Insights in Aged-Care Policy From "Down Under," Part 1.
During my two weeks in Australia, I encountered a country making fundamental changes to its long-term care policies. Like the United States, Australia is facing its own 21st-century demographic challenge. The percentage of Australians over age 65 is expected to rise from 12% of the population to around 25% by the middle of the century. That mirrors the rise in the United States from 13% to an estimated 20% of the population by 2050. Australia's responses are in some ways similar to America's--and in others undeniably different.
Just as in the United States, the Australian government attempts to limit the amount it spends on aged care, both by setting the rate it pays providers and by controlling the number of residents or home care clients that providers can serve at government expense. Many American states use certificates of need to regulate the number of nursing homes that operate within the state. In Australia, providers receive government licenses for beds in "residential care facilities," which include nursing homes arm what are known as hostels. Hostels provide basic personal care services, similar to assisted living facilities in the United States (except without the chandelier in the lobby). In addition, the Australian government grants licenses for providing home care through what are called "community service packages."
Unlike the United States, Australia has not experienced a large growth in construction of private-pay assisted living facilities. As a result, there is a shortage of both nursing home and hostel beds as people live longer and their
care needs increase. The government is actually encouraging providers to build by issuing new licenses, based on regional census data, for residential care beds. The government's goal is to have in place 100 licenses for every 1,000 persons over the age of 70 in each region. The providers I spoke with seemed eager to get new licenses, leading me to believe that government reimbursement is more equitable than in the United States.
Part of Australia's efforts to prepare for its own senior boom is an emphasis on allowing people to age in place. A key to this are Australian policies aimed at narrowing the distinction between nursing homes, which developed as part of the country's medical system, and hostels, which developed out of government housing programs.
For example, Australia's new reimbursement system allows hostels to be paid for nursing home care if they choose to provide it. Many of the hostels I visited had been remodeled as part of a building certification program that began in 2000. They had been redesigned to facilitate residents' aging in place as they transition from what is called low to high residential care. In many of the residential care facilities I visited, the only obvious difference between the rooms of nursing home and hostel residents was the type of bed they slept in. Residents needing hostel-level care had regular beds, while those needing nursing care had adjustable hospital beds.
In addition to encouraging the building of new residential care facilities, the government is also issuing new licenses to expand the services offered to the elderly in the community. David Saddler, executive director of Aged Care New South Wales, an association of "church and charity" providers, and a former official with the government's Home and Community Care (HACC) program, said, "When the government began paying for community services, something unexpected happened. Providers would specialize in one service or another. One might provide lawn maintenance, while another provided housekeeping services." He said this made it very difficult or people to track down all the services they might need or to update them as their needs changed.
"The government's solution has been to develop community care packages," Saddler said. "With the packages, providers receive a uniform payment based on the level of care needed. They are responsible for either providing or arranging for all the care and services a client might need. This adds in the element of case management that was sorely missing in the previous system."
Providers are allowed to charge a modest fee for most community services, but they cannot refuse to provide services to someone who cannot afford to pay. Although this struck me as an interesting use of case management and capitated payments--concepts at the core of managed care--I realized that instead of the focus being on reducing costs, it really seemed to be on coordinating care.
The government is just getting ready to report on the results of a two-year trial of so-called extended-care community packages, which are designed to deliver nursing home care to people in their homes. The closest parallel in the United States is probably the PACE (Program of All-inclusive Care for the Elderly) Medicaid waiver program that allows for the delivery of skilled nursing care in community settings.
I asked Warrick Bruen, assistant secretary of the Community Care Branch for the Department of Health and Aged Care, what happened when a person could no longer be cared for in the community but did not want to leave home.
"Of course we can't force anyone to move against their will," Bruen said. "However, our assessment teams are trained to advise people about the limits to the care that can be provided through the community service packages. But sometimes that is not enough. I have seen families make incredible efforts in order to keep someone at home."
The assessment teams Bruen referred to are an interesting feature of the Australian system. While most Americans find entry into our long-term care system to be confusing, Australia has developed a well-organized point of entry into its long-term care system through its network of 140 government-sponsored aged-care assessment teams (ACATs). To gain access to nursing homes, hostels or community service packages, a person must be assessed by an ACAT. Ideally, the assessment teams are multidisciplinary, with members that include medical staff, social workers and geriatricians. The assessment consists of only 21 questions but ranges over a variety of topics-from difficulties with activities of daily living to a person's access to informal caregiving from family and friends. Aged-care providers I talked to and others were generally satisfied with the assessment system.
Bruen told me, "The primary purpose of the teams is to assess individuals and educate them about their options. Their role as 'gatekeepers' into our aged-care system is secondary."
Before the assessment teams were created, people had a difficult time learning about what services and providers were available in their community. People were often placed in inappropriate settings. Now individuals are usually referred to ACATs by their family physicians. Bruen said that this year his department will unveil a national toll-free number that will put people in contact with their nearest assessment team.
Case in Point
There is no substitute for a firsthand look at another country's facilities, and I was lucky to visit Avery Gardens just a few weeks after it opened. It is a new residential care facility in Coolangatta that, from the beginning, was built with the idea of implementing the Eden Alternative. Only about one dozen of its 60+ beds were filled during my visit. The staff were busy filling out the Residential Care Subsidy (RCS) paperwork for each resident so that the facility could receive the proper government reimbursement. Although the RCS is short--only 21 questions long, like the ACAT assessment--it was unusual for staff to have to fill out so many at once.
As a new facility, its modular design interested me. It had a lot of small meeting spaces and kitchenettes where residents, families and visitors could socialize in small groups. Like many other facilities I visited in Australia, it had a barbecue outside that families could use.
I went expecting to see architectural concepts that would be supportive of an environment featuring plants, animals and children. Staff told me that a koala and her baby did live among the gum trees that grow behind the facility, but apart from that, nothing about the physical plant seemed different from other homes. In speaking with the staff, though, I could tell that they were excited about implementing the Eden concept, no doubt an advantage in itself in making the Eden Alternative work.
Visiting a new home that was still mostly unoccupied gave me an opportunity to really talk with staff about reimbursement and regulatory issues. The comparison with the U.S. system was informative.
The Australian financing system recognizes that residential care consists of both healthcare and "accommodation" expenses. While the government pays for the resident's healthcare costs, providers are allowed to charge their hostel residents an accommodation bond-basically a loan residents make to the provider while they are living in the hostel. Regulations govern how much of a resident's assets must be left intact after paying a bond or when calculating accommodation fees for nursing home care. Bylaw, the minimum amount of assets a person must be left with when calculating a bond amount is AUS$24,500 (about $13,700 in U.S. dollars). Once a bond is collected, the provider is allowed to draw down a certain percentage (currently about 9%) of the bond for each of five years. The hostel also keeps the interest earned on the bond during the entire time the resident lives in the facility. When the resident leaves, the balance of the bond is refunded.
Nursing homes are financed differently. High-care-level residents who can afford to are expected to pay an accommodation fee for the first five years they are in a nursing home. The maximum amount of the fee is AUS$12.33 (or about $7.00 U.S. dollars) a day. Nursing homes cannot collect bonds from their residents, but if a person enters as a hostel resident, the provider can keep earning interest on the bond until that person leaves and the bond is refunded.
Australia, like most industrialized countries (the United States being an exception) assumes the responsibility of providing for the bulk of all its citizens' healthcare needs, not just those who are poor or have spent down to the point of becoming poor. In fact, Australians were surprised to hear that our system requires people to spend their savings before they qualify for government help through Medicaid. Although the Australian system expects those who can afford it to contribute to the cost of providing for their long-term care and housing, the system is also careful to serve those without houses to sell or life savings to spend. At the same time the Australian system protects at least some portion of a person's life savings.
To prevent a two-tiered system from developing, every residential care facility is required to provide care to a certain percentage of residents, determined for each region by the federal government, who cannot afford an accommodation payment. In addition to the government payment for care and services, providers receive what is called a concession payment from the government to cover the accommodation costs of these residents--a payment that from what I could determine seemed generally acceptable to providers.
Part 2 of this article will appear in a future issue of Nursing Homes/Long Term Care Management and examine the Australian equivalent of the RUG system and the Australian accreditation process.
Robert Greenwood was, at the time of this writing, public information specialist for the American Association of Homes and Services for the Aging. Currently, he is director of public affairs for the National PACE Association. Alexandria, Virginia.
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|Date:||Jun 1, 2001|
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