Submission to the ProductivityCommissionPublic Inquiry onCaring for Older AustraliansNorthside Community Forum Inc27 July 2010Page 1 of 1427 July 2010

BackgroundNorthside Community Forum Inc. („NCF‟) works for the benefit of people who are aged,people with disabilities and carers who live in the Northern Sydney region. The NorthernSydney region includes the eleven local government areas of Hornsby, Ku-ring-gai, Ryde,Hunters Hill, Lane Cove, Willoughby, Mosman, North Sydney, Pittwater, Manly andWarringah. The region‟s boundaries coincide with the Northern Sydney Aged Care and Homeand Community Care (HACC) Planning Regions.VisionA just and inclusive community is a vibrant and healthy community.MissionTo build dynamic community care in the Northern Sydney region that expands opportunitiesfor carers, older people, and people with a disability, their families and friends.AimsIn pursuing its mission Northside Community Forum Inc. aims to enhance and enrich thequality of life of people and relieve poverty, sickness and distress in the Northern Sydneyregion by ensuring high quality community care services are available in the region and bylinking people with information, advice and support services.Working collaboratively with partners and stakeholders, NCF builds the capacity of theNorthern Sydney region community care sector by: Linking carers, older people, and people with a disability, their families and friends toinformation, advice and services.Linking community care organisations to information, advice, training, and support andnetworking opportunities.Supporting and resourcing community care organisationsCoordinating information and consultation within the community care sectorParticipating in the planning and development of the community care sectorResponding to government initiatives, actions and policies that affect the Northern SydneyregionWorking collaboratively with individuals, partners, funding bodies and other stakeholders.Page 2 of 1427 July 2010

Focus of submissionThis submission is based on the knowledge and experience of the Northern Sydney serviceproviders gathered through a local community care forum meeting for the purpose of thissubmission. The submission focuses on community care.1.Strengths of HACC ServicesUnder the current HACC service types there are definite strengths that have developed over25 years of HACC Services in NSW which need to be maintained in order to maintain thequality of service when the Commonwealth take over the administration of HACC services. 1.1 Person Centered ApproachTo maintain IMPACT as underpinning principle of Community Care:Person-centredCulturally-appropriate, socially inclusive,Flexible & responsiveSupportive & enables the positive relationship between consumers and carers.Recognised as a fundamental and valued part of society that grows and develops to meetthe changing expectations of consumers, carers, funders & the workforce.Innovation is constant and aims to increase capacity & improve outcomes for consumers.Management of programs ensures effective allocation of resources to attract and retain theappropriate calibre of staff.Pathways for access are clearly identified through service promotion.Accountability measures focus on services‟ ability to deliver consumer outcomes rather thanservice system outputs.Collaborative relationships challenge the assumptions of existing care models.Training & development is ongoing and provides staff and volunteers with appropriate skillsand knowledge to meet all levels of need.Service providers see the need to preserve the person centred care approach to CommunityServices which is seen as a highly valuable and essential part of HACC services. It has apreventative aspect to frail age as well as being rehabilitative and has long been a model ofbest practice in disability support services.1.2 Sector DevelopmentSector development in the community aged care system should focus on continuousimprovement in the knowledge, skills and good practice of the workforce through forumsthat promote networking and information-sharing, as well as enabling accessible, relevanttraining and development opportunities at individual and organisation levels. Partnershipsand collaboration should benefit both service providers and their clients.Strengths of the current HACC system in NSW include: The 25-year history of the Program has created best practice by a skilled workforce,including many paid workers, volunteers and managers who have been involved for morethan 10 years.Clear lines of communication with Project Officers from Ageing, Disability and Home Care(NSW funding body), who are easily accessible to answer questions and initiate servicePage 3 of 1427 July 2010

Community development workers who canvass issues with service providers, assist withstructural issues and capacity building, including: HACC DOs, Aboriginal HACC DOs, LocalGovernment Workers, Multicultural Access Projects, Carer Support Projects, DementiaAdvisory Services.HACC DOs and HACC-funded local government workers facilitate HACC/Community CareForums that provide opportunity for strategic discussion and action.Funding for community and sector development projects, both recurrent and one-off innature encourage and enable provider agencies to work together for clients.Peak Organisations such as NCOSS and networks work across service types and the wholesector.1.3 Service DeliveryThe range of service types available: HACC is able to provide a service mix to meetindividual needs and recognises that some clients need just one service and not a wholepackage e.g. social support services can be just as important as domestic assistance orpersonal care in assisting people.Service types like Social Support and Centre Based Day Care, and even CommunityTransport, address issues around social isolation; they enable clients to maintain lifestyle,establish/maintain contact with the community.Partnerships and joint client care arrangements between providersThe mix of small, medium and large providersThe use of volunteers creates financial efficiencies in service types like Social Support inNSW and adds an important community dimension to service management and delivery.The number of existing providers who use models to promote client independence1.4 Communication with Government organisationsService providers have valued the presence, availability and interaction of ADHC personnelat Community Forums and at the community organisation service level. It is hoped that thislevel of interaction will be maintained with DoHA Personnel.1.5 Advantages of Keeping services LocalLocalised services for local needs - Local knowledge. Frail aged and disabled people oftencan't leave their own area - just for a day trip – it is too exhausting. They need local events.Rather than isolating people - HACC services take people out of home and do things withvolunteers - strength of HACC is connecting with community.Keeping Community Services based locally within the area it services has the advantage ofhaving Specialist knowledge which is often lacking in centralised service models that arelocated away from the area for whom they are providing services.Having centralised organisations providing multiple services under one umbrella also meanstravel time by staff is unproductive lost time.Smaller organisations through the networking forum process can ensure that clients haveaccess to a wide range of local services through referral processes.One central body in control of all systems doesn‟t work but one central phone numberwhere people can access information on where (suburb, phone number) potential clients canobtain the information, referral or services they need could be helpful.From smaller NGO perspective, there‟s the need to maintain the advantages of smallmedium local services and not be “swallowed up”.Older clients have more complex needs but prefer local support.Localized cases need to cut out centralized systems and reconnect with the communityPage 4 of 1427 July 2010

Community care organisations and their staff and volunteers are generally locally based;this creates efficiencies in not wasting resources in travel time and helps address socialisolation of people requiring support living in their own homes.Local, community based organisations have knowledge to be relevant and responsive toneed, and to create appropriate services:Local community organisations have a local presence which makes them attractive to peoplewho find it difficult or embarrassing to access support services.“No wrong door” system where the person can get assistance from anyone organisation inthe system whether they are information and assessment or a direct service provider. Theservice providers need to be funded to take on more of this responsibility with regards tomaking a referral to another service which often entails several phone calls to differentservices and filling out forms.1.6 Individual NeedsCurrently each service provider assesses the client without funding parameters per client;potentially HACC clients can receive all service types they need. Maintain individualised caseplans and goals that are not limited by HACC service type restrictions.Brokerage funds and other arrangements that cover the cost of (and thereby enable use of)interpreters for assessments.2.Challenges:Challenges of the current community aged care system include: 2.1 MDS (Minimum Data Set) Reporting:HACC services worry about the role of HACC Minimum Data Set (MDS) in planning anddetermining new funding; services are only asked to report time spent on direct, individualclient contact, not group activities, organisational planning, staff support and developmentetc.; it measures quantity of services given, not quality or outcomes for clients.If this is the tool for determining future funding arrangements by the Commonwealth then itneeds to be modified to ensure that all service activities are captured including theorganisational administrative. Currently a 5% administrative component is allowed. There isno research or evidence to support this figure and it does not accurately reflect anorganisational activity.MDS data was not originally intended as a funding mechanism determinant – inaccuraciesand narrowness of its scope of reporting may adversely affect smaller organisations.A true reflection of the costs are not measured e.g. A worker might have to drive for 25minutes to see a client, but the only time accounted for is the time spent with the client.The reporting mechanism needs to account for ALL time (not just time with client)Outputs do not accurately reflect how many service types a client receives e.g.: 2 hours ofcare/1 meal is often 1 outputThere is a need for outcome based measurements to complement outputs.MDS Outputs are down because it takes more time to deliver services to people withincreasingly complex needs – this is not adequately reflected in MDS reporting.2.2 Single Point of AccessPage 5 of 1427 July 2010

There are concerns about the single point of access and single point of entry into HACCservices. This makes it more difficult for many eligible clients to make contact and receiveservices. Refers to Hunter Access Point Pilot. 2.3 Affordability of Community services in the futureThat those who cannot afford private community care continue to have access to affordablecommunity care in the futureKeeping services affordable i.e. utility rate rises last week. Pensioners are delaying puttingthe heating on. Buying less fresh fruit because of the costs. We need to make sure peopleare still willing to contact services because we are local.Looking after older and more disadvantaged people through Homecare or equivalent. HACCusers contribute 5%. There is a concern that HACC may change average contribution to20%.Lack of a nationally-consistent HACC fees policy and the need to provide clearer and morespecific guidelines (e.g. for assessing financial disadvantage and capping/ reducing fees),while catering to diverse circumstances.2.4 Aged care/ Person with disabilityWhen does an aged person become disabled? When will they be classified as a client with adisability - needing a chairlift? Are you looking after the person because they are disabled/aged? Will clients with a mental illness be classed as having a disability?What is the situation if a person is under 65 with an intellectual disability?Double administrative work for co coordinators under the new Commonwealth Statearrangements for HACC services is of concern.In regards to mental health: getting referrals for mental health clients not coping e.g.meals. But in the new system they won‟t be counted.Separating between aged care and disability care needs more detail.GAPS – Interface – issues of health and community services – how will they work moreclosely together.Where does one responsibility stop and another start? Concern over transition from under65 to over 65 years service –There needs to be clear policy and guidelines.A streamlined system so that all services involved in providing services will know forexample when a client has been admitted into hospital. I.e. delivering meals/wheels informing Food Services that the client is in hospital.Organisations in place need to be granted a degree of flexibility so they can be responsive.Flexibility taken away will be very detrimental and distressing2.5 Transport IssuesPublic Transport on weekends does not meet the needs of frail; aged & people with disabilityBuses don‟t always cater for wheelchair users. There are wheelchair accessible buses, butsometimes the person may need a carer to safely access the bus service.Buses often don't run on weekends and this may be the only means of transport for HACCeligible clients.Community Transport services are overwhelmed by demand created by insufficienttransport provisions by other programs and jurisdictions, such as health-related transport(NSW Health).2.6 Challenges/weaknesses of a centralised systemThere are extra costs with a centralized agency.Page 6 of 1427 July 2010

Local councils are more inclined to support local services. Economies of scale - Good will oflocal area is really important for funding. Large services don't have local support. 20million service - council won‟t provide good will. (printing/brochures) hidden costs thatpeople don't benefit from.Local community supports shouldn‟t be taken for granted.2.7 VolunteersCentralised services would result in a loss of volunteers who generally volunteer in theirlocal area for HACC services.Currently certain HACC service types such as Neighbour Aid depend heavily on volunteerHACC services. There is a danger that HACC Community Services will lose volunteers if localservices are no longer available.The need to keep the value of the volunteer by providing worker support for themThe financial value of volunteers is huge to the industry and cannot easily be replaced withpaid workers.Australian Government community care programs do not utilise and promote volunteerworkforce the way HACC does.2.8 FundingPlanning and funding: competitive tenderingTransparency and not politics in selection of tender application is requiredNeed for someone local who knows the organisation and what they are doing in reviewingfundingSmaller agencies having to work longer and beyond normal business hours- more support isneededPerformance management of organisations and better support systems for management.The successful tender trend in the last lot of tenders all the larger organisations who canafford to pay for a consultant to write a tender received the funding. Only one smallcommunity organisation that received funding - that was in the CBD. More transparency incriteria would be fairer and more equitable.Often an organisation successfully providing a HACC service type misses out on a tender toincrease funding for the same HACC service type it already provides. Instead it goes toanother orrganisation who has not previously provided the service and who then spend thefunding on infrastructure whereas the funding could have gone into directly service throughthe existing local service. This is an inefficient way of servicing the local need and is asignificant disadvantage with competitive tendering. “With more players it takes a longertime to „start up‟”Department Veteran Affairs (DVA) clients come off DVA because they do not give the sameservices/ social support as the HACC ProgramThe Change to Commonwealth will impact on who gets funding and could disadvantagesmaller NGO A spread of organisation models of delivery from small/medium to larger willensure that client needs are met.Funded providers question some of the unit costing accuracy on which funding allocationsand organisations‟ funding agreement outputs are based.Lack of understanding of „full cost recovery‟ requirements when using certain HACC servicetypes (such as Food and Transport) by providers or clients already funded for the sameservice type/s through other programs; some clients are inappropriately receiving a HACCsubsidised service because of the failure of the other program to meet their needs or paythe purchase fee.Page 7 of 1427 July 2010

Competitive tendering has removed the incentive for services to work together, as theyonce did.Current planning and funding processes assume HACC is only addressing low needs andCACP/EACH is for higher needs; actually, some personal care and case managementproviders in NSW are providing support above the limits of CACP/EACH and certainlyVeterans Home CareIt is vital to consult the local community in planning and funding allocation processes andthat decisions are based on solid information about how local services interact with existingcommunity networks. Many times agencies have been selected by a National selection panel– that does not have any idea of the local issues – or how a particular service providerwould perform in relation to other services; as a result, the services have failed or struggledto get referrals.2.9 Workforce:The pay rise in QLD has drawn people into the community sector. This would support thesector in NSW and across Australia.There is a great need for training and career pathways.Portability of experience; skills; qualifications and long service leaveCALD – Difficult working with candidates who have no car/ no license/ speak anotherlanguage.need to maintain and develop the workforce to retain staff: financially linked2.10 Increase of people with dementiaThe sector is not yet ready for increased dementia.Change is needed for delivering services: a holistic approach – health/aged care: with acontinuum of care.Existing clients require increasingly more services and one on one care as dementiaincreases2.11 Medical General Practitioner involvementThere is a lack of consistency in referrals by GP‟s across the sector. Referral from GP‟shelpful to clients but it should not become necessary to have a referral from anywhere toaccess services such as the 1800 052 222 Carelink contact number.There needs to be streamlining process with a single phone number that will provide accessto many services.Local services are often able to establish local networks with local GP‟sGP get financial incentives. GPs – often don‟t explain to CALD patient what they are actuallydoing. Patient requires more support i.e. interpreter services to be provided.2.12 Social issues.The issue of large/expensive residences where people are asset rich but cash poor needs tobe examined in terms of access and eligibility of clients to HACC services given that thereare already waiting lists for complex needs and as the life span of the population increasesso too will the demand for services. We are looking at eligibility and means testing whilstmaintaining affordability.There are often OH&S issues with regard to providing Home Maintenance & HomeModification. Some dwellings need extensive renovations that are outside the Home Modseligibility. Other services need to be brought in. Will this flexibility of referral and service bemaintained?Page 8 of 1427 July 2010

Homeless people are eligible for HACC services and need to be considered in the transitionprocess.2.13 Flexibility of service deliverykeeping member of the community independent - we will lose the local communityperspectiveThere is a concern that with two different funding bodies for over 65 years and under 65years:The current system will lose it flexibility resulting in people not having access to services.Co coordinators then looking after the system, have to do the work twice reporting to community government and state.Access to private hospitals referral rate from private hospitals can be higher than public:35-15%. 15% in a region in North Sydney. The reality is that for some patients the days oflooking after ourselves are long gone.2.14 Informed Choice for clients’People need to know their options so that people can pick the most suitable choices forthemselves.For people in the community to have a local centre to go to for advice is what people want.People need advice but also need to talk about their issues until they know what they wantor need and find out what is available.A preferred client based approach rather than a bureaucratic approach.Carelink gives options but allows people to make the final decision. This is important tomaintain. Health relies on a streamlined system provided by Carelink. It is very client based- Disability pension - aged care pension.2.15 Individual NeedsAssessing the individual needs of the current community aged care system include:Without a central register, service level assessors rely on clients to know and declare whichservices they are already using; even when questioned thoroughly, some clients double-upon service (whether through confusion or deliberate misinformation)Clients have multiple assessments which is distressing to many clients and not time wellspent for service providers.The Australian Government community care programs do not allow a focus on social supportthe way HACC does; prioritisation of limited funding allocations per client in CACPs andEACH means many clients are not assessed for (and do not receive) essential socialisation,in favour of Personal Care and Domestic Assistance, which may be the choice of the budgetconscious assessor rather than the client.3. Possible Solutions:3.1 No Wrong Door PolicyA no wrong door policy through localised community service organisations captures moreenquires and allows anyone can come in any door and receive the services they need ratherthan having a single access point through a referral process and local services.Universal Access to anyone who needs assistance due to functional disability. In accordancewith HACC‟s stated aim, we should describe prospective service users as “older peoplePage 9 of 1427 July 2010

requiring support to enable them to live at home and participate in the community safelyand independently”, not just sick people exiting hospital if we move toward a clinical model.A socially inclusive approach that is sufficiently broad to take into account all peoplerequiring support whether they have a medical condition or not.At access point/s, the system should channel people to short term wellness/restorativeapproaches, where appropriate, rather than long-term supports they may not need. Accesspoints need to be open beyond business hours, including weekends and Public Holidays, torespond when crises occur and/or when working carers are able to access support. Accesspoints need to be visible in communities and well-promoted directly to the communitythrough community development as information campaigns are not sufficient to explain thecomplexity and responsiveness of Community Care to the greater community as awarenessof Community Care is poor therefore something more than just information needs to bedone.A reformed community aged care system should have an Information and Referral hotline,with national/state multilingual phone lines similar to Centrelink which provide specialistculturally and linguistically appropriate service that liaises with regional access andinformation services.Any new referral and assessment pathway/s should be clear and easy to understand andfollow. “A no wrong door system” where the person can get assistance from anyoneorganisation in the system whether they are information and assessment or a direct serviceprovider. The service providers need to be funded to take on more of this responsibilitywith regards to making a referral to another service which often entails several phone callsto different services and filling out forms.3.2 WellnessHACC provides services for people when they are already less able physically and mentally.The recently developed Wellness approach is working with ageing from the perspective ofwellness, promoting activities and services connected with improving and maintaining thequality of life and health rather than waiting till a huge proportion of the older population isalready in the early stages of dementia.Include in future budgeting for wellness activity and a change in emphasis from the existingHACC target group to add keeping people well and independent for as long as possible.The health aspect of Health and Ageing could think about its contribution to wellness just asmuch or more than home care and the role of the existing funding devoted solely to HACC.HACC is already looking at its role in working with clients earlier and keeping themindependent longer. This needs to be maintained.The eligible Target group could extend to all the over 65s by promoting wellness and thuspreventing people becoming HACC clients at risk of institutionalisation.Existing positions would need to be funded to work with the existing HACC and new'wellness' target groups.Dept Health and Ageing should fund coordination of services involved with hoarding directedat dealing with the behaviour rather than the symptom - the acquisition of things. LocalCouncils need advice not to use public health regulations to totally clear sites but to involvehealth services appropriately as early as possible. I understand wholesale clearing of siteshas occasionally resulted in suicide.3.3 Transition in Client needs from low need to high needPage 10 of 1427 July 2010

oFrom Low need to complex need with clear pathways and guidelines and criteria thatsupport Home and Community Care and makes a clear distinction between HACC and Healthservices whilst maintaining a smooth transition when needs change and become morecomplex.3.4 Industry BenchmarksAt the moment we have a loose monitoring system -there needs to bemeasurements to properly monitor with Industry benchmarksA licensing system. – Meeting standards every 3-5 years.Improved3.5 Transition Phase from State to Commonwealth administration:To provide sustainability for organisations to transition by assurance that funding willcontinue usingPre qualifying strategies to prepare for 2015.3.6 Hospital dischargeIn some areas discharge has been handled well with arrangements for discharge careorganised in advance by social workers.A more consistent policy and procedure to avoid last minute arrangements would supportRespite and Carelink so that there is no late Friday calls asking for Personal care (shortterm) or referral to a client who is not eligible for HACC services. This would involve fundingto support the re-establishment of both short-term personal care and domestic assistanceservices, which are in high demand.Also increased funding for ADHC Case Management services so that they are able tomanage their own clients well, without resorting to Carer Respite (when it is notappropriate).Joint training for health and community staff on the discharge process and options for posthospital care.Inability of HACC services to provide short-term care, including gap-filling during periods ofcrisis due to episodic conditions or increased frailty due to illness; transitional care is onlyavailable from hospitals.3.7 Centralised Referral System and AssessmentIn order to provide a better information and referral system there is a need forMore regular assessment (quarterly) and the resources to do this.A Centralised IT system that would support information/referral sharing (CIARR) –It would be a great advantage to have a more transparent system. Keeping access toclient‟s easy.3.8 Waiting ListsThere is currently no policy requirement in the HACC Guidelines for waiting lists. Eachorganisation has its own policy on waiting lists.Some individuals are on more than one waiting list for the same service types; this candistort reporting on unmet need, as some clients are double-counted and/or becoming „lost‟in the system.If a waiting list is developed it needs resources to be managed and administered in a waythat:ensures clients receive services;Page 11 of 1427 July 2010

oooothat there is equity for all clients;Means testing;raising fees;making different requirements3.9 Transitioning Into a New SystemCurrent community aged care providers are concerned with: oooUncertainty about the future of HACC;Lack of information from governments to enable workers to plan their lives and informclients.Uncertainty about organisational survivalAbility to recruit and retain staff due to poor pay levels, low morale, lack of career pathwaysetc.The transition process could be supported by:Retention of HACC development workers and other local sector development workers andtheir products which include: client brochures, HACC orientation packs, websites/intranets,Newsletters, workforce training, individual advice to service providers and users, communityeducation, research and development, advocacy, targeted initiatives, among others.Community care provider networks and their products, including regular forum meetings,protocols/agreements fo

Strengths of HACC Services Under the current HACC service types there are definite strengths that have developed over 25 years of HACC Services in NSW which need to be maintained in order to maintain the quality of service when the Commonwealth take over the administration of HACC services. 1.1 Person Centered Approach