Residential aged care: Proposed alternative models for allocating places

From a consumer perspective, the government can give a weighting to applications that prioritise people with particular needs but who might not otherwise be attractive clients to service providers.

The ACAR can also help to ensure provision of services in thin geographical markets.

They are in keeping with the maxim that should guide all (or nearly all) well-intentioned interventions in the provision of essential services: first do no harm.

We don’t want a change in the system that will result in decline of residential aged care places or the quality of care provided.

We don’t want a system that either providers or consumers will find financially unsustainable.

We don’t want a system which only caters adequately to mainstream demographics and service needs, depriving consumers with special needs or those who are in comparatively thin geographic markets to be deprived of the care they need.

We do want changes that will give consumers greater power, choice and control.

Elements of this model can address some of the problems identified in the current system.
As identified in the Discussion Paper, these include:

• Reduced locational controls so that where providers have less demand or capacity to use their allocated places, these places can be reallocated to areas of higher demand and capacity.

• Discourage the hoarding of non-operational places against possible future demand and as a protection against competition from other providers

These changes to the model are unlikely to introduce much improvement in access to respite without addressing other matters which make offering of respite places unattractive to providers. These matters are discussed under Question 35.

See answer to Question 35 below.

Benefits would include greater flexibility in reallocating places to higher areas of demand.

We understand that assigning places on the basis of specific consumer assessed need is an incentive for providers to meet the real demands of the neediest consumers. As such it is likely to be more responsive to demand than the current system of broad-based ageing population estimates of needs.

However, we are unsure of how such a system would work out with respect to ensuring adequate access to residential care in less populous areas and for special needs groups.

We note the observation in the Discussion Paper that the acuity of care needs of older people residing permanently in residential aged care coupled with the staffing levels and skills mix required to operate residential aged care may mean there is less flexibility for quick adjustments to be made to workforce capacity in response to possibly more dynamic consumer demand patterns. We have concerns that dynamic national variations in consumer assigned places will adversely affect the sustainability of residential aged care in smaller population centres. For this reason, under this model it may be necessary to establish priority queues on a regional basis.

We understand that assigning places on the basis of specific consumer assessed need is incentive for providers to meet the real demands of the neediest consumers. As such it is likely to be more responsive to demand than the current system of broad-based ageing population estimates of needs.

However, we are unsure of how such a system would work out with respect to ensuring adequate access to residential care in less populous areas and for special needs groups.

We note the observation in the Discussion Paper that the acuity of care needs of older people residing permanently in residential aged care coupled with the staffing levels and skills mix required to operate residential aged care may mean there is less flexibility for quick adjustments to be made to workforce capacity in response to possibly more dynamic consumer demand patterns. We have concerns that dynamic national variations in consumer assigned places will adversely affect the sustainability of residential aged care in smaller population centres. For this reason, under this model it may be necessary to establish priority queues on a regional basis.

Urgency of need should take priority over date of approval. The criteria for urgency of need should include the inability of family carers to continue to provide care in the home where care requirements and the amount of care they provide exceeds the capacity to provide replacement care through a home support package

As would be expected, Carers Australia has a very strong focus on the provision of respite care. However, we also note that the allocation of residential respite places under the current ACAR model is not responding to consumer demand. A 2018 Carers Australia national survey of services that help family and friend carers to access planned and emergency respite in residential aged care revealed that, despite a very high demand for both planned and emergency respite, three quarters of the organisations surveyed reported high levels of difficulty in accessing respite when it was needed.

While there are a number of reasons for this – including the use of respite places for other short-term accommodation purposes and the very low levels of subisidies and supplements for residential respite – the current method of allocation of subsidised respite places through the ACAR has also been cited as a disincentive for providers.

As noted in the Aged Care Financing Authority’s (ACFA)2018 Report on Respite for aged care recipients (https://agedcare.health.gov.au/acfas-report-on-respite-for-aged-care-recipients), the administrative difficulties associated with managing their respite allocation can be a real disincentive for providers who will not be subsidised if they exceed their allocation. This, along with the comparatively low level of subsidies and supplements for respite care compared to permanent care, provides another reason why providers may not be willing to offer respite care. One of the conclusions of the ACFA report is that the market should be able to respond to consumer demand Recommendation 12 of the report is that:

“If neutrality in the funding of respite and permanent residential care is achieved, the Government should remove the minimum and maximum allocation rules for respite care and allow providers respond to consumer demand for respite, subject to appropriate transitional arrangements and monitoring of the impacts of such as change on respite availability.”

While there are always concerns about the impact of opening up what might be described a regulated niche market to the laws of supply and demand, it might be worth piloting this model to ascertain its impact on the provision of residential respite, bearing in mind the stipulation that other disincentives for providing respite would also need to be addressed at the same time.

The more decision-making power and influence is put into the hands of consumers, the more providers will be forced to respect their needs and preferences – providing of course that those consumers have a real choice when they need to access residential aged care. An important proviso is that consumers and those assisting them to exercise choice have the right amount of information and understanding to make good choices and that information is provided in such a way as to avoid information overload.

One risk factor we are aware of is that the financial performance for the residential aged care sector is declining, particularly for non-for-profit providers and in rural, outer regional, and very remote areas. To the extent that this reflects difficulties in adapting to large number of sector reforms in recent years, we would have some concern that the introduction of another major reform in too short a period of time may result in the closure of residential facilities which, in turn, will impact adversely on consumers seeking to find facilities which can meet their needs and preferences.

An important lesson from NDIS implementation is that both providers and consumers need time to transition to major changes in service delivery and that the systems are in place to support this transition.

It would have impacts on the long-awaited reforms to the provision of residential respite.

We are not sure if this question means that allocated places no longer exist or if the model leads to the withdrawal of residential respite places.
In the case of the withdrawal of allocations, we point out in Question 35 that the current ACAR allocations are not resulting in sufficient supply of residential respite care to meet demand – although other factors such as unattractive rates of subsidy and the use of short-term beds for other purposes are also at play here.

There will always be a need for respite in residential care for high acuity residents. However, residential respite is not the preferred option either for carers or the people being cared for. It has a great many drawbacks. These include:

• Many places are booked months in advance, while in other places, respite cannot be booked far enough ahead and for the times they are needed (for example, so carers can plan and book holidays).
• Residential aged care facilities usually impose minimum stay periods, which does not suit many carers, who may need, or prefer, to have shorter and more frequent breaks.
• Moving to an institutional environment can be a very alien and disconcerting experience.
• Delays in ACAT assessments mean that carers are often unable to access respite when they need it.

Paid care in the home is a much less disruptive option, but expensive if paid for out of packages and unaffordable (unless the consumer can cover the costs) for those on lower level packages.

Cottage care is also a preferred option. Its advantages are:

• the older person may use the day care facilities, with occasional overnight stays, so are in familiar surroundings with people they know (this can be particularly important for people with dementia)
• overnight stays are in a house or homelike environment, rather than an aged care facility, so it is more normalised than residential respite in an aged facility and may even feel like a holiday for the consumer •
• cottages offer dedicated short-term stays, so there is a known number of beds and respite clients are not competing with people looking for a permanent residence
• there is greater flexibility, and can suit carers who prefer to have one or two nights respite more regularly, rather than blocks of respite, or can be used in combination with blocks of care (for example, a carer may have a two week holiday once a year and a night or two break in other months)
• it can take pressure off residential facilities that have competing high demands from consumers seeking permanent residence and those seeking respite care.

One option which might have merit is to preserve ACARs for short-term accommodation – such as respite, transitions from hospital, and reablement – but extend these to community settings such as cottage care. Advantages would be to provide an incentive for providers to expand the number of dedicated facilities for these purposes. However, in this instance too, the subsidies would have reflect the costs of providing services which will be higher due to lower economies of scale.