturally-specific) brings expertise that has generic relevance in service delivery - for example, an enhanced capacity to individualise care according to specific need.
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Referrals

Of the 308 new referrals received by day respite projects during the period July-December 2009, only 23 (7.5%) did not meet the eligibility criteria for the project to which they applied – indicating that the projects had been promoted effectively and referral sources had been informed accurately. The final Site Data Collection in 2010 found that targeted promotion by DDR sites was thought to have led to increased awareness among local health care providers and increased word-of-mouth based information about the DDR services in the local community.

Almost half of all projects reported being unable to offer respite involving care recipients with high-level care needs (i.e. requiring two staff), and more than a third of projects were unable to offer respite for care recipients with high-level challenging behaviours, that is, abusive, intrusive or inappropriate behaviours – see the Site Data Reports. Given the impact of these behaviours on carers, and their intensified need for respite and support, it is of concern that so many DDR projects are excluding people with such complex needs. Reasons given for the inability to accommodate such clients included – insufficient staff resources (i.e. unable to provide the one-on-one support required), lack of staff with skills to manage challenging behaviours, and inappropriate physical infrastructure such as the lack of a secure facility.

All projects cited community programs or services as a source of referrals, indicating that this is probably the primary referral source for the day respite program as a whole. Most projects also received referrals from health professionals other than GPs and self-referrals from Carers. Hospitals were the fourth most common source of referrals, followed by an aged care facility and GPs. Interestingly, Commonwealth Carer Respite and Carelink Centres were identified by relatively few sites, despite playing a key role in linking carers to respite and other support services. This may be due to residential care staff being unaware of these services (which would be more familiar to those in the community aged care sector), or the Carer Respite and Carelink Centres not being aware of the DDR services, or both. A reconciliation was undertaken with the Commonwealth Respite and Carelink Centres database and this showed that 11 of the DDR projects were not recorded on the service directory data base2.

Assessments, Care Plans and Reviews

Analysis of detailed Site Data for the period July-December 2009 (see Accompanying Report 7) showed that the median time between referral and the completion of the assessment process was 7.0 days, with 15.2% of care recipients assessed on the same day that they were referred. Changes to assessment processes had occurred during 2010 at less a third of the sites, and these changes had mostly involved undertaking a more detailed assessment of the care recipient in relation to their health and medical status, behavioural profile, social needs and activity preferences. Some sites reported making changes that involved an increased focus on the needs of the carer, for example, their goals for respite and providing additional information about available services and resources at the time of assessment - refer to Accompanying Report 8 for further details.

According to the Site Data for July-December 2009, a Care Plan had been prepared for 92% of clients. Of those who did not appear to have a care plan, the majority had only recently been referred to the service and had not yet received any respite. However, around 3% of care recipients spread across seven projects appeared to be without a care plan despite having received at least one day respite service.
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Three quarters (74.5%) of care recipients had their first care plan prepared on or before the date of their first service, whereas one quarter had begun attending the service before a care plan had been prepared. The latter may in fact be an effective approach in cases where observation of the care recipient in the day respite context would assist in the development of their care plan, assuming that any risk factors had already been identified during the initial assessment process.

Around two thirds of care recipients with care plans had had those care plans reviewed at some time during their involvement with the day respite service. It appears that reviewing care plans every 3 months or so is a common practice, with 89% of care plans being reviewed within three months of the client’s most recent service.

Final Site Data Analysis identified changes to care planning processes at around half of the sites, mainly involving a broadening of the scope of Care Plans to provide a more comprehensive view of both carer and care recipient goals and needs – see Accompanying Report 8.

Staffing

According to Site Data submitted regarding the staffing of the DDR services, the total FTE for most projects was split across many individual staff members which indicates that the majority of day respite staff were not employed full-time. Total FTE at each site ranged from 1.2 FTE at Stepping Out to 11.4 FTE at Garden City – with these two extremes corresponding to their operating hours.

Across all projects, for every FTE day respite staff member (regardless of role) there were on average 7.7 day respite places used per week. In terms of staff providing direct care to care recipients, there was on average one direct care staff member per 12 places.

However, within this range there was substantial variation in the ratio of FTE staff to the number of respite places used per week, perhaps reflecting operational characteristics such as the specialist focus of each service. For example, a service such as Garden City, which specialises in frail elderly care recipients with dementia, operated with only 3.7 care recipient places per direct care staff member, whereas a service specialising in younger clients such as Bethavon was able to operate with 23.3 care recipient places per staff member.

Sharing of staff

Sharing of resources between the RACF’s other programs and the day respite services was evident in relation to staffing. Site Data show that many day respite staff members were also employed part time by other areas of their organisation. Almost half (49%) of all day respite staff also worked in their RACF’s Residential care service.
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This means that staff are being exposed to a wider than normal range of work experience, which can be seen as beneficial for them and therefore, for their clients. (This was also the view of staff surveyed by the evaluators in our surveys of carers, care workers, care coordinators and service directors.)

This practice varied greatly between project sites, from services where all day respite staff worked also in residential care through to projects where none of the day respite staff worked in residential care.

Days and Hours of operation

Across the sites significant diversity was evident in operating days and hours (as reported in the first Site Data Collection, with respect to the end of 2009), from smaller services with few operating days and relatively short operating hours such as Stepping Out in Melbourne (open for 8 hours per day on two weekdays only), through to large services such as Garden City in Brisbane which operates 7 days per week for 13 hours per day. Twelve projects reported that they were operating on exactly the same days/hours of which they were funded, whereas the actual operating hours of the other projects varied from their funded operating hours in a number of different ways, indicating that demand levels had not been accurately forecast.

DDR services were being provided on weekends3
    • On both weekend days at 7 sites
    • On one weekend day at 10 sites
    • Not at all at 12 sites.
The final Site Data Collection showed that the majority of sites (74.2%) had not changed their operating days or hours during 2010, and of those who did report change, all but one had increased their hours or days in response to changing client needs.

Although carers have been very positive in their ratings of DDR services, where unmet need was expressed through open-ended feedback, the most commonly cited area of unmet need related to accessibility outside of normal working hours. While the evaluators realise that service providers face challenges in providing these hours if demand is not sufficient to achieve viability, the impact on those carers needing this support is substantial.

Activities provided

DDR services are offering the range of activities to be expected in a day respite program (e.g. arts and crafts, games, music, physical activities), with some going beyond this to offer significantly different activities.
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The initial Site Data analysis showed that over three quarters of the time spent in day respite across all projects involved some kind of activity, with the three activities involving the most time being games, exercise/physical activity and arts and crafts. Not surprisingly, the proportion of time spent engaged in organised activities varied greatly across projects, depending on specialist focus. The service model has the capacity to provide a wider range of activities for care recipients relative to most day respite services and is beneficial for RACF residents because of their ability to participate in day respite activities.

The final Site Data Collection found that 71% of sites reported changes in 2010 to the types of activities offered to care recipients, with many identifying a broadening of activities. Some sites had also focused on developing activity menus that were more appropriate for particular groups of clients while others had designed activities to increase care recipients’ engagement with the local community.

Additional services

Survey feedback from carers and care providers indicates that more activities than would otherwise be available in a day respite service are being provided, drawing on the programs and resources of the RACF, and the specialist focus of some DDR sites (eg healthy ageing). Site Data analysis shows that all projects gave day respite clients access to some type of additional service provided by the RACF. These involved –
    • nursing services and referral to other RACF health and support services (93.1% of sites)
    • use of residential respite (89.7% of sites)
    • allied health services (82.8% of sites)
    • health monitoring (75.9% of sites)
    • hygiene services (72.4% of sites)
    • medical services (51.7% of sites).
These represent value-add services that would not normally be accessible in community-delivered day respite care.

In 2010 thirteen of the 31 sites reported changing the range of services offered. Changes focused on carers included an increase in carer education and referral services, a streamlining of respite booking systems, the introduction of overnight respite and the provision of personal care services. New services for care recipients offered by some sites included occupational therapy, art therapy and music therapy.
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Transport

The research literature is clear in finding that transport plays a key role in making day respite services accessible. For some carers, the time required to transport the person in their care to and from day respite may add to their burden and provide a disincentive to participate. Findings from the evaluation surveys and case studies reinforce the predominant literature view, confirming that transport is a critical success factor for the DDR service model.

According to the most recent Site Data Collection (2010), only three projects do not currently offer any type of transport to their care recipients. It was evident from the different approaches to transport that services are tailoring their transport to user need, and to local conditions.
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Transport costs tended to be subsidised by the day respite service to minimise any financial burden on clients. Site Data collected for the period July-December 2009 showed that almost half of all projects which offered transport reported that this was free for all clients, while two projects sought donations for transport and the remainder charged a set fee. Fees charged for both-way transport ranged from $2 to $8, with the average fee being $4.77. Fees for one-way transport ranged from $2 to $5, with an average fee of $2.80.

It was evident from the Surveys and the Site Data Collections (see Accompanying Reports 4, 7 and 8) that services are tailoring their transport provision to user need, and to local conditions. Transport costs tended to be subsidised by the day respite service to minimise any financial burden on clients, however some sites have experienced difficulty in meeting the demand for transport.

Final Site Data Analysis found that during 2010, a third of sites reported a change in their transport service that in most cases involved additional servicing in response to increased demand. Sites also indicated that meeting transport demand is an ongoing challenge. Only two sites reported a change in transport fees during 2010, while all other sites that charged a fee had kept these fees at the same level – see Accompanying Report 8.

Accessibility of DDR services

Findings from the analysis of site data and SAR reports, and from surveys with carers, care workers, care coordinators and service managers, indicate that DDR services are paying attention to accessibility issues on a number of issues.
Services are financially accessible, with user financial means being taken into account and a low level of fee being charged for day respite services, including for transport.
  • The provision of transport by almost all services has been a critical success factor in enabling carers to support the person in their care participating in DDR services. The means-tested cost of transport services reinforces their accessibility.
  • Location has also been addressed with the higher than normal representation in inner regional, remote and very remote areas. The barriers faced by carers living in such locations will have been reduced or removed by this strategic placement of DDR services.
  • The outcomes from the perspective of cultural accessibility are mixed. A number of services are either Indigenous-specific or culture-specific, and for these communities, DDR services are extremely accessible. However, survey feedback indicates that for culturally generic services, staff training and experience in working inclusively with people from Indigenous backgrounds, or from culturally and linguistically diverse (CALD) backgrounds, will need further development.
  • Accessibility for carers of people with dementia appears to have been addressed by the many DDR services identifying this as a specific focus, and by some specialising in these services. However, the existence of challenging behaviours has been identified as a reason for exclusion and from this perspective, DDR services can be considered to be largely inaccessible.
  • Employed carers are a special need group and few DDR services offer specialist services for them. A major need will be hours of operation that support carers’ employment. Hours of opening varied significantly across projects so it is difficult to draw a conclusion about their accessibility on this dimension. However, a relatively small proportion of carers are dissatisfied with DDR services’ hours of opening.
  • The RACF location of DDR services can be a barrier for some carers and care recipients. However, in most cases this has acted as an initial deterrent only, and in reducing fears about residential care, has provided a bridge that smooths entry to permanent care if and when this becomes necessary.
  • Finally, DDR services should link carers to a range of other services, and this appears to be an area requiring further investment, including linkage to Commonwealth Carer Resource Centres and Carelink. Without this linkage, DDR carers may be missing access to a range of community based respite services and support. However, the final Site Data Analysis findings showed that during 2010 some sites had actively fostered greater linkage with these Centres – see Accompanying Report 8.

Complaints about DDR services

All Care Coordinators and Service Directors who responded to our survey indicated that there was a formal complaints mechanism in place for their DDR service, as would be expected and the majority of RACFs indicated that no formal complaints had been made to date.
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Thirteen carers (4.4% of those surveyed) reported that they had felt the need to make a complaint about their DDR service, only four of whom stated that the process for making a complaint was made clear to them. These carers came from eleven different sites, and related to –
  • Reduced resourcing as the program has increased its numbers
  • Resourcing that restricts services, particularly, transport and the range of activities available
  • Failure to maintain continuity of care workers
  • Billing processes
  • Failure to provide after hours’ access
  • Poor quality of care.
These findings are consistent with those arising from the analysis of SAR data. The evaluators analysed four items from the complaints section of the SAR which are not normally entered into the Department’s spreadsheet, extracting information from the paper forms for 2008/09 and 2009/10. This showed that:
  • In 2008/09 there were 42 complaints recorded, 28 (66.7%) of which related to systemic issues. Of these, 16 (57.1%) were resolved.
  • In 2009/10 there were 41 complaints recorded, 19 (46.3%) of which related to systemic issues (a reduction from the previous 12 months). Of these, 10 (52.6%) were resolved.
  • Overall, in terms of the number of carers and care recipients involved with the program, the number of complaints is quite low – equivalent to less than 3 complaints per 100 carers/care recipients who used DDR services.
The complaints most commonly reported by the projects involved:
  • Transport issues;
  • Lack of availability of weekend or overnight respite, or limited availability of respite for care recipients with high care needs;
  • Meals;
  • Facilities (e.g. parking, toilet facilities, telephone system, entrance); and
  • Fees.
The information provided by the projects indicated that almost all of the complaints made regarding transport, meals, facilities and fees had been resolved, commonly through changing the underlying procedures, processes, equipment or physical environs involved. The area where it was most difficult for the projects to effect change involved requests for respite at particular times of the day or week, and for particular types of care recipient such as those with high care needs. However a number of projects did respond to those requests by changing their hours of operation and/or staffing.

Findings relating to the Effectiveness of the DDR model

Guiding Evaluation Question

What have been the benefits to carer and care recipients accessing DDR services?

Effectiveness concerns the extent to which the program’s objectives are being achieved, or are expected to be achieved, and the benefits for its participants.
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Respite-related benefits and outcomes

Carers have provided very high survey ratings (out of a maximum 5 points) for the following benefits of DDR services –
  • Provision of a break or ‘time out’ (average rating 4.4)
  • Provision of time for carers to fulfil other responsibilities (4.4)
  • Provision of increased socialisation opportunities for care recipients (4.5)
  • Provision of opportunities for care recipients to participate in activities helpful to their condition (4.5)
  • Delaying of the need to place the care recipient in full time care (4.1).
And to a lesser extent -
  • Provision of more time for carers to work (3.8).
Open-ended feedback from carers further supports these ratings.
      ‘Without the help I received, I wouldn't have been able to carry on.’
‘It is something that is needed for carers as you know that they are safe and in good hands and you get a chance to do a lot of things that take a fair bit of time.’

Health and wellbeing related benefits and outcomes

The survey profile of DDR carer health and wellbeing highlights the importance of day respite services being able to deliver health-related benefits for carers. From the carer perspective, their participation in the program has -
  • reduced their stress (4.3)
  • reduced worrying about care recipient (4.3)
  • had a positive impact on their mental health (4.3)
  • provided more time to address own health issues (4.1)
And to a lesser extent -
  • improved their health and wellbeing (3.9).
Survey feedback from care workers and care coordinators supports these findings. Care workers and care coordinators also rate highly the program’s –
  • provision of effective ongoing support to carers (4.5 and 4.6 respectively).
      ‘It has reduced the stress I was feeling immensely and given me a greatly needed break. I can relax knowing Mum is in good care and having a good time. (carer)

Service access and usage benefits and outcomes

A potential benefit of the DDR service model lies in the capacity to make carers more aware of, and more linked to other services that can support them, or the person in their care. Carers were less positive than the two groups of service provider stakeholders in rating the program on its service access and usage related benefits. However, their survey ratings confirm the DDR services’ provision of these benefits -
  • Made carers more aware and informed about residential aged care (4.1)
  • Made carers more aware of other services for them or for care recipients (4.1)
  • Made carers more confident about using respite in a residential setting (4.2)
  • Made it easier for carers to access other services for them or for care recipients (4.0)
And to a lesser extent –
  • Linked carers to other services for them or for care recipients (3.7).
As linkage to other services is a key requirement of NRCP funding, this is an area requiring attention. In particular, a close collaboration between DDR services and the network of regional Commonwealth Carer Respite Centres is required. This will link carers to emergency or unplanned short-term respite access, ensuring their access to a range of respite services to meet changing or diverse needs.
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Care workers and coordinators also identify the benefit of –
  • making it easier for carers to access respite services offered elsewhere (4.3).

Benefits and outcomes for care recipients

Extensive literature reviews have found no reliable experimental evidence that respite care provides significant short or long term benefits to care recipients (Arksey et al, 2004) or that it adversely affects them (Mason et al, 2007), regardless of respite care model – see Accompanying Report 1 for further details. Nevertheless, Carers, Care Workers and Care Coordinators surveyed for the evaluation have identified benefits relating to the DDR services’ social impact on care recipients, but less so in relation to improving physical or cognitive functioning.

Carers have given very positive ratings to the achievement of –
  • The opportunity for increased socialisation (average rating 4.5)
  • The opportunity to participate in activities (4.3)
  • Improved social functioning of care recipients (4.1)
  • Delaying the need for care recipients to enter full time residential care (4.1).
      ‘Activities have been so beneficial. Within a couple of weeks of attending my mum is a lot happier, eating properly and giving her something to talk about. Been Brilliant.’

Benefits and outcomes for RACF residents

Benefits have been identified for RACF residents, which is a less expected finding. Unintended positive effects of the program identified by care workers, care coordinators and service directors cited benefits for residents that include –
  • A wider range of activities to access and
  • Increased socialisation opportunities through their interaction with DDR care recipients.
The positive impact of new infrastructure and related resources will also be benefitting residents in some facilities, and less directly, residents can be expected to benefit from the increased learning and training opportunities available to staff.
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Unintended positive outcomes

Guiding Evaluation Question

What have been the unintended effects of the Initiative, including any adverse consequences for carer/recipient?

Across all four stakeholder groups surveyed there was a pronounced trend to identify significantly more positive than negative unexpected outcomes. These involve six types of benefit –
  • Improvements in the care recipient’s condition (identified by all four stakeholder groups)
  • Improvements for carers - more informed about aged care services, making new friends, becoming less socially isolated, less stressed, having more time, able to be in paid work, improved confidence to use respite services (identified by all four stakeholder groups)
  • Facilitation of the transition from community care to residential care when this is needed, in part due to demystifying the residential care environment (identified by all four stakeholder groups)
  • Benefits for the RACF – improved service networking and profile with other services, enhanced public image through reduced stigmatization of residential provision, cross-fertilisation of resources; enhanced physical infrastructure, staff have wider range of training etc (all three service provider groups)
  • Benefits for residents – wider range of activities to access, wider socialisation opportunities through interaction with DDR service (all three service provider groups)
  • Flexibility and quality of services provided; receiving services not expected eg health monitoring (identified by carers only).

Unintended negative outcomes

The following unexpected negative effects were identified by one stakeholder group each – either carers, or care workers.
  • Dissatisfaction with fees charged or inefficient billing processes (carers only)
  • Dissatisfaction with the standard of care provided (carers only)
  • Anxiety about relinquishing care during the respite period (carers only)
  • Initially negative behavior by RACF community care staff due to lack of understanding of DDR service and its relationship to RACF community services (care workers only)
  • Difficulties arising from co-location with a RACF, in particular, possible cross-infection risks (care workers only)
  • Challenges associated with providing individualised and quality care for consumers with high or complex need (care workers only).
It can be seen that carers’ unexpected negative effects of the DDR service were quite different from those of care providing staff and managers, with the exception of concerns about resourcing.
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Rating the overall effectiveness and impact of DDR services

All four stakeholder groups surveyed were asked to provide overall ratings for the (a) effectiveness and (b) impact of the program and these were remarkably consistent across all four groups surveyed indicating strong and positively directed agreement about the Program outcomes for both carers and care recipients.

However, Carers have been consistently less positive in comparison to staff and managers, in line with the findings of other comparative analyses undertaken for the evaluation. They have provided average ratings of 4.5 for both the effectiveness and impact of DDR services. While these are very positive, those of Care Workers are slightly higher (4.5 and 4.6), those of Care Coordinators are higher again (4.6 and 4.7) and those of Service Directors are the highest (4.6 and 4.8). Carers’ ratings of the effectiveness and impact of DDR services also varied significantly across sites – as the Figure below demonstrates.

Comparative ratings of effectiveness and impact of DDR services on carers and care recipients
image showing Comparative ratings of effectiveness and impact of DDR services on carers and care recipients

Impact of providing DDR services on participating RACFs

Guiding Evaluation Question

What have been the effects of providing DDR services on the operations of residential aged care facilities in providing care to full time residents?

The provision of DDR funded day respite services has had a number of impacts on participating RACFs, and in large part, these have been positive in nature. The four key impacts identified concern -
  1. Physical infrastructure - improvements to the physical infrastructure funded by the day respite service, either in developing new buildings or renovating existing buildings, have been of benefit to the organisation as a whole. These offer new opportunities for service delivery while being critical to the effectiveness of the DDR service.
  2. Staffing - the impact of the DDR Initiative on the staff of participating RACFs has been mixed but in the longer term brings benefits for most (depending on how effectively the integration of the day respite service is managed and staff are supported in this process). The sharing of staff between the respite and residential services was often reported as leading to healthy cross-fertilisation and exchange of ideas across program areas. It also means that staff are being exposed to a wider than normal range of work experience and service users and able to benefit from broader learning opportunities (for example, through shared training programs). This can be seen as beneficial for them and therefore, for their clients.
  3. Resource usage – it was common for day respite service providers to report significant economies of scale due to sharing and consolidating resources with their auspicing RACF. Such vertical integration is described as bringing financial benefits from resource sharing, and service delivery benefits arising from shared staffing, rostering and training arrangements and the development of common social and recreational programs. This was usually regarded as adding value – for both the RACF and the day respite service and clients of both programs.
  4. Service networks – as discussed, the impact on RACF service networks was variable, and would have been influenced by pre-existing service provision range and therefore, networks with other providers. Impact appears to have varied according to the work role of staff and managers.
In addition, DDR services have been found to bring benefits for RACF residents through increased socialisation and access to a wider range of activities – as discussed earlier.
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Some case study sites, and some of those surveyed, reported initial resistance by RACF staff to the presence of the day respite service, particularly when co-location and sharing of resources was involved. However, over time, and as communication and other processes were streamlined, there was also a trend for increasing acceptance. Many sites reported a smooth transition from implementation of the day respite service to ongoing collaboration between RACF and respite staff.

Findings relating to the Efficiency of the DDR model

Efficiency is concerned with how economically resources have been utilised, and how inputs (funds, expertise, time, etc.) are converted to results or outputs. The evaluation has collected information about staffing levels and usage (both DDR funded and unfunded) and staff : client ratios, as key input factors and taken as results quantifiable information about hours and days of respite received, management of demand levels, carer satisfaction with outcomes and whether or not projects are in deficit or surplus. In addition, evidence of economies of scale and value-adding have been identified as an indicator of effective and efficient use of resources.

However, it should also be noted that is difficult to determine precisely the cost effectiveness of the DDR Initiative as a whole as there are a range of variables to take into account. Relevant variables include location (the more remote the higher many costs will be and the greater will be the difficulty of achieving economies of scale), the level of care provided, the needs of care recipients (for example, those with dementia will require significantly more support), facility size and the capacity to achieve synergies in resource usage. Furthermore, with new initiatives there will be start up costs that will reduce over time.

Inputs

The DDR services have been able to achieve economies of scale by sharing staff-related and service provision-related resources. In addition, the RACFs have benefitted from the infrastructure provided through the DDR Initiative, with service users also gaining from the enhanced service provision made possible by building design and renovation. During 2010, 42% of sites reported that they were continuing to receive additional infrastructure support to better meet the needs of high care recipients (refer to Final Site Data Analysis in Accompanying Report 8).

Sharing of staff across programs is also exposing staff to wider learning opportunities, and residents as well as care recipients can be expected to benefit from this. In addition, DDR clients are likely to benefit from the value-add of access to services available in the RACF. The two most commonly cited services were nursing services and referral to other RACF health and support services (27 sites), followed by use of residential respite (26 sites), RACF allied health services (24 sites), health monitoring (22 sites) and hygiene services (21 sites).

Across all projects, for every FTE day respite staff member (regardless of role) there were on average 7.7 day respite places used per week. In terms of staff providing direct care to care recipients, there was on average one direct care staff member per 12 places. However, within this range there was substantial variation perhaps reflecting operational characteristics such as the specialist focus of each service and the implications of that focus on staff : care recipient ratios.
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In addition, 23 projects indicated that operating their DDR service involved the use of additional unfunded staffing from the RACF. Most commonly, this involved Managers, Nursing staff, particularly RNs, and Domestic staff. In terms of time, the greatest unfunded contributions came from Care/Support Workers, Domestic staff and Managers. While this has entailed a small amount of time per week per site, when considered across the DDR program as a whole it represented the equivalent of over 30 full time staff per week (30.5 FTE) in total, an average of 1.1 full time staff member per project. This is not necessarily an efficiency indicator for individual projects, but from a program perspective is a further value-add for overall respite resource provision. The trend to receive unfunded support in the form of input from RACF staff was found to have continued during 2010, based on reporting for the final Site Data Analysis (Accompanying Report 8.)

Outputs

According to SAR data, the number of care recipients assisted by DDR services increased 14.6% from 1,246 in 2008/09 to 1,428 in 2009/10, and the number of carers using the DDR service had increased by 13.1% from 1,262 in 2008/09 to 1,427 in 2009/10 (refer to Accompanying Report 9)4. If each of those carers used the service once per week (as is the average indicated by data from the first Site Data Collection), this would mean that the original Budget estimate for the DDR Initiative quoted by the Department, which estimated that the measure would help carers of frail older people at a rate of 1,200 per week, had been met.

The total number of hours of respite delivered per annum had increased 33.8% from 252,788 hours in 2008/09 to 338,302 hours in 2009/10, partly due to ongoing growth in service delivery and partly due to delays in commencement of the service at some sites.

The number of respite hours delivered per annum per carer (i.e. the total number of hours delivered divided by total number of carers) increased from 200 hours in 2008/09 to 237 hours in 2009/10, an increase of 18.5%. This equates to an average of 3.9 hours per carer per week in 2008/09 and 4.6 hours per carer per week in 2009/10. However it should be noted that there can be a very broad range of service use patterns, with some carers using the day respite service only occasionally, others using it weekly, and others using it up to 7 days per week. Therefore a slightly different picture of the average number of hours delivered per carer will be generated when using data based on individual care recipients, as was collected for the period July-December 2009 (see Accompanying Report 7). Statistics calculated using this data showed that the average (mean) number of hours that each care recipient attended day respite during that period was just over 6 hours per week, higher than the figure based on SARs data, due to the very high usage of care recipients at some services (e.g. 7 days per week).
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Demand and unmet need

Demand for DDR services in RACFs

Guiding Evaluation Question

What have been the levels of demand for DDR services?

In reviewing demand levels, the evaluators extracted additional data from hardcopy SAR forms pertaining to the number of hours of respite funded (rather than hours actually delivered) and the reasons given by projects for any difference between the hours funded and hours actually delivered. Those data items are not normally entered into the Department’s spreadsheets. The difference between the number of funded respite hours and the number of respite hours actually delivered can be seen as a measure of unused (or over-used) capacity in a service. An indicator of unused/overused capacity was defined as the proportion of funded respite hours that were actually delivered, i.e. calculated as hours delivered as a proportion of hours funded.

For the program as a whole, the proportion of funded hours that were actually delivered rose from 38% in 2008/09 to 51% in 2009/10. This suggests that while the number of respite hours delivered increased by about a third between 2008/09 and 2009/10, it appears that around 49% of the stated capacity is still unused and therefore there is scope for substantial growth in the program (see Section 3.3 of Accompanying Report 9).

These findings are further explained by information from the Site Data Collections which indicated that in an attempt to better meet actual demand, more than half of the projects had changed their operating days/hours from those originally proposed, and that these variations had mostly continued through 2010. Reasons given indicated that demand levels had not been accurately forecast prior to opening the service. This issue was also acknowledged by many sites when giving reasons in their SARs for significant variations between their funded respite hours and the actual respite hours delivered.

It is also important to note that almost all of the individual projects, including two of the projects identified as showing the greatest underuse, did demonstrate growth between 2008/09 and 2009/10 in terms of the proportion of funded hours that they actually delivered. While many projects clearly faced unexpected challenges in establishing and running their service, it appears that over time these issues are being addressed.
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Demand is also reflected in vacancy rates (ie the average number of vacant places per week as a percentage of the average number of places offered per week, as collected in the first Site Data Collection), and waiting lists (collected by the SARs). These showed that –
  • The vacancy rate varied greatly across projects – ranging from a high of 67.0% to zero vacancies (i.e. operating at capacity). The overall vacancy rate during the period July-December 2009 was 32%, representing over 400 vacant places per week in total. Furthermore, 81% of these vacancies were mainly due to lack of demand. This information raises concerns about methods used to determine demand levels.
  • At 30 June 2009 there were only 28 carers on waiting lists for the program as a whole. By 30 June 2010 this had more than doubled to 67 carers – an increase of 139.3%. Only six projects reported a waiting list at 30 June 2009, however at 30 June 2010 ten projects had a waiting list. As the DDR services become more established it can be expected that waiting lists will increase and these rates need to be plotted over time.
It was not possible to benchmark these rates against other NRCP funded day respite services due to a lack of available comparable data.

In order to accurately assess which services had the greatest unmet need, the SAR data on waiting lists was combined with the SAR data on service capacity (see Accompanying Report 9). In 2009/10 six projects were delivering 100% or more of the respite hours for which they had been funded, and had a waiting list, indicating clear unmet need for those services. Other projects with a waiting list in 2009/10 had delivered less than 70% of their funded respite hours, which reflected situations where the particular days or times requested by carers were unavailable rather than overall lack of capacity.

For those projects where unmet need is clearly evident, should ongoing funding be sought, it would be important to identify other day respite services in or near the same location as part of the process of determining the most efficient way to meet demand.

Costs of delivering DDR services in RACFs

Guiding Evaluation Question

What have been the costs of delivering DDR services?

As the literature review indicated (see Accompanying Report 1), there is little consensus among researchers about the variables required to measure the cost-effectiveness of respite care services (Carers Australia, 2007: 20). Determining the range of variables that can be taken into account when determining the costs of respite is an inexact science, and setting the boundaries for inclusion and exclusion is difficult. Should it, for example, include the costs to government of medical care for carer stress or ill health arising from their caregiving role? Should it include the taxes lost when carers must leave the paid workforce in order to provide care? (Keefe & Manning, 2005: 8).
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It is difficult to determine the cost effectiveness of the DDR Initiative as a whole, as there are a range of variables to take into account. Relevant variables include location (the more remote the higher many costs will be and the greater will be the difficulty of achieving economies of scale), the level of care provided, the needs of care recipients (for example, those with dementia will require significantly more support), facility size and the capacity to achieve synergies in resource usage.

The cost (expenditure) per hour of respite funded, the cost per hour of respite actually delivered and the cost per carer was calculated for the Demonstration Day Respite program as a whole and for individual projects, by combining data from Service Activity Reports (SARs) with expenditure data from the Financial Accountability Reports (FARs). A summary of that information is presented below – refer to Section 5.4 of this report, and Accompanying Report 10, for further details.

The cost per hour of respite delivered for the program as a whole appears to have decreased over the last two financial years, from $35.75 in 2008/09 to $30.37 in 2009/10. There is significant potential for DDR service delivery costs to decrease over time to towards equivalence with the cost of DDR hours funded ($16.92 in 2009/10).

The annual cost of respite delivered per carer had remained steady at around $7,000 – $7,161 in 2008/09 and $6,940 in 2009/10.

Revenue, expenditure and surplus

According to FAR data for the year 2008/09 for the 30 DDR Pilot projects the total revenue (income) was $9.79m and the total expenditure was $9.04m, leaving a surplus of $0.75m. Based on the 27 projects for which 2009/10 data was available, it appears that the total revenue and total expenditure will be slightly higher in 2009/10 compared with 2008/09, however, the surplus is likely to be of similar magnitude. The surplus for 2008/09 was modest, representing 7.7% of total revenue that year. This can be seen as an indicator of efficient use of resources. Apart from avoiding a deficit situation, a modest surplus as opposed to a significant surplus, indicates a maximising of available resources to meet consumer need.

In 2008/09 eighteen of the 30 DDR projects reported a surplus and the remaining twelve reported a deficit. Averaged over all 30 projects, the average surplus/deficit was $24,964. In 2009/10, 16 of the 27 DDR projects which supplied FAR data reported a surplus, one project reported an even balance ($0) and 10 reported a deficit. The average surplus/deficit for these 27 projects was $14,021.
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The total revenue reported for the program in each financial year mainly comprised operational revenue – 84% of total revenue. The remainder included the surplus retained from the previous financial year (12% of total revenue in 2008/09 and 10% of total revenue in 2009/10), fees collected from users of the service (3% in 2008/09 and 5% in 2009/10), and other revenue including small amounts of interest received on government funds (less than 1% of total revenue).

The total expenditure reported for the program in each financial year mainly comprised direct costs – 75% of total expenditure in 2008/09 and 71% of total expenditure in 2009/10 – the remainder being indirect costs.

Appropriate levels of user fees for DDR services

Guiding Evaluation Question

What have been the levels of user fees for DDR services and how efficiently and appropriately have these been applied?

The DDR sites are clearly taking into account financial need in the fees or donations being charged, and in some cases, waiving these altogether. The first Site Data Collection revealed that the majority (89.7%) of DDR clients were charged a small fee, with the average set fee for a day respite attendance being $12.60. Some paid donations in lieu of fees (5.2%), and no fee was charged for 5.1% of all clients, spread across 16 projects. Sites are also heavily subsidising the costs of transport (see Section 3.8.3).

A care package was specified as the source of the fees/donations for 12.3% of care recipients indicating that these individuals were already part of the aged care service system, for which an assessment of ability to pay fees would have also been made.

It is therefore unlikely that fees paid by users will cover the costs of delivering DDR services – funding provided to sites as pilot projects will have been critical to meeting those costs. Any contribution to service delivery costs by fees will have been minimal rather than significant, as demonstrated by the proportion of total revenue accounted for by fees collected from users of the service (3% of total revenue in 2008/09 and 5% of total revenue in 2009/10) – see Section 5.4.2.

Our feedback from interviews and surveys with care coordinators and service directors indicates that consultation has occurred between sites and carers, and that fees being charged are likely to be appropriate and reflect capacity to pay. This means that appropriate means testing has taken place, and this applies to both service fees as well as transport fees (see Section 3.8.3). Survey feedback from carers indicates that they are satisfied with current fee rates (see Section 4.3) and open ended feedback from them provided only a few instances of specific dissatisfaction with fees.

Future funding options

Guiding Evaluation Question

What are the appropriate options for future funding of this type of respite?

Case study findings reported most of the 13 sites studied to be financially viable due to the grant-based nature of funding, but unable to survive on user pays funding. FAR and SAR data analysis confirm that services are operating with a modest surplus, as discussed.
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The grants based funding provided for the DDR pilots has been effective not only in meeting service costs but for a number of other reasons –
    • Its four year timeframe, as opposed to a one year timeframe, has enabled issues associated with service establishment to be addressed and lessons learned from the path-finding nature of these pilots to be identified and absorbed.
    • The long timeframe has also supported services to be innovative and flexible, which would have been far less likely if funding had been provided on an annual basis.
    • It is very important for carers and care recipients to have a guarantee of service continuation.

      At the same time, the provision of a service for four years will have raised expectations among service users of the continuation of DDR services and if the Program is not continued or absorbed into the NRCP, the negative impact on them will be significant (based on the positive feedback that the evaluation has identified).
There is inconclusive evidence about whether the amount of funding provided has inhibited or enhanced the services provided. However, it is more likely that the guarantee of four years of funding support has been deemed by providers to be worth investing RACF time and resources in developing DDR services.

Should the DDR pilot be continued as an ongoing component of the aged care respite service system, it is highly unlikely from the evaluation findings that it will be able to rely on a user pays model (if it is to be an equitable and accessible program). This means that funding will need to be recurrent, but based on meeting a set of required deliverables. These could be derived from the findings of this evaluation.
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1. Note that activity data for 2007/08 was deemed too unreliable to be included in final reporting.
2. The evaluators are very appreciative of the assistance provided by Ms Kerry Fischbein, Assistant Director, Carer Programs, Community Programs and Carer Branch, Department of Health and Ageing.
3. Two sites did not provide this information.
4. Note that activity data for 2007/08 was deemed too unreliable to be included in final reporting.

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