DOI: 10.1111/j.1741-6612.2012.00641.x
Research Waiting times for Aged Care Packages: The need to know Maria Griffiths, Robyn Russell, Gillian Brunker and Margaret Boccalatte Aged Care Assessment Team, Older Person's Community Services, Townsville Health Service District, Townsville, Queensland, Australia
Paul Goldstraw Gerontology Services, The Townsville Hospital, Townsville, Queensland, Australia
Aim: To establish local waiting times for access to Aged Care Packages (ACPs). ACPs are federally funded and designed to support older people to remain independent in their own homes for as long as possible. Access to an ACP is via the Aged Care Assessment Services (ACAS) process. Initial investigations suggested that significant waiting times existed locally. Methods: Analysis of ACAS data was undertaken retrospectively and prospectively to identify type of ACP and date of approval. Date of provision was obtained from ACP providers. Results: Two hundred and eighty-five ACPs were approved, but only 35 were provided. At up to 12 months after approval, 88% of the cohort were still waiting to receive an appropriate package. Conclusion: Long waiting times exist, which has implications both for the individual and the care/health sectors. It is suggested that monitoring waiting times should be a requirement for the future. Key words: Aged Care Assessment Service, Aged Care Package, waiting time.
Introduction In Australia older people are supported to remain independent in their own homes by the provision of Aged Care Packages (ACPs). The Federal Government provides funding to State and Territory Governments to operate the Aged Care Assessment Service (ACAS) which assesses the need of the individual older person and approves access to individually tailored packages. Three types of ACP are provided: Community Aged Care Packages (CACPs), providing up to 6 hours per week; and Extended Aged Care at Home (EACH) and Extended Aged Care at Home – Dementia (EACH-D), both providing up to 15 hours per week [1]. Services include: personal care, social support, transport, home help, meal preparation and gardening. The recipient can be charged up to but not exceeding 17.5% of the basic rate of a maximum single pension. ACAS can also recommend services for which approval is not required, namely home and community care
programs (HACC), which also provide domestic assistance, home modifications and maintenance, personal care, community nursing, food services, respite and transport. These services are also federally funded at contracted levels to private providers. This funding, and the number and types of package available, are determined nationally by the Australian Government. Comparing the number of packages approved with the potential number available suggested that there were possible delays amounting to years. Assuming a 1-year turnover of CACP usage, the waiting time in North Queensland for access would be 2.7 years. It is possible that the approved number of packages is outstripping supply to a level that is likely to result in a significant waiting list that is unknown to health-care providers and planners. This has implications for federal funders, providers and tertiary hospital services. A review of the experiences and perceptions of ACAS in Victoria by interviewing ACAS teams highlighted variability of access to packages. The study also reported perceived waiting times varied from days to years [2]. Moreover, the Townsville Hospital, a North Queensland tertiary hospital, data showed that 50% of older people waiting in hospital for nursing home care have never previously received services [3], also implying low availability or access. Approval for a package is recorded in the ACAS database, but no state or federal agency monitors access by the length of waiting time for the package to be provided, the duration of time that it is used, or the progression through the care system to differing and sequentially higher degrees of support. In addition, there are no data on whether the approved type of package is actually delivered [4]. Waiting lists are a strategy used within health services to achieve equity of access, priority of access and appropriate funding to provide such services [5]. It seems important therefore to establish a local knowledge base of waiting times to access packages and to understand the personal journey of an older person through the care system. Aim This study was undertaken to establish the waiting times for all types of ACPs within the Townsville urban area of the Townsville Health Service District, North Queensland, Australia.
Methods Correspondence to: Dr Paul Goldstraw, Gerontology Services, The Townsville Hospital. Email: [email protected] 26
A de-identifying data collection tool was developed which records date of approval, type of package, basic demographic
Australasian Journal on Ageing, Vol 33 No 1 March 2014, 26–28 © 2012 Townsville Health and Hospital Services, Institute of Emergency & Medical Services, The Townsville Hospital Australasian Journal on Ageing © 2012 ACOTA
bs_bs_banner
W a i t i n g
t i m e s
details, and Modified Barthel Index (MBI) and Mini-Mental State Examination (MMSE) scores. The study was performed retrospectively for 3 months, and then prospectively for the following 3 months. From previous years’ ACAS data, this would provide approximately 300 approvals for monitoring. Monitoring of access to the approved package was by weekly telephone contact with private providers to determine the date of provision and the type of package offered. Monitoring was later reduced to monthly as few weekly positive responses were being provided. The time of follow-up was for 12 calendar months following the first entry onto the waiting list of the retrospective group.
f o r
A g e d
C a r e
P a c k a g e s
(Table 1). The provision of the inappropriate lower level of care package, that is CACP instead of EACH, reduces the overall number waiting. These clients have been included in Table 1 to demonstrate the potential skewing of the data but are not included in the final analysis because they did not receive the recommended ACP. Two hundred and fifty-four clients (87%) of the cohort had carers; all those receiving approval for EACH-D had carer. Only 29 clients (10%) had no carer, and this information was missing for a further 2 clients. Moreover, the data showed that of the 35 clients who received ACPs the majority (31/35, 89%) were already receiving services. ACPs were provided to only 4/35 (11%) of older clients with no carer.
Results
Discussion
Two hundred and eighty-five ACPs were approved; these comprised 174 CACP, 91 EACH and 20 EACH-D. MBI and the MMSE data demonstrate levels of physical and social impairment associated with the different packages (Figure 1). MMSE was lowest in the EACH-D approvals. Similarly, the MBI was lower in the group approved for EACH than in the group approved for CACP.
The vast majority of older people approved for an ACP were still waiting after 1 year, the duration of the study. Not all of the small number of packages provided matched the approved need of the individual. CACPs were provided instead of EACH, a time difference of 9 hours per week, to eight clients. This could represent providers providing what is available rather than nothing at all. However, this potentially compromises the client and imbalances the care system with inappropriate care support.
Only 35 packages were provided during the year. The majority of older people, 250 (88% of the cohort), were still waiting at 9 months to 1 year after receiving their approval. The waiting time for all care packages to be provided ranged from -30 (for those provided before the assessment) to 190 days. For those provided after the approval, the mean waiting time was 42 days (range 0 to 190 days) (Table 1). Those continuing to wait for a CACP numbered 156 (90% of the group), for an EACH 86 (95% of the group) and for EACH-D 16 (80% of the group) (Figure 2). For all packages the combined waiting number was 250 (88% of the cohort) (Table 1). Not all the provided packages were at the approved level; eight clients approved for an EACH received a CACP
Figure 1: Cognitive and functional scores at assessment by type of Aged Care Package.
Score
Aged Care Package, MMSE and MBI 90 80 70 60 50 40 30 20 10 0
MMSE
MBI
MBI, Modified Barthel Index; MMSE, Mini-Mental State Examination. EACH-D.
CACP;
EACH;
What is not known is whether a package was offered to some clients and refused. There are financial and personal implications of refusing a package. An older person who receives services through HACC may choose not to take up a package because of the potential higher cost, which is not compensated for by the higher level of service. Another issue is that a change in providers may be necessary to move from HACC to CACP or EACH as the person’s needs increase. Such a change could also influence the older person’s decision whether to accept a package. This issue will be explored in a follow-up study with this cohort. The majority of both approved and provided packages were given to clients who had a carer. Obtaining a package may rely upon strong advocacy by the older person or their carer. Accessing a package may be more difficult for people who live alone than for those with a carer, and awareness of the support services available may also be lacking. Their need is only recognised when they present to the Acute Tertiary State Funded Health System. This issue is particularly concerning as by 2031 there will be a 118% increase in the lone person household [6], in Townsville, with the predominant group being older than 65 [7]. As health and care systems run in parallel, a deficit in care provision will lead to an increase in demand for hospital care, as identified by the queuing that occurs in acute hospitals for persons waiting for nursing home care [8]. This inference is supported by a follow-up of this study in which 63% of the cohort were admitted to acute hospital using 4447 bed days [9]. Providers are obviously caught in the dilemma of package provision. The number provided either on the day or before
Australasian Journal on Ageing, Vol 33 No 1 March 2014, 26–28 © 2012 Townsville Health and Hospital Services, Institute of Emergency & Medical Services, The Townsville Hospital Australasian Journal on Ageing © 2012 ACOTA
27
G r i f f i t h s
M ,
R u s s e l l
R ,
B r u n k e r
G
e t
a l .
Table 1: Number of Aged Care Packages (ACP) approved by type, and respective waiting times ACP type
Total approved
Total provided
Number waiting
Percentage waiting
Waiting time, days (mean)
Waiting time, days (range)
CACP EACH EACH-D All ACP
174 91 20 285
18 5 (CACPs 8) 4 35
156 86 (78) 16 250
90 95 (86) 80 88
39 79 (40) 45 42
-30 to 141 29 to 146 (-9 to 190) -6 to 112 -30 to 190
Bracketed data depict inappropriate lower level of ACP delivery and data effect.
Figure 2: Percentage of old people waiting for a Community Aged Care Package (CACP), Extended Aged Care at Home (EACH) or Extended Aged Care at Home – Dementia (EACH-D) Aged Care Packages (ACP). Percentage of old people still waiting at 1 year for an ACP
major deficit. Monitoring package waiting times should now become a requirement. Moreover, the implications of long delays should also be monitored in more detail. This would provide Federal and State Governments with the information required to meet current older people’s needs and assist in planning for the future.
100
Percentage
80
Key Points • Aged Care Package waiting times are long. • Data on waiting times should be collated at local, state and federal levels. • Delayed community support increases acute hospital usage.
60 40 20 0
CACP
EACH
EACH-D
References 1
the day of approval suggests provision of service to an existing client that is administratively corrected as the appropriate ACP becomes available with that provider. This is also confirmed by the high percentage of older people in the study who received an ACP who were already receiving support of some kind. The corollary is that those not receiving services are less likely to be provided with a package. A priority tool is being developed by the local ACAS to help providers to allocate packages, but this will be only part of a solution to the waiting times identified in this study.
2
3 4 5 6 7
The data demonstrate that the majority of older people are still waiting at 9 months to a year for an ACP to be provided to the recommended level. Therefore, our local community care system seems to be failing. The fact that no agency collates this information and provides it to Federal and State Governments, as is done with surgical waiting times, is a
28
8 9
AIHW. Aged Care Packages in the Community 2009–10: A Statistical Overview. Aged care statistics series no. 34. Cat. no. AGE 65. Canberra: AIHW, 2011. Stephens D, Wells Y, Gardner I. Approving for a Community Aged Care Package: Experiences and perceptions of six metropolitan aged care assessment service teams. Australasian Journal on Ageing 2011; 30: 77–81. White C, Goldstraw P. Acute hospital-nursing home care decision making. Australasian Journal on Ageing 2011; 30 (S1): 41. DOHA Regional Office. Townsville, North Queensland – ipse dixit. Queensland Health Strategic Plan 2011–2015. [Cited 2011.] Available from URL: http://www.health.qld.gov.au/about_qhealth/strat_ plan/intro.asp Taylor A. Regional Seminar 2009 QLD Department of Infrastructure and Planning Household Projections 2008 Edition – What are the Further Demographic Changes in Townsville. Taylor A. Regional Seminar 2009, DIFU Projection of Household Dwellings and Living Arrangements 2009 Edition – What are the Further Demographic Challenges in Townsville. Travers C, McDonnell G, Broe G et al. The acute-aged care interface: Exploring the dynamics of ‘bed blocking’. Australasian Journal on Ageing 2008; 27: 116–120. Russell R, Brunker G, Boccalatte M et al. The implication for North Queensland health services of aged care package accessibility. The Australasian College of Tropical Medicine 2011; 12 (S1): S12.
Australasian Journal on Ageing, Vol 33 No 1 March 2014, 26–28 © 2012 Townsville Health and Hospital Services, Institute of Emergency & Medical Services, The Townsville Hospital Australasian Journal on Ageing © 2012 ACOTA
Research Waiting times for Aged Care Packages: The need to know Maria Griffiths, Robyn Russell, Gillian Brunker and Margaret Boccalatte Aged Care Assessment Team, Older Person's Community Services, Townsville Health Service District, Townsville, Queensland, Australia
Paul Goldstraw Gerontology Services, The Townsville Hospital, Townsville, Queensland, Australia
Aim: To establish local waiting times for access to Aged Care Packages (ACPs). ACPs are federally funded and designed to support older people to remain independent in their own homes for as long as possible. Access to an ACP is via the Aged Care Assessment Services (ACAS) process. Initial investigations suggested that significant waiting times existed locally. Methods: Analysis of ACAS data was undertaken retrospectively and prospectively to identify type of ACP and date of approval. Date of provision was obtained from ACP providers. Results: Two hundred and eighty-five ACPs were approved, but only 35 were provided. At up to 12 months after approval, 88% of the cohort were still waiting to receive an appropriate package. Conclusion: Long waiting times exist, which has implications both for the individual and the care/health sectors. It is suggested that monitoring waiting times should be a requirement for the future. Key words: Aged Care Assessment Service, Aged Care Package, waiting time.
Introduction In Australia older people are supported to remain independent in their own homes by the provision of Aged Care Packages (ACPs). The Federal Government provides funding to State and Territory Governments to operate the Aged Care Assessment Service (ACAS) which assesses the need of the individual older person and approves access to individually tailored packages. Three types of ACP are provided: Community Aged Care Packages (CACPs), providing up to 6 hours per week; and Extended Aged Care at Home (EACH) and Extended Aged Care at Home – Dementia (EACH-D), both providing up to 15 hours per week [1]. Services include: personal care, social support, transport, home help, meal preparation and gardening. The recipient can be charged up to but not exceeding 17.5% of the basic rate of a maximum single pension. ACAS can also recommend services for which approval is not required, namely home and community care
programs (HACC), which also provide domestic assistance, home modifications and maintenance, personal care, community nursing, food services, respite and transport. These services are also federally funded at contracted levels to private providers. This funding, and the number and types of package available, are determined nationally by the Australian Government. Comparing the number of packages approved with the potential number available suggested that there were possible delays amounting to years. Assuming a 1-year turnover of CACP usage, the waiting time in North Queensland for access would be 2.7 years. It is possible that the approved number of packages is outstripping supply to a level that is likely to result in a significant waiting list that is unknown to health-care providers and planners. This has implications for federal funders, providers and tertiary hospital services. A review of the experiences and perceptions of ACAS in Victoria by interviewing ACAS teams highlighted variability of access to packages. The study also reported perceived waiting times varied from days to years [2]. Moreover, the Townsville Hospital, a North Queensland tertiary hospital, data showed that 50% of older people waiting in hospital for nursing home care have never previously received services [3], also implying low availability or access. Approval for a package is recorded in the ACAS database, but no state or federal agency monitors access by the length of waiting time for the package to be provided, the duration of time that it is used, or the progression through the care system to differing and sequentially higher degrees of support. In addition, there are no data on whether the approved type of package is actually delivered [4]. Waiting lists are a strategy used within health services to achieve equity of access, priority of access and appropriate funding to provide such services [5]. It seems important therefore to establish a local knowledge base of waiting times to access packages and to understand the personal journey of an older person through the care system. Aim This study was undertaken to establish the waiting times for all types of ACPs within the Townsville urban area of the Townsville Health Service District, North Queensland, Australia.
Methods Correspondence to: Dr Paul Goldstraw, Gerontology Services, The Townsville Hospital. Email: [email protected] 26
A de-identifying data collection tool was developed which records date of approval, type of package, basic demographic
Australasian Journal on Ageing, Vol 33 No 1 March 2014, 26–28 © 2012 Townsville Health and Hospital Services, Institute of Emergency & Medical Services, The Townsville Hospital Australasian Journal on Ageing © 2012 ACOTA
bs_bs_banner
W a i t i n g
t i m e s
details, and Modified Barthel Index (MBI) and Mini-Mental State Examination (MMSE) scores. The study was performed retrospectively for 3 months, and then prospectively for the following 3 months. From previous years’ ACAS data, this would provide approximately 300 approvals for monitoring. Monitoring of access to the approved package was by weekly telephone contact with private providers to determine the date of provision and the type of package offered. Monitoring was later reduced to monthly as few weekly positive responses were being provided. The time of follow-up was for 12 calendar months following the first entry onto the waiting list of the retrospective group.
f o r
A g e d
C a r e
P a c k a g e s
(Table 1). The provision of the inappropriate lower level of care package, that is CACP instead of EACH, reduces the overall number waiting. These clients have been included in Table 1 to demonstrate the potential skewing of the data but are not included in the final analysis because they did not receive the recommended ACP. Two hundred and fifty-four clients (87%) of the cohort had carers; all those receiving approval for EACH-D had carer. Only 29 clients (10%) had no carer, and this information was missing for a further 2 clients. Moreover, the data showed that of the 35 clients who received ACPs the majority (31/35, 89%) were already receiving services. ACPs were provided to only 4/35 (11%) of older clients with no carer.
Results
Discussion
Two hundred and eighty-five ACPs were approved; these comprised 174 CACP, 91 EACH and 20 EACH-D. MBI and the MMSE data demonstrate levels of physical and social impairment associated with the different packages (Figure 1). MMSE was lowest in the EACH-D approvals. Similarly, the MBI was lower in the group approved for EACH than in the group approved for CACP.
The vast majority of older people approved for an ACP were still waiting after 1 year, the duration of the study. Not all of the small number of packages provided matched the approved need of the individual. CACPs were provided instead of EACH, a time difference of 9 hours per week, to eight clients. This could represent providers providing what is available rather than nothing at all. However, this potentially compromises the client and imbalances the care system with inappropriate care support.
Only 35 packages were provided during the year. The majority of older people, 250 (88% of the cohort), were still waiting at 9 months to 1 year after receiving their approval. The waiting time for all care packages to be provided ranged from -30 (for those provided before the assessment) to 190 days. For those provided after the approval, the mean waiting time was 42 days (range 0 to 190 days) (Table 1). Those continuing to wait for a CACP numbered 156 (90% of the group), for an EACH 86 (95% of the group) and for EACH-D 16 (80% of the group) (Figure 2). For all packages the combined waiting number was 250 (88% of the cohort) (Table 1). Not all the provided packages were at the approved level; eight clients approved for an EACH received a CACP
Figure 1: Cognitive and functional scores at assessment by type of Aged Care Package.
Score
Aged Care Package, MMSE and MBI 90 80 70 60 50 40 30 20 10 0
MMSE
MBI
MBI, Modified Barthel Index; MMSE, Mini-Mental State Examination. EACH-D.
CACP;
EACH;
What is not known is whether a package was offered to some clients and refused. There are financial and personal implications of refusing a package. An older person who receives services through HACC may choose not to take up a package because of the potential higher cost, which is not compensated for by the higher level of service. Another issue is that a change in providers may be necessary to move from HACC to CACP or EACH as the person’s needs increase. Such a change could also influence the older person’s decision whether to accept a package. This issue will be explored in a follow-up study with this cohort. The majority of both approved and provided packages were given to clients who had a carer. Obtaining a package may rely upon strong advocacy by the older person or their carer. Accessing a package may be more difficult for people who live alone than for those with a carer, and awareness of the support services available may also be lacking. Their need is only recognised when they present to the Acute Tertiary State Funded Health System. This issue is particularly concerning as by 2031 there will be a 118% increase in the lone person household [6], in Townsville, with the predominant group being older than 65 [7]. As health and care systems run in parallel, a deficit in care provision will lead to an increase in demand for hospital care, as identified by the queuing that occurs in acute hospitals for persons waiting for nursing home care [8]. This inference is supported by a follow-up of this study in which 63% of the cohort were admitted to acute hospital using 4447 bed days [9]. Providers are obviously caught in the dilemma of package provision. The number provided either on the day or before
Australasian Journal on Ageing, Vol 33 No 1 March 2014, 26–28 © 2012 Townsville Health and Hospital Services, Institute of Emergency & Medical Services, The Townsville Hospital Australasian Journal on Ageing © 2012 ACOTA
27
G r i f f i t h s
M ,
R u s s e l l
R ,
B r u n k e r
G
e t
a l .
Table 1: Number of Aged Care Packages (ACP) approved by type, and respective waiting times ACP type
Total approved
Total provided
Number waiting
Percentage waiting
Waiting time, days (mean)
Waiting time, days (range)
CACP EACH EACH-D All ACP
174 91 20 285
18 5 (CACPs 8) 4 35
156 86 (78) 16 250
90 95 (86) 80 88
39 79 (40) 45 42
-30 to 141 29 to 146 (-9 to 190) -6 to 112 -30 to 190
Bracketed data depict inappropriate lower level of ACP delivery and data effect.
Figure 2: Percentage of old people waiting for a Community Aged Care Package (CACP), Extended Aged Care at Home (EACH) or Extended Aged Care at Home – Dementia (EACH-D) Aged Care Packages (ACP). Percentage of old people still waiting at 1 year for an ACP
major deficit. Monitoring package waiting times should now become a requirement. Moreover, the implications of long delays should also be monitored in more detail. This would provide Federal and State Governments with the information required to meet current older people’s needs and assist in planning for the future.
100
Percentage
80
Key Points • Aged Care Package waiting times are long. • Data on waiting times should be collated at local, state and federal levels. • Delayed community support increases acute hospital usage.
60 40 20 0
CACP
EACH
EACH-D
References 1
the day of approval suggests provision of service to an existing client that is administratively corrected as the appropriate ACP becomes available with that provider. This is also confirmed by the high percentage of older people in the study who received an ACP who were already receiving support of some kind. The corollary is that those not receiving services are less likely to be provided with a package. A priority tool is being developed by the local ACAS to help providers to allocate packages, but this will be only part of a solution to the waiting times identified in this study.
2
3 4 5 6 7
The data demonstrate that the majority of older people are still waiting at 9 months to a year for an ACP to be provided to the recommended level. Therefore, our local community care system seems to be failing. The fact that no agency collates this information and provides it to Federal and State Governments, as is done with surgical waiting times, is a
28
8 9
AIHW. Aged Care Packages in the Community 2009–10: A Statistical Overview. Aged care statistics series no. 34. Cat. no. AGE 65. Canberra: AIHW, 2011. Stephens D, Wells Y, Gardner I. Approving for a Community Aged Care Package: Experiences and perceptions of six metropolitan aged care assessment service teams. Australasian Journal on Ageing 2011; 30: 77–81. White C, Goldstraw P. Acute hospital-nursing home care decision making. Australasian Journal on Ageing 2011; 30 (S1): 41. DOHA Regional Office. Townsville, North Queensland – ipse dixit. Queensland Health Strategic Plan 2011–2015. [Cited 2011.] Available from URL: http://www.health.qld.gov.au/about_qhealth/strat_ plan/intro.asp Taylor A. Regional Seminar 2009 QLD Department of Infrastructure and Planning Household Projections 2008 Edition – What are the Further Demographic Changes in Townsville. Taylor A. Regional Seminar 2009, DIFU Projection of Household Dwellings and Living Arrangements 2009 Edition – What are the Further Demographic Challenges in Townsville. Travers C, McDonnell G, Broe G et al. The acute-aged care interface: Exploring the dynamics of ‘bed blocking’. Australasian Journal on Ageing 2008; 27: 116–120. Russell R, Brunker G, Boccalatte M et al. The implication for North Queensland health services of aged care package accessibility. The Australasian College of Tropical Medicine 2011; 12 (S1): S12.
Australasian Journal on Ageing, Vol 33 No 1 March 2014, 26–28 © 2012 Townsville Health and Hospital Services, Institute of Emergency & Medical Services, The Townsville Hospital Australasian Journal on Ageing © 2012 ACOTA
