Evaluation of the consumer - directed care initiative - Final Report

5.7 Delivery and coordination

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Delivery and coordination refers to the organisation, delivery and monitoring of supports once the care plan had been put into place. It included the coordination and delivery of care and services by in-house and brokered providers, purchase of other equipment and other items, quality assurance and monitoring, confirmation of services received and payment of invoices, budget management and reporting, and review of the care plan.

Models of coordination

Providers used a mix of approaches for delivery and coordination of CDC and CDRC. The evaluation identified four broad models of coordination.

Providers developed these models based on their prior experience (both with aged care and other community services, particularly individual disability supports, for those providers involved in delivering other community services), research on the operation of other CDC models, and consumer feedback and input.

Providers used a range of direct and indirect approaches to include consumer feedback in their coordination model design, including focus groups, reference groups and historic feedback (including formal satisfaction surveys) from existing clients.

1. Progressive or tiered model

Under this model, there are up to three levels of CDC. Each level has a fixed administration fee, but the proportion of the budget for support coordination and management compared with delivery of supports (brokered or in-house) varies depending on the level of participant or carer control.

At the initial level, there are more funds for care planning and management to cover the initial care assessment and planning, arranging and coordinating supports, and building the participant or carer’s capacity to self-direct their package over time. As the participant or carer’s capacity increases, they are able to take on more responsibility and progress to the next level of control and self-direction. The proportion of the budget allocated to the CDC provider for care planning and management decreases, and the proportion available to the participant to purchase supports and other goods and services increases. The coordinator is still involved, but primarily in a support role. At the third level, the participant or carer takes on full responsibility for care planning and management.

There are generally no timeframes set for progression between tiers – it will vary based on the individual – but the expectation is that all participants or carers can progress to higher tier levels (with the exception of CDCHD participants who all received some case management in accordance with the guidelines).

This model was used by a limited number of CDC providers. It appeared to be the most sophisticated and transparent model, providing a clear pathway for clients through the increasing levels of control (though most participants tended to take longer than anticipated to progress through the levels).

This model was not used by CDRC providers.

2. Capacity building or mentoring model

Under this model , the initial care planning and management phase is relatively intensive and focuses on putting the supports in place and building the capacity and confidence of the participant or carer to self-direct. Over a period of time, usually a few months, the support coordination and management tapers-off and the participant or carer takes on more coordination responsibilities. The period of initial mentoring varies depending on the individual, but the individual’s capacity to self-direct is a key factor that is considered in the initial CDC assessment.

The proportion of package funds available for supports does not increase as provider care planning and management decreases. Additional care planning and management can be purchased if the participant or carer wants some ongoing or periodic support. As with the progressive/tiered model, there is always a case management component in CDCHD. Under this model the provider retains responsibility for administration.

This model was used more widely by CDC providers than the progressive/tiered model, and it had similar advantages in terms of transparency and clarity of client pathways. From a provider perspective the main disadvantage was that the cost of the initial intensive care planning was not always recouped from package budgets.

This model was also used by some CDRC providers.

3. ‘DIY’ optional model

Under this model, participants are able to choose a ‘DIY’ support coordination and management model, where they undertake all ongoing support coordination and management tasks more or less immediately, with some initial training and support in budget monitoring, use of timesheets, scheduling of service providers by the CDC provider. Participants can also choose to purchase additional care planning and management from the CDC provider. Fees for care planning and management are based on the costs of care planning and management for different package levels.

This model was intended for participants who were receiving a standard care package prior to their CDC package, and who might be looking for additional support hours or funds and had capacity to self-direct. As with the progressive and mentoring models, the provider retains responsibility for administration, and a component of case management remains embedded in CDCHD.

This model was not widely used by CDC or CDRC providers. Where it was used, it particularly appealed to younger carers who wanted to take an active role in the support coordination and management, but who still liked having the ‘safety net’ of access to additional support coordination and management if needed.

4. Enhanced choice model

This appeared to be the predominant model used by CDC and CDRC providers.

This model does not differentiate between the provider’s administration and care planning and management functions. The extent to which participants or carers coordinate their supports varies between individuals, though providers retain a significant degree of responsibility for support coordination (particularly where the majority of services were provided in-house by the CDC provider rather than brokered). The major difference for participants or carers compared with standard packaged care is that they have more choice, more flexibility in service delivery, and an ability to accrue surpluses for additional expenditure. The actual level of control participants or carers exercised under this model was limited in practice, however.

A number of providers intended to implement one of the first three approaches, but in practice defaulted to the ‘enhanced choice’ approach – usually because the time needed to build participants’ capacity and confidence to self-direct was greater than anticipated. Top of page

Delivery of supports

Use of in-house and brokered services

Providers indicated that most CDC participants were happy to access all or most of their supports from a single provider (usually the CDC provider). While providers would broker services from another agency where specifically requested by a participant, it was often incumbent on the participant to know what they wanted (i.e. a specific support worker, or a specific language ability). However, the CDC providers have an incentive to encourage clients to use their own in-house services, and some CDC providers had an internal organisational policy to increase their in-house services and decrease their use of brokered services.

For many participants, the decision to use the provider’s in-house services was based on price, as the cost of brokered services was often higher, particularly in areas where there was limited choice and if the CDC provider charged an additional fee for arranging the brokered services.

One CDC provider also suggested that brokered services were sometimes more expensive because of opportunistic price gouging. They reported that, on several occasions, they had approached local agencies about brokering services in response to specific participant requests, and the agencies took the opportunity to inflate their prices for the quoted services because they knew the participant had specifically requested them. In each of those cases, however, the client elected to use the less expensive in-house services once the options and prices were put to them.

It was not clear the extent to which participants were actively ‘encouraged’ to use in-house services, but it is clear that the detail and level of information given to participants about brokered providers differed between CDC providers. Some providers gave participants detailed information and price lists as a matter of course; others only provided the information verbally or on request.

In the case of CDRC, the majority of services were brokered.

Use of informal services

One of the conflicts faced by providers was where a participant or carer requested the services of a person known to them (such as an independent support worker, a member of their extended family or neighbour, a private cleaner, a handyman, or a preferred taxi company or driver).

Because CDC providers were accountable for the quality and safety of supports provided with CDC and CDRC funds, most CDC providers required that support providers either be approved aged care providers, or that they enter into a service agreement with the CDC provider. Entering into a service agreement usually requires an ABN, workers’ compensation and public liability insurance, and a criminal history check for support workers employed by the organisation.

Furthermore, the CDC and CDRC operating guidelines allow the use of informal workers – excluding family members – so long as usual requirements for workers’ compensation, superannuation and insurance were met.

Some people were unable or unwilling to meet these requirements, which meant that the CDC or CDRC provider was unable to engage them to deliver supports to a person on the package. This effectively meant some participants were prevented from using their preferred provider, despite the policy intention of CDC and CDRC (as indicated in the operating manual) to allow funds to be used to engage informal services.

There were some cases where a CDC package was used to employ a family member or neighbour to deliver care. The way in which this was done was to have the family member become an employee or contractor of the CDC provider (or another agency).Top of page

Management of budgets

Approaches to managing the individual budget were quite different for CDC and CDRC. The key difference was that CDC providers were able to determine package allocations and administration fees, while both the CDRC package allocation and administration fee was fixed.

Determining the size of a CDC package

The CDC operational manual clearly indicates that providers should ‘assess the needs of the care recipient and carer together to develop a budget for the care recipient based on those needs’, with the proviso that ‘care recipients with the same or similar needs should receive comparable allocations of budgets and services’. The manual specifically states that individual budgets need not exactly match the subsidy income paid to the provider for that client.

Despite this flexibility, in almost all cases providers chose to set their CDC package amounts at the relevant subsidy levels. Many felt it was important, from a transparency perspective, to set the package allocation at the subsidy levels because the amounts were publicly available and potentially known to participants.

Some providers thought it was important to have the flexibility to modify the individual package allocations according to participant need, but still used the subsidy levels to determine package allocations (often because they were unaware that they were able to change it, or because they had already set their package allocations by the time the revised guidelines were distributed to them). That the majority of providers chose not to adjust package allocations was particularly interesting given the concerns several raised about not being able to ‘pool’ CDC subsidy funds for distribution based on variable client need (something which commonly occurs with standard packaged care income).

Even when providers were aware that they could determine package amounts themselves, many highlighted the potential difficulty in determining an appropriate package level for a participant. Planning discussions with participants and carers were often framed around the pre-determined package amount (with participants and carers being aware of the package amount from the start). Hence there was little scope to modify the package amount during or following the planning discussions and the participant or carer had come to see the amount as “their budget”. Having the ability to accrue and expend individual budget surpluses was a particular attraction of CDC for many participants and carers, and so it would have been a difficult negotiation for a provider to then effectively reduce or remove that potential surplus by reallocating some of “their” budget.

An alternative approach – one closer to that described in the CDC manual – would be to work with a participant to determine their needs and goals (using a goals-based process) without discussing the size of the package, and following this discussion the provider could either estimate the cost of the package, or determine the size of the package using their own pre-determined categories or levels. However, providers noted that ‘costing’ a package would be more time-consuming and may result in inequities across providers, although they also noted that it could result in the most appropriate package allocation for each participant.

A predominant view among providers was that the three package levels did not take into account the range of needs among participants, and in particular that the gap between a CDCL package (with a subsidy level of $13,248 per annum in 2010-11) and a CDCH package (subsidy level of $43,982 per annum in 2010-11) was too great. This was also a common concern for standard packages generally, however, and does not relate specifically to CDC.

Determining the size of a CDRC package

The size of a CDRC package was set by the Department at $4,200 per package per annum. There was no evidence that providers deviated from this amount.

A number of CDRC providers were dissatisfied with their inability to modify the size of the package to take account of participants’ differing support needs, and thought a single package amount of $4,200 did not take into account the range of needs. Many suggested a tiered approach be used similar to CDC, where two or three packages be defined (i.e. low need and high need).

Contingency and surplus funds

The CDC operational manual requires that individual budgets include a ‘small amount to cover contingencies’, which are defined as ‘emergency scenarios where needs change’. Aside from the provider administration charges and the contingency, the manual indicates that ‘the remainder of the allocated budget is available to the care recipient to direct to services of their choice.’

Many CDC and CDRC participants were building up these funds for use in an emergency, for a later period when they knew they may need more support (for example, if they were expecting to be admitted to hospital), or for supports or additional goods or services which were costly and one-off (for example, a holiday for a CDRC participant, or an electric lifting bed for a CDC participant).

A number of participants considered this aspect of the initiative to be particularly important and beneficial, particularly CDRC participants and CDCH and CDCHD participants (where the scope to build up a contingency was greater than for CDCL).

However, providers seemed to differ in their approach to contingencies:

• Providers tended to direct a certain amount of the participant’s monthly budget towards a contingency and reflected this in the budget statement. Any other unspent funds for the month would also go towards this surplus or contingency.
• A small number of CDC providers did not allow participants to build up surplus funds. These providers typically budgeted on a month-by-month rather than an annual basis (where participants would have a monthly allocation of hours or funding), and if participants did not utilise their monthly allocation, they would lose any unspent hours or funding.
• Most providers (CDC and CDRC) allowed participants to build up surplus funds, though they were often unclear about the rules around carrying it forward to a subsequent year. As a result, some providers encouraged their participants to spend all of their allocation in the financial year.¹⁴
• Some providers allowed participants to build up funds and to carry forward any unspent amount to the subsequent financial year.

Data was not collected on the size of contingency funds and surpluses accumulated by participants.

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14. The operational manual for CDC allows funds to be carried forward; the CDRC manual is silent on whether funds to be carried forward.

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