Evaluation of the consumer - directed care initiative - Final Report

Executive summary

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The consumer-directed care initiative

The consumer-directed care initiative (‘the initiative’) aims to provide community aged care consumers with greater control of their lives by allowing them, to the extent that they are capable and wish to do so and relative to their assessed care need level, to make informed choices about the types of care services they access, and the delivery of those services, including who will deliver the services and when they are delivered.

As part of the initiative, a total of 1000 non-ongoing flexible care places were allocated through the Innovative Pool Program for consumer-directed care (CDC) packaged care: 500 places in 2010-11 and a further 500 in 2011-12. Four-hundred CDRC packages were also provided to carers and funded through the National Respite for Carers Program (NRCP): 200 packages in 2010-11 and a further 200 in 2011-12. At the time of the evaluation CDC and CDRC packages were expected to be available until 30^th June 2012.

The evaluation

The purpose of this evaluation was to assess the effectiveness of consumer-directed care approaches in the Australian community aged care context by examining the implementation, operation, impact and cost of the consumer-directed care initiative.
There were four key objectives for the evaluation:

1. to evaluate the Department’s implementation of the initiative and ongoing administration, and the operationalisation of CDC by providers and centres (process evaluation)
2. to evaluate the impacts or benefits of the CDC initiative on participants and their carers, including impacts or benefits in terms of their ability to achieve their personal goals and on their quality of life, recognising the length of time that the CDC initiative has been in operation (outcomes evaluation)
3. to determine the cost of the initiative and assess the value for money of consumer-directed care in community aged care, relative to the outcomes achieved (cost analysis)
4. to identify barriers to success and key achievements, and key lessons from the initiative to inform future roll-out.

The scope of the evaluation encompassed the first 500 CDC packages and 200 CDRC packages approved in 2010-11. It did not encompass the further 500 CDC and 200 CDRC packages approved in 2011-12.

Implementation and operation of the initiative – program implementation

The implementation of the program was done over a relatively short period of time, and the length of time between providers being informed that they had secured CDC or CDRC packages and rolling-out packages to participants was very short. As a result providers had little time to develop their approach to CDC and CDRC and to select participants.

Providers indicated that they would have preferred more proactive support from the Department during the implementation, in addition to the helpdesk and frequently asked questions that the Department published. Providers suggested that some initial training or face-to-face briefings by the Department would have been useful, as well as more regular information exchange and discussion with other providers and the Department. In addition, providers would have preferred earlier provision of operating manuals.

The degree to which providers were already flexible and person-centred in their approach influenced the degree of change that was needed for them to implement CDC. This was evident from the variations and inconsistencies in the way CDC was implemented and operated across different providers, and the degree to which CDC was different from standard packaged care. Variations were particularly notable in planning processes, in providers’ degree of flexibility around the range and choice of services offered to participants, and in providers’ openness to allowing package funds to be used for innovative or non-traditional supports.

Implementation and operation – participant selection and planning

In selecting potential participants, providers commonly targeted those with a carer or a family member actively involved in the older person’s life (for consumer-directed high care (CDCH) participants and consumer-directed high care – dementia (CDCHD) participants). For low care participants, providers looked to people who they thought had sufficient capacity and who might have an interest in self-direction. There was a higher level of interest by potential participants in CDCH and CDCHD packages than there was in consumer-directed low care (CDCL) packages.

CDRC providers tended to target potential participants who were already known to them, and who were considered a ‘priority’ (such as carers under stress or who had little or no access to formal supports), and who had the ‘capacity’ to participate in CDRC. A number of providers targeted younger carers of frail older people who they considered were more appropriate for CDRC than older carers.

CDC and CDRC and planning processes were either goal-based or menu-based. Goal-based planning focussed on identifying the goals, desires and objectives of the participant and carer, and then looking to identify possible care and support options. Menu-based planning focussed on the Aged Care Assessment Team (ACAT) needs assessment and provision of a list of available supports, providers and price list to the participant or carer. Goal-based planning tended to be used with CDRC participants, for CDCH and CDCHD participants, and by providers who were more ‘person-centred’ in their approach to CDC and CDRC.

Implementation and operation – delivery and coordination

CDC and CDRC were characterised by an initial period of intensive assessment and planning involving participants, followed by an ongoing and variable level of support coordination and management once services were in place.

There were different models for delivery and coordination of CDC and CDRC. The predominant model offered participants ‘enhanced choice’ of supports, with providers maintaining responsibility for coordinating and managing packages. Other models incorporated different levels of participant control and self-management, with the level of support coordination and management undertaken by providers decreasing as participants’ moved towards managing their package themselves.

Most participants were able to manage their package to some degree, at least to the level of making simple, day-to-day bookings and scheduling changes, maintaining timesheets, and managing problems such as support workers being late. However, few participants took on a substantial self-management role – either because they were not given that option by their provider, had no interest in self-managing their package and their support arrangements, or did not feel that they were able to.Top of page

Extent to which CDC was person-centred and increased choice and control

CDCH and CDCHD participants and their carers were more interested and actively involved in planning and decision-making. CDCL participants were less interested in the planning aspects of CDC, particularly if they had transferred from a CACP and were satisfied with their current support arrangements. The majority of new participants were focussed on which supports they could access – similar to new standard package recipients.

CDCH and CDCHD participants, and specifically their carers, appeared to be more actively involved in planning and decision-making. Some participants and carers (usually younger carers) with prior experience of community care had clear ideas about what they wanted in terms of supports, and what they wanted to be ‘different’ with their CDC package – largely driven by dissatisfaction with their previous package.

Participants chose similar types of supports as those available under standard packaged care and generally used their package for ‘core services’. They exercised choice and control over how the services were delivered, including choice of support worker, and being flexible in delivery days/times and tasks undertaken by support workers. Some participants also used part of their package funds for innovative and non-traditional supports, though provider attitudes to requests for supports that were different from the ‘usual menu’ of services varied.

Several CDC providers had concerns about balancing the consumer choice element of CDC with the provider’s duty of care. Several providers gave examples of requests by participants or carers for specific items or supports that they had refused – mainly because they considered that the request would compromise the participant’s care and wellbeing (for example, where it reduced the level of personal care or clinical care that a participant could access). Other providers were also concerned by participants choosing to build up a sizeable contingency fund by foregoing some regular supports. While providers discussed and negotiated alternatives with participants, it highlighted one of the key tensions in the CDC model.

Extent to which CDC enhanced community-based care

Even after a short period of operation, CDC appeared to have a positive impact on participants’ level of satisfaction with various aspects of their life. Participants reported increased satisfaction with their ability to participate in social and community activities, their ability to visit family and friends, the quality of their home life and close relationships, and their health and wellbeing.

Satisfaction was generally higher for CDCH participants than for CDCL, indicating that there is potentially more benefit for people with higher levels of need (and receiving more sizeable packages). Satisfaction was also generally higher for CDC participants who had prior experience of packaged care compared with those participants with no prior experience of packaged care, indicating that CDC represents an improvement over standard packaged care for many participants.

On the validated measure of wellbeing, however, there was no statistically significant difference between the CDC participant group and the standard packaged care comparison group.

Extent to which CDRC was person-centred and increased choice and control

There were considerable benefits for carers from being able to plan supports in advance, and from simply being involved in the planning process. For many carers, they felt that they were being recognised and valued as carers – often for the first time.

CDRC allowed carers to focus on themselves, rather than the person they care for. Most participants were actively involved in planning, though for some it took a while to determine what they wanted to use their package for.

The relationship with the coordinator was particularly important and valued by participants. The strength of this relationship (and the effectiveness of the coordinator’s skills) seemed important for clients in building their capacity to self-identify needs and goals, building their capacity to self-manage, and receiving emotional support and advice on a wide range of issues related to their caring.

CDRC provided more choice of supports and more control and influence over the supports carers received than the National Respite for Carers Program (NRCP) or other community care programs that carers had experienced.

Extent to which CDRC enhanced community-based care

Even after a short period of operation, CDRC had a considerable positive impact on carers. Many participants felt that their capacity to continue in their caring had increased since commencing on the package, and for many having a package gave them the chance to put energy back into their caring role.

CDRC also had a positive impact in terms of carers’ level of satisfaction with different aspects of their life - including their ability to participate in social and community activities, their ability to visit family and friends, the quality of their home life and close relationships, and their health and wellbeing.

However, the relatively generous size of a CDRC package during the period of the evaluation is likely to have had some impact on the benefits realised.

It is also noted that, on the single measure of wellbeing, there was no statistically significant difference between the CDRC participant group and carers accessing supports through NRCP.

Cost and cost-effectiveness of the initiative

Providers incurred costs relating to the development and set-up of CDC and CDRC, and met these costs themselves. While some set-up costs will not be incurred again by existing providers if the initiative is expanded, new providers can expect to incur some costs. Further, there is likely to be additional costs incurred for systems development as the number of packages reaches a critical mass and processes need to be automated.

Providers also incurred some ongoing costs which were not being met from package funds. The extent to which these costs will continue is unclear, though they may decline over time as providers become more familiar with the approach and participants take on a greater self-management role.

Given the timing of the evaluation it was not possible to undertake a cost-effectiveness analysis. It is therefore not possible at this point in time to say whether consumer-directed care is cost-effective, or more or less cost-effective than standard packaged care and respite. A cost effectiveness analysis is only feasible once the initiative has been operating for a longer period, that is, when outcomes from the initiative are clearer and are able to be quantified more precisely, and when costs of the initiative have had time to stabilise.
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