Transitioning to Consumer Directed Care: Reflections on change
INTRODUCTION
As AMCS continues along the path of Consumer Directed Care (CDC), the new changes implemented in the Government-funded stay at home care services for the elderly are about to be implemented. While the new model will provide more choice for consumers, adapting to the reforms for care providers has been surrounded by doubts and concerns. Transitioning to CDC packages has been a major learning curve for aged care providers and their clients in understanding their care options and being able to negotiate how these are provided. With the aim of contributing to the understanding of the CDC and how it will be implemented, four of our AMCS care facilitators have provided their personal accounts of some of the apprehensions they initially confronted. They relate their hands-on experiences dealing with individual clients leading up to the introduction of CDC for seniors on 1 July 2015. They talk frankly about, at times, the seemingly overwhelming responsibilities of their new roles, the wider range of services, setting up new goals and their concerns about effectively communicating these changes to elderly clients, especially those without family carers who could help explain the new CDC process. It is hoped that these stories will further understanding about the value of clear processes in establishing new processes and encourage better service delivery focusing on choices and flexibility.
AMCS' CARE ADVISORS REFLECTIONS ON CDC:
Cloudia’s reflections Shortly after I commenced as a care advisor, I attended LASA training with Ekram and Eloina, and it all started from there. CDC itself wasn’t a change of culture for me although my new position was, but I knew that it would be a change for clients and the organisation. Within a short time, one of our team colleagues project managed CDC and soon we were preparing to implement it. I felt a huge responsibility rolling out CDC and it came with many questions: How are we going to deal with budgets? How will clients afford to contribute? Are we going to lose clients? How are we going to survive? Since I started transitioning my clients to CDC, I have come across different scenarios and reactions from them and their carers. In the beginning it was challenging to explain CDC to elderly clients, especially those without carers present. It took us a couple of months to understand what CDC is about, and having to explain it in a one-hour transition session to clients was a not easy. Reactions varied amongst clients and carers. One client described the contingency fund as “black magic” and the reform as a “rip-off from the government”. On one hand, some clients were not happy with direct debit and being charged a daily fee instead of fee for service. On the other, the majority of clients saw CDC as a more transparent system that gave them more control over their package and more choice. I was surprised that even clients who were asked to contribute much more than previously had no problem, as long as we continued to provide the care they already had and we sent them monthly statements so they know how the budget is working. For many clients what is most important is the care they are receiving, not the contribution. From my perspective, the individualised budget gives clients more power and control. CDC is also contributing to more family involvement and clients’ independence. Clients now rely on themselves or a family member to manage their package and ask for the assistance they really need. However, the individualised budget disadvantaged some clients who were benefiting from the pool of funding and it is a shame that existing clients are not eligible for financial hardship assistance.
During the last couple of months, I faced many challenges and had days when I felt stuck, especially when it came to getting the budget right at the beginning. Another major difficulty was, and still is, signing up new clients. Clients are comparing between HACC and HCP prices and are choosing to stay with HACC. This is definitely a gap in the reform the Government needs to look into and study further. Until today, conflicting information and unclear answers make the process difficult. The experience of rolling out CDC was problematic, although the knowledge and skills I have gained from this experience are very valuable and outweigh the negatives. Looking back on how I started my CDC transition as a professional and how much I’ve developed since then with tasks such as preparing care plans and the budgets and so forth, makes me feel more confident and keeps me motivated. CDC transition not only contributed to the development of my skills and our team's skills but also impacted on the image of the organisation in a positive way. By transitioning most of our clients, developing connections and networks and re-establishing the CALD network meetings, we are ahead of many other organisations, including those who ran the pilot. Our HCP team made it its mission to get it right and stand out among the rest. Eloina’s reflections When AMCS decided almost nine months ago that it was time to tackle the CDC, I had mixed emotions. I wondered how the new reforms would look in practice, how such changes would affect the CALD community, most importantly our clients, and what would they say. I had so many questions running through my head that at times it felt quite overwhelming, I was even dreaming about the CDC! As the information came flooding in and we reviewed our procedures, policies, costs and so forth, I was becoming more knowledgeable, not only about CDC but also about the real cost of what it meant to operate and work for a not-for-profit organisation. Yet I was terrified about the biggest challenge to come – trying to explain this to our clients. As I look back on all the changes we have undergone since those first few weeks, not just as an organisation but also individually, it is amazing to think
that we have now transitioned almost of our clients onto CDC. We’ve had our ups and downs, have come across issues that we needed to investigate and have adopted to change. I went through a stage where I questioned whether or not I was up for the challenge or was it time to move on. It was made clear to me that our case management roles, as we knew them, were changing and this is what scared me the most. I didn’t sign up to be a sales rep, a financier or a marketing specialist, but I don’t give up too quickly and I’m glad that I didn’t give in to those early days of fear. My skills have grown and I am now confident in my knowledge delivering the CDC to clients and their families, carers or guardians. I think this has been the most welcoming surprise of the CDC, working with families and seeing them become more involved with what is happening and wanting to play a bigger role in the care of their family member receiving the package. I can already see that it has assisted in improved care coordination for our clients, especially because the client now understands how the funding and their budgets work. Many are looking forward to saving for certain pieces of equipment they thought they could never purchase or managing their services because they need assistance with transport next month. It is refreshing and exciting to see them become much more actively involved. Hania’s reflections From the outset I felt excited about CDC. It was an opportunity to learn new things – up-skilling, moving on, continuous improvement of service delivery to our clients. There is never any time in AMCS to be bored! When I first read about CDC I felt surprised about many aspects such as the client’s choice of services; time of the services and care workers’ assistance; paying fees; working together on a care plan and service plan; setting up goals; managing budgets. I thought we had already been doing that ... what was so different? The idea became clearer soon after – an individual budget! My first emotion was one of uncertainty. Can I do it? Is it going to be userfriendly? Am I going to be successful in convincing our clients, their families and carers about all the new requirements?
By 28 February 2015, of thirty-five clients that I oversee, thirty-one had been transferred to CDC. Eleven of these clients and their families were very happy with direct debit and the whole CDC idea. One client was not happy with direct debit, to the point that he wouldn’t sign the agreement until recently. Another was unhappy with the caveat interest clause in the agreement and didn’t wish to be transferred for that reason. Twenty-two consumers have signed the agreement because they understand that changes will go ahead, no matter what they think about it. How do I feel about CDC now? Understanding Individual Budget well now, I am looking into the future with optimism. I believe that our consumers will have more choice and flexibility in choosing what is important for them. I am glad that their families will have more opportunity to participate in care, such as lawn mowing, home maintenance, shopping, taking parents to see the doctor and so forth. This way consumers will have more funds to spend on dealing with social isolation (building social engagement and community involvement). However, I do reflect on consumers who have no family or friends and who need many hours of assistance to be able to stay at home for as long as possible. I guess close monitoring of their budget by a care advisor and looking for smart solutions in delivering assistance is the only way at present. Liz’s reflections When the Government announced the new aged care reform, my initial reaction was: How is this going to work? How will these changes impact AMCS clients? The majority of my clients are from a CALD background, mainly from Eastern Europe, who immigrated to Australia post-war. English is their second language and for some it is very limited. Their stories are similar: they came to Australia with very little possessions or money, they usually worked long hours doing physical labour to provide a better life for themselves and their families. Depending on the hardship they experienced, some of my clients are very cautious or even suspicious when changes occur; for example, signing documents or providing bank details for direct debit.
My concern was mainly for clients with changing care needs, particularly a decline in cognition. Without a carer or family support, how will these clients manage a CDC package, monitor their budget, navigate new technology or choose services appropriate for their care needs? Will they be disadvantaged if they refuse to co-contribute to their package, even if they do have the financial capacity to contribute? Our HCP program had over two years to prepare before the CDC model would be officially implemented on 1 July 2015. AMCS was proactive in providing staff with information and training available at the time. However, the information provided in the sector was unclear and conflicting. The guidelines were still in the draft stage, which made it difficult to progress in making any significant changes. Staff were also concerned about their positions and how their roles might change. There was talk in the sector about organisations merging to remain competitive in this new environment. All this uncertainty created some anxiety and stress. When the final guidelines were released in mid 2014, the picture was slightly clearer. AMCS went into action mode, starting a CDC project group that worked on creating new documents, agreements and a CDC information booklet for new and existing clients. By the end of 2014 the care advisors were ready to transition 125 existing clients. It was a nervous time for all of us and there were many “what ifs�. What if the client asks questions we don’t have answers for? What if the client refuses to sign the agreement or direct debit? The HCPP team met on a regular basis to work on strategies to resolve any issues and to exchange any new, relevant information. So far I have transitioned half of my caseload, I am happy to say the overall experience has been positive, this has increased my confidence and any reservations I had at the start. I found clients and carers who were more informed by having done their research prior to the transition made the process easier. I guess the same applied to me: the more knowledge, skills and experience I obtained, made the transition and challenges easier. Transitioning clients with high care needs was challenging because if they continue with the same service provision, they will need to contribute more
towards their package. In one case the contribution was more than double what they were paying under the fee for service arrangement. Fortunately, the family was prepared to contribute to continuing with the existing services. However, the budget did not allow for garden maintenance to continue and the family decided to make other arrangements. In this situation the family expressed disapproval with the new reform as they felt it would disadvantage clients who have no family members to assist. On a positive note, some clients were happy to have more choices with service provision and more control over how funds are spent. One client stated how happy she was to have direct debit, which meant she didn’t have to go to the bank and wait in a queue. The same client was also happy to contribute more to increase her services; however, she was referred to AMCS community visitor program, which provided free fortnightly visits from matched volunteers. Her budget was not affected and the contribution did not increase. Needless to say, this client was very happy. What I have learned from this experience is, regardless of any changes that occur in the sector, I will continue to be passionate about providing elderly people with quality service and support so they can continue to stay at home for as long as possible.
Clients stories regarding Consumer Directed Care transition and benefits.
Mrs S. Mrs S had been a client of AMCS since 6 December 2012 on an HCPP level 2 package. Due to her dementia, her children were overseeing the package, payment of invoices and coordinating her services. The family wanted to avoid placing Mrs S into a nursing home as her wish had always been to remain living in her own home. Services of one hour a day, five days a week, were put into place to assist Mrs S and give peace of mind to her children, knowing that someone was visiting at least once a day. No other services were being utilised by the package. By March 2013, the family realised that extra help was needed and began to access the AMCS Premium Service (Brokerage) to provide an extra thirty
minutes of service a day for five days a week. With the coordination of rostering, AMCS assisted the family by organising these services to occur once in the morning (HCPP) and once in the afternoon (Brokerage). This gave great assurance to the family, especially to the client’s daughter, J, who lived with her mother and also worked full-time. Prior to the CDC, J found herself paying almost $700 a month for all services provided by AMCS (around $100 for HCPP fee for service and $600 for AMCS Premium service). During the transition of the existing package to CDC, J specified that she did not wish to alter her mother’s services. With the development of Mrs S’s care plan and the budget including all services from both HCPP and Premium, a new contribution figure had been reached. The CDC had allowed J to place all her mother’s services into the HCP program fund and in being able to remove the Premium service, reduced her previous costs. J agreed to contribute the maximum daily fee of 17.5% as well as an additional daily fee to keep her mother’s funding up to date. This equalled a monthly contribution of just over $500. This meant that J was saving between $150 and $200 a month. She had been expecting that, with the introduction of the CDC, she would be required to contribute more than the $700 she had previously been paying and was surprised and relieved that she would now be able to save a little. Mr B. Mr B is 85 and has a German background. He lives with his wife in their own home. Both of them have been assessed for level 2 of the HCP program. Their family does not provide practical support. Mr B has post-polio syndrome and extremely limited mobility. Around five years ago he took a driving test and his licence was cancelled. He said he “wasn’t happy about it, it was impossible to live, and this was the worst thing that could happen to anyone”. He didn’t leave the house since. He hadn’t visited his GP, hairdresser, dentist or podiatrist (he cut his toenails himself and didn’t wish to go to the podiatrist), and was reluctant to use taxis as he worried about transferring out of the seat.
During the care advisor’s first visit, she found Mr B to be withdrawn and he didn’t participate much in any conversation. After discussion about what Mr B used to enjoy and what he had stopped doing, he reluctantly decided to go out with the care worker to pick up his mail from the end of the driveway. Today Mr B is a different man – talkative, smiling, more relaxed, always looking forward to the day when the care worker comes to assist with transport to go shopping (he has learnt to hold onto the shopping trolley while walking) or visit the hairdresser, GP, podiatrist and so forth. He would like to be more independent and has bought an electric wheelchair so he can pick up the mail from the mailbox at the end of the long lane. Mr B told the care advisor that the day he accepted the assistance of the AMCS organisation was “the best day of my life”, adding “the second after marrying my wife”. He finds AMCS direct care workers very professional, caring and patient; they helped him to rebuild a sense of feeling a valuable part of the community.
Ms J. Ms J is 88 and of Polish heritage. She lives alone in her own home and has no family or friends. She has a number of medical conditions and a history of being in hospital regularly. Ms J’s GP communicated to the care advisor that she should be in a nursing home by now. In the hospital, however, medical staff found Ms J to be cheerful, talkative, independent in her personal care such as washing and grooming, and able to make a cup of coffee in the kitchen. Ms J told the care advisor that she was feeling very lonely at home and was longing to be amongst people. The care advisor has organised two seniors clubs for Ms J to visit on Mondays and Thursdays, and a volunteer via the AMCS Friendly Visiting program on Sundays.
Ms J is happier now, more cheerful and more talkative; she has less anxiety and sleeps better, she says. Everyone has noticed a change for the positive: Royal District nurses who attend Ms Jackson daily, Direct Care workers and workers at the social club. Even her GP has said all the results from her last
medical checkups are good. And, most importantly, Ms J hasn’t been to the hospital for eight months now.
Mrs D. Mrs D is 66 and has a Ukrainian background. She has been assessed for the level 2 HCP program. She lives at home alone; her daughter is her primary carer and visits a few times a week. However, this assistance is not sustainable. Mrs D is limited by poor mobility and reduced confidence. She had become housebound and isolated from community activities.
Mrs D is very happy to be assisted by AMCS with home cleaning and companionship for shopping, but her biggest joy is to learn that the care worker can also assist her going for walks around the block and they can take her friendly dogs. She said she wasn’t aware of that possibility and it would make her very happy because she is longing to walk and her dogs need the exercise as well. The care advisor has rostered Mrs D care worker, who likes dogs and understands their ways.
Mrs W. Mrs W is 79 and has an Egyptian background. She lives alone and suffers from reduced mobility. Although Mrs W has a very supportive family, she still requires support with minimal home care and shopping. Mrs W worked with an AMCS care advisor on her care plan and budget, and she chose to have two different care workers rotating shifts weekly so she can meet new people. Mrs W loves to speak English and chose to have English-speaking care workers so she could practice her English more. AMCS assistance allows Mrs W to stay independent, socially involved and active. It also allows her to practice her English, which she is afraid is deteriorating.
Mrs H. Mrs H is 79 and has a Turkish background. She lives at home alone and suffers from schizophrenia. Mrs H is socially isolated due to her mental condition. She is always anxious when meeting new people and does not like
going out and socialising. AMCS offered Mrs H services to assist her to maintain living at home independently for as long as possible. She wanted some assistance with home care, but more importantly, Mrs H agreed to go out with AMCS care workers to have a coffee and do some shopping if needed. AMCS services changed Mrs H’s life and her daughter was surprised that she agreed to go out with our care workers. AMCS services assisted Mrs H to interact with people more often and provided respite for her daughter as well.
Ms K. Ms K is 91 and comes from Poland. She lives at home alone. Before she was transitioned to CDC, AMCS used to provide her with some home care services and occasional transport to medical appointments. Ms K’s daughter, M, is involved in her care and assists her with transport to medical appointments regularly. M was glad to hear that she has the option to contribute and get extra support services for her mother. M also appreciated the fact that they can top up and get extra support in case she would like to go on a short holiday. M was pleased that, as a principle carer, AMCS can support her more with caring for her mother. Ms K’s individualised budget assisted her and her daughter with prioritising and determining care needs and receiving assistance accordingly.
CDC Summary
Professional, caring and patient. Quality service and support. Getting it right and leading the way.
This AMCS report on the transition to Customer Directed Care offers firsthand experiences by four staff members who describe a mosaic of personal responses to the roll out of the new and “sometimes overwhelming” social reforms and how they adapted to change.
Four care facilitators provide first-hand examples of how a number of their elderly clients responded to CDC as they set goals, plan and manage new options together.
Finding answers and solutions to their needs and better serving clients through Government reforms aimed at improving stay at home care for the individual.
Offering new choices and flexibility. An increase in family involvement. Improved care coordination.
Beneficial outcomes for care facilitators include: Up-skilling, gaining confidence, overcoming uncertainly and doubts about how CDC would be received by patients and their families. Strengthening networks. Increased levels of involvement. Creating budgets and costings. Filtering information. Seeing positive results and leading the way.
Beneficial outcomes for clients include: Becoming actively involved in managing their changing care plans. Increased socialising and overcoming isolation. Regular outings and visits for medical services. Improved communication skills and companionship. Providing respite for family carers. Physical exercise. Direct debit banking.
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27/04/2015