With major reforms to community aged care due to commence on 1 July 2015, Enis Jusufspahic outlines the risks to clients of the removal of case management from the basic care level program.

The Home and Community Care (HACC) Program has provided supports for people over 65, younger people with disability and their carers to remain living independently in their own homes since 1985. HACC currently has seventeen service types, including in-home services like Domestic Assistance and Community Nursing, and out?of?home services such as Community Transport, Social Support, and indirect services such as Case Management. Service contracts are based on a particular service type and service providers are held accountable for outputs for that service type only. This is the reason why the HACC sector is highly specialised, with many funded organisations providing only one type of service.

The program was jointly funded by the state and federal government, but administered by the state government. In 2011, changes under the Health and Hospitals Reform Agreement saw the federal government take over funding and administration of the program for people over 65 and the state retained responsibility for younger people with disability. When further reforms to aged care and disability commenced in 2012, HACC service providers were given three year funding contracts, which are due to expire in July 2015.

The federal government department administering the Commonwealth HACC Program for people over the age of 65 [and Indigenous people over 50] released a Design Paper [i] earlier this year which outlined its vision for the future of HACC – which will merge with two or three other community aged care programs into the new Commonwealth Home Support Programme (CHSP) in 2015.

The Paper introduces a two tiered Aged Care System administered by:

1. My Aged Care – informational and referral service which performs the initial intake and screening for those want to have access to the CHSP. Provided that the person is found eligible, they will be referred to a Regional Assessment Service who will then assess the person’s needs and draw up a care plan.
2. Aged Care Assessment Team – team of clinicians usually placed in a hospital who assess people for access to Home Care Packages and Residential Aged Care.

The paper states that from 1 July 2015 case management will no longer be funded, and suggests that older people who need ongoing case management will be directed by My Aged Care for a face-to-face assessment to identify those who are vulnerable and require linking services such as “tailored advice, guided referral, active assistance with linking to services in and outside aged care, care coordination and short term case management.”[ii] If the linking service is not enough then a case management client may be referred to an Aged Care Assessment Team to determine their needs and eligibility for Home Care Packages or residential aged care.

Transfer of HACC Case Management Clients to Home Care Packages

Home Care Packages were created to meet the person’s ongoing needs and include a minimal case management component which focuses on care coordination and assessment e.g. “identifying goals, building care plan, referrals and ongoing monitoring.”[iii] Whereas HACC Case Management services are targeted at “people who need specific types, mixes or levels of support services that are not usually provided by community care services and who need a case manager to help organise them”^[iv]

HACC Case managers work in this grey area between social housing, chronic disease management, mental health, aged care and disability. These services were funded to find solutions in the local community for those clients who need somebody to bring together all their supports from other sectors and advocate on their behalf for access to services and their legal rights as well as working on the person’s self-care capacity.

Home Care Packages do not offer sufficient hours of service for complex needs case management clients. Many people in the sector are concerned that costing out case management in the same way as other service types fails to acknowledge its real value and would amount to a significant decrease in number of hours offered to the client transitioning from HACC case management.

For example, Social Work is costed out at $140.83 an hour at the NDIS Hunter Launch Site.[v] This would mean that a Level 3 package at $30,000 with a 10 per cent administration fee would be able to provide 3.7 hours of case management a week without any other support services. HACC case management clients received up to 6 hours of case management support a week. Arguably, there would not be enough hours of service, even on the highest level packages, and in most regions there are long waiting lists for packages, which would make a transfer very difficult.

High needs group and case management as advocacy

Having reviewed a number of de-identified files of older people receiving case management support, I have come to the conclusion that there is a group of case management clients – who have significant cognitive impairments due to dementia, mental health or degenerative diseases – such that they are not able to advocate for themselves. They would be deemed eligible for HACC services, as their need for support with daily living activities stems from their illness, yet they do not fit within the service type specific responses (e.g. transport, meals, day care) offered by the HACC service system, as they require more intensive advocacy style support to deal with potential homelessness, guardianship, Centrelink etc.

The CHSP Design Paper mentions that all advocacy funding in the HACC program is to be transferred to the National Aged Care Advocacy Program. In NSW, there is only one service provider funded under this scheme – The Aged-Care Rights Service. Service providers in Eastern Sydney have identified a need for local services due to increasing numbers of people with complex needs, who require ongoing advocacy, and suggest that due to increasing complexity of the client group, advocacy services need to be expanded through a grants process, in order to fill this gap.

Long Term Case Management in Other Community Based Programs

Assistance with Care and Housing for the Aged Program (ACHA) is also being considered for inclusion in CHSP. It is similar to HACC Case Management, with a focus on housing and care needs of older people. The National Aged Care Alliance (NACA) recommends that ACHA case managers need to be able to “provide case management and face to face assessment that has an uncapped time period for interventions”[vi] This is an excellent recommendation, acknowledging the need for an uncapped time period for interventions in order to achieve sustainable positive outcomes. However, this element of the program would need to be expanded in order to accommodate clients transitioning from HACC Case Management.

Mental Health Case Management is another service similar to HACC Case Management. There is a recognition by the funding body that many people with a history of mental illness have a need for ongoing case management[vii], due to a complex array of needs. Because they are not adequately supported in the community they also experience a ‘revolving door’ of discharge and re?admission to hospital.[viii]

Chronic Disease Management and Mental Health Case Management are available in the community but are limited to the person’s specific condition. A person with complex needs may end up with a mental health case manager, as well as a chronic health case manager and housing case manager. HACC case managers are currently able to work across all sectors to bring supports together. This translates into better outcomes for the person and costs savings across different sectors.

Conclusion: Impact of removing Case Management as a Service Type

The removal of case management as it exists in the HACC Program creates a gap in support for vulnerable older Australians that can’t be met elsewhere in the current system. Significant changes are required if clients are to be successfully transitioned to other support services. There is a real risk that if these people’s needs are not dealt with in the community setting they will end up in acute services much earlier, which would put more pressure on health, mental health, housing and homelessness services.

Considering the increasing complexity of the client group, we recommend expanding other Case Management services as well as extending the capacity of the My Aged Care Linking Service to provide ongoing case management in situations where the person is not able to be supported elsewhere.

Enis Jusufspahic is the Home and Community Care (HACC) Development Officer (Eastern Sydney)