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Business Design Update
Aged Care Gateway Advisory Group Melbourne 26 February 2014
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Outline Vision for the Aged Care Gateway Assessment Outcomes
Wellness Philosophy Reablement Key Gateway Functions Pathways Registration and Screening Assessment for Home Support Services Assessment for Aged Care Services* * Assessment of application for approval as an aged care recipient under the Aged Care Act 1997 for access to Residential Care, Packaged Care, Transition Care
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Vision for the Aged Care Gateway
The Gateway is a consumer focused service which is central to improving access to aged care information and services. It seeks: “To make it easier for older people, their families, and carers to access information on ageing and aged care, have their needs assessed and be supported to locate and access services available to them.” Source: Aged Care Gateway Concept of Operations, June 2013
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Assessment Outcomes The Productivity Commission in its Caring for Older Australians Report (August, 2011) suggested the following outcomes for aged care assessment: ‘A national suite of standardised and validated assessment tools (see box 9.3 for one possible approach) should aim to achieve outcomes that: promote independence and build on an older person’s strengths identify restorative options that accord with an individual’s own aspirations identify when a more in-depth assessment is needed provide adequate follow up, with timing depending on the nature of the assessment use electronic records, attached to a more detailed e-health record, where possible support other aspects of care facilitation, such as identifying the need for a care coordinator to help with making appointments with care providers and helping choose an appropriate provider or providers, linking health and care providers and arranging transport. This suite would be structured to enable a single initial assessment as a foundation, with various triggers that indicate the need for more complex assessments where required.’
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Assessment Outcomes (cont.)
The National Aged Care Alliance, in a discussion paper released in January 2014 summarised the objectives of assessment as follows: ‘Assessment is the cornerstone of a responsive, well targeted and sustainable aged care service system. Australia’s current assessment system is fragmented, based on funding programs rather than on the individual, differs between organisations and creates variable outcomes for individuals. The current reform process provides an opportunity to significantly improve the assessment approach and process. This is important because getting assessment right in a service system achieves the following outcomes: 1. Supports older people’s independence and access to the right type and level of service they need at any given point in time; 2. Ensures that older people with similar needs, regardless of where they live, their cultural or ethnic background or the services they access, have a similar outcome in terms of the level of resources made available to support them; and 3. Effectively manages access to, and controls public expenditure on, Government funded aged care services.’
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Wellness Philosophy ‘A philosophy that focuses on whole of system support to maximise clients’ independence and autonomy. It is based on the premise that even with frailty, chronic illness or disability; people generally have the desire and capacity to make gains in their physical, social and emotional wellbeing and to live autonomously and independently. It emphasises prevention, optimising physical function and active participation. It focuses on finding the service solutions to best support each individual’s aspirations to maintain and strengthen their capacity to continue with their activities of daily living, social and community connections. The provision of reablement services is part of this philosophy.’ Source: ASSESSMENT AND THE AGED CARE SERVICE SYSTEM, National Aged Care Alliance, January 2014
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Reablement ‘The use of timely assessment and short term, targeted interventions to: Assist people to maximise their independence, choice, health outcomes and quality of life; Appropriately minimise support required and reliance on future and or alternate support; Maximise the cost effectiveness of programs; and Support people to continue to participate and remain engaged in their local communities as they wish.’ Source: ASSESSMENT AND THE AGED CARE SERVICE SYSTEM, National Aged Care Alliance, January 2014
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Service Planning and Delivery
Key Gateway Functions Registration Screening Service Planning and Delivery Assessment Re-assessment Matching and Referral
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Pathways Gateway contact centre Assessor Service Provider Enquiries
Registration Screening Referral Assessor Home Support Assessment Comprehensive Assessment Referral for Home Support Services Referral for Aged Care Services Service Provider Initiate Re-assessment Service Planning & Delivery Initiate Re-assessment Initiate Re-assessment Initiate Re-assessment Monitor Client Care Needs
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Registration WHO WHAT Clients
Gateway contact centre Assessors Service Providers WHAT Record of client details including representative(s) Establish who can access client information and act on their behalf HOW Telephone Registration Online Registration Proof of Identity check OUTCOMES Client Record Centrally available Screening, Assessment, Referral, and Service history
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Screening WHO Gateway contact centre Assessors WHAT Collecting information on function, carer, home and safety, and health Screening eligibility for care HOW Screening Questionnaire Action plan Central Client Record OUTCOMES Referral to Home Support or Comprehensive assessment Referral direct to CHSP Service Provider Information Provision
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Assessment WHAT Assess and develop support plan for: WHO
Home Support Assessor Comprehensive Assessor Delegate WHAT Assess and develop support plan for: CHSP services Packaged care Residential care Transition Care HOW Home Support Questionnaire Comprehensive Questionnaire Central Client Record OUTCOMES Recommend CHSP services Approve: Packaged care Residential care Transition Care
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Utilising Gateway Systems to match, refer and update client record
Matching & Referral WHO Gateway contact centre Assessor WHAT Identifying services (funded and non-funded) that match needs Referral to providers of funded aged care services Providing service information HOW Utilising Gateway Systems to match, refer and update client record OUTCOMES Service provider acceptance or refusal Effective referral management
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Service Planning & Delivery
WHO Service provider WHAT Accept referral and review support plan Undertake service specific assessment and develop service plan Monitor and review HOW Acceptance/rejection of electronic referrals Recording summary of service plan on client record Updating client record of key service events OUTCOMES Deliver services consistent with client’s goals and needs Initiate re-assessment where circumstances change Attainment of client goals and reduced need for services
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Re-assessment WHAT WHO Re-assessment initiated by: Scheduled review
Assessor WHAT Re-assessment initiated by: Scheduled review Changed circumstances Client request HOW Home Support Questionnaire Comprehensive Questionnaire History from Client Record OUTCOMES Referral for CHSP services Approval for: Packaged care / Transition care / Residential care Reduce or cease services
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Registration and Screening
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Assessment for Home Support Services
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Assessment for Aged Care Services
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Neil Mann Aged Care Gateway Business Design Team
Questions Neil Mann Aged Care Gateway Business Design Team
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