Australia: Consumer Directed Care (CDC) – Want vs Need

1. Introduction

The process of discussion between the home care service provider and the client (and/or the client's carers/family members) is now a formal part of Commonwealth funded community care services with consumer directed care ("CDC"). As a result, service options have become more transparent to consumers. Good service providers historically had high engagement with consumers. With CDC, there will be more information available to consumers so that they can make informed decisions – and you will see more elderly people stay at home longer with the appropriate home care support.

Each home care service provider must incorporate CDC into their policies and procedures, arrangements with clients, update their information brochures and record the discussion process. Training of staff is also important.

CDC gives older people and their carers greater say about the types of care services they receive and the delivery of those services.

The legal obligations in relation to CDC are in the Aged Care Act 1997 (Cth) which in turn refers to:

1. the User Rights Principles 2014 (Cth); and
2. conditions of Commonwealth funding – refer to the Home Care Programme Guidelines – which relate to home care packages.

2. What is Consumer Directed Care?

The Department of Social Services, in the Home Care Packages Programme Guidelines (July 2014) ("Guidelines") defines "consumer directed care" (CDC) as:

"a way of delivering services that allows consumers to have greater control over their own lives by allowing them to make choices about the types of aged care and services they access and the delivery of those services, including who will deliver the services and when. Under a CDC approach, consumers are encouraged to identify goals, which could include independence, wellness and re-ablement. These will form the basis of the Home Care Agreement and care plan".

The consumer decides the level of involvement they wish to have in managing their package, which could range from involvement in all aspects of the package, including co-ordination of care and services, to a less active role in decision-making and management of the package.

The objective of CDC is to provide greater transparency to the consumer about what funding is available under the package and how those funds are spent.

3. CDC principles

Under the Guidelines, the following principles underpin the operation and delivery of packages on a CDC basis:

3.1. Consumer choice and control

Consumers should be empowered to continue to manage their own life by having control over the aged care services and support they receive. This requires the provision of, and assistance to access, information about service options that enable a consumer to build a package that supports them to live the life they want.

3.2. Rights

CDC should acknowledge an older person's right (based on their assessed needs and goals) to individualised aged care services and support.

3.3. Respectful and balanced partnerships

The development of respectful and balanced partnerships between consumers and home care providers, which reflect the consumer and provider rights and responsibilities, is crucial to consumer control and empowerment. Part of creating such a partnership is to determine the level of control the consumer wants to exercise. This will be different for every individual, with some people requiring or wanting assistance to manage their package and others choosing to manage on their own.

Consumers should have the opportunity to work with the home care provider in the design, implementation and monitoring of a CDC approach. Home care providers should be encouraged to include consumers in their CDC redesigns. Care and services must be within the scope of the Home Care Packages Program.

3.4. Participation

Community and civic participation are important aspects for wellbeing. CDC in aged care should support the removal of barriers to community and civic participation for older people, if they want to be involved.

3.5. Wellness and re-ablement

CDC packages should be offered within a restorative or re-ablement framework to enable the consumer to be as independent as practical, potentially reducing the need for ongoing and/or higher levels of service delivery.

Many people enter the aged care system at a point of crisis. Such situations may require the initial provision of services designed to address the immediate crisis. However, there should always be an assumption that the older person can regain their previous level of function and independence with re-ablement services being offered at a time that suits/supports the individual circumstances.

3.6. Transparency

Under a CDC package, older people have the right to use their budgets to purchase the aged care services they choose. To make informed decisions about their care, older people need to have access to budgeting information, including the cost of services, the contents of their individualised budgets and how their package funding is spent.

4. Mental capacity to make decisions

In aged care, the difficultly is ascertaining whether or not the client is mentally capable to make their own decisions.

If the client is mentally incapable, then there may be disputes. It is extremely difficult if the patient has mild dementia with intermittent cognitive periods, has appointed an enduring guardian and the resident and the guardian disagree about what services should be provided.

We have come across a number of cases where:

1. the client is in denial of their needs or the need to seek assistance;
2. the client is too proud to seek assistance but requires it;
3. the client does not agree with the service provider;
4. disputes with family members about appropriate care;
5. self-interested family members, acting against the best interests of the client.

5. CDC is mandatory for home care packages, but what if the consumer does not want a home care agreement?

From July 2015 all home care packages must be delivered on a CDC basis. The CDC requirements are set out in the Home Care Package Guidelines.

Section 2.3 of the Home Care Packages Programme Guidelines state:

"While the home care provider must always offer and be prepared to enter into a Home Care Agreement, the consumer may choose not to sign a Home Care Agreement.

In such cases, the home care provider is still required by legislation to observe its responsibilities to negotiate and deliver the level and type of care and services the consumer needs.

It is important that the home care provider documents the reasons for not having a signed Home Care Agreement and the basis on which agreed care will be delivered."

6. What if there is disagreement over a want vs a need?

CDC does not go so far to require the service provider to do as the consumer directs. A service provider may decline a consumer request in certain circumstances. However, services providers will need to justify such decisions.

If there is disagreement between the service provider and the consumer, section 3.1.8 of the Home Care Package Guidelines 2014 provides the following guidance.

"The following list provides a guide to home care providers as to when it might be reasonable to decline a request from a consumer.

• The proposed service may cause harm or pose a threat to the health and/or safety of the consumer or staff.
• The proposed service is outside the scope of the Home Care Packages Programme.
• The home care provider would not be able to comply with its responsibilities under aged care legislation or other Commonwealth or State/Territory laws.
• The consumer's choice of service provider is outside the home care provider's preferred list of service providers and all reasonable effort has been made to broker an acceptable sub-contracting arrangement.
• The requested service provider will not enter into a contract with the home care provider.
• There have been previous difficulties or negative experiences with the consumer's suggested service provider.
• Situations in which a consumer may want to go without necessary clinical services (resulting in a possible compromise of their health and/or wellbeing) in order to "save" for a more expensive nonclinical service.
• The cost of the service/item is beyond the scope of the available funds for the package."

The above is provided as guidance only and is not an exclusive list.

Where the home care provider is unable to give effect to the consumer's preferences or request for services, the reasons must be clearly explained to the consumer and documented.

7. Duty of care issues and commentary

Each service provider must undertake their duty of care and advise of material risks. In relation to risk and liability there needs to be a balance between the autonomy of the client and risk management.

There has been and will continue to be a duty of care owed by service providers to safeguard the health and wellbeing of consumers – CDC does not change this.

CDC requires service providers to be more transparent and competitive.

All service providers should have policies and procures in place to ensure compliance with work, health and safety laws, privacy, consent and consumer rights. They should all have appropriate insurance. CDC does not change these legal obligations.

10. Further information

For more information refer to:

• the Home Care Packages Programme Guidelines July 2014;
• Evaluation of the Consumer-directed care initiative – Final Report (KPMG);
• User Rights Principles 2014 (Cth);
• Aged Care Act 1997 (Cth); and
• Department of Social Services' Information on Consumer Directed Care Packages⁸.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.