UnitingCare Australia welcomes the opportunity to provide feedback on the discussion paper on a new program for In-Home Aged Care. UnitingCare Australia recognises and applauds the Government’s prioritisation of aged care reform and the consultative footing it has taken on this priority.

As outlined by the Royal Commission into Aged Care Quality and Safety, the current In Home aged care system requires improvement to deliver the Aged Care Australians deserve.

Through this submission we seek to emphasise the following four essential enablers of high quality In-Home Aged Care:

• Providing enough time to implement reforms,
• Clear responsibilities and roles,
• Effective communication and reporting, and
• Efficient and sufficient funding.

Providing enough time to implement reforms

The Government is seeking to commence the new In-Home Aged Care Program on 1 July 2024 but there are enormous policy issues to be settled and extensive reform is being undertaken across the sector more broadly.

There are eight Departmental consultations closing this quarter that are focused on the Aged Care sector, including major inquiries into:

• A New Approach to Regulating Aged Care,
• Aged Care on-site pharmacists,
• Towards an Aged Care Pricing Framework,
• Code of Conduct for Aged Care,
• Consultation on the strengthened Aged Care Quality Standards, and
• Independent Capability Review of the Aged Care Quality and Safety Commission.

There are fundamental design questions still to be settled in Home Care ahead of 1 July 2024, like:

• How self-management will work?
• How do we set up a work-force model for success?
• What is the role of the care partner?
• Who will pay and how much?
• How and where will information about care and costs be reported and shared?
• How will people effectively navigate a multiple service provider approach?
• How will the transition of existing people in the aged care system be achieved within the time frame?

Each of these issues and many others, once settled, will require considerable planning and preparation by providers.

Policy issues should be settled at least 12 months prior to the anticipated start date.

Clear responsibilities and roles

Care partnership should be broken-down into clinical functions and co-ordination functions. Splitting out care co-ordination and clinical care management allows providers the necessary flexibility to deliver care efficiently and to the highest standard.

The necessary skills and qualifications associated with each group of functions are distinct.

Care co-ordination is the administration of clinical and person care services for the consumer. Clinical care is addressing the changing clinical needs of the older Australian. (See Figure 1.)

Figure 1 – Clinical and co-ordination functions in care delivery

Clinical functions	Coordination functions
Ongoing review of the suitability of support arrangements, Receiving notifications, care issues and medical reports and responsibility for re-assessment, Advising the care team on care needs, choices and goals, and Ensuring care needs are being met.	Budget management, Care statements, Co-ordinating all care services, and Co-ordination reporting.

The diversity of tasks between each function group means that often it will be inappropriate and inefficient for one person to undertake both sets of responsibilities. This is especially true given the workforce shortage is particularly acute in clinical workers. Many providers already provide this combined function with multi-disciplinary care management teams.

Self co-ordination is suitable for people without clinical training while clinical care requires relevant qualification. Self-management where there are no, or minimal, clinical needs will often be appropriate and efficient, self-clinical care for emerging health conditions and increasing frailty will rarely be appropriate and efficient.

Flexibility needs to be built into the clinical and co-ordination function delivery to ensure clients receive an efficient and high standard of care.

Effective communication and reporting

Current communication and reporting systems are not sufficient to meet the goals of current reform. Systems will need to be developed to manage effective communication and reporting. The question of who carries reporting responsibilities needs close consideration as this has significant impact to care and regulatory outcomes. For example, the current SIRS in Home Care draft guidelines suggest that where more than one provider is involved in service delivery, they are not responsible for reporting incidents that are not related to their own staff providing care.

If a client is receiving clinical care from more than one provider, it would need to be explicitly known who is carrying the risk and responsible for reporting. It is also essential that all providers have a clear sense of when, how, and with whom they are required to communicate.

There are additional needs arising from multiple service providers, multiple billers, and self‑budget management:

• A payment system must account for available funds at any given time, approved service types, and claims against services from providers,
• The payment system would need to be accessible for a diverse client base with a mix of digital literacy skills,
• The system would need to be intuitive to calculate how many services of each type could be delivered with the budget over the life of the budget,
• The communication across the platform should have regard for the level of services being delivered, and
• Many organisations have already invested considerable resources into software making it important to understand the interface between systems.

Efficient and sufficient funding

A fixed care price subsidy has potential as an effective mechanism for the delivery of In‑Home Aged Care. It is essential that the subsidy is set at an appropriate level to cover all the costs of care delivery including a sufficient margin for investment and viability. It is also essential that sufficient service standard is available without any additional charge.

Fixed care price subsidy needs to be enough to provide a sufficient standard of service without additional charge while ensuring provider sustainability.

We note that consumer frustration with financial engagement is disappointingly high. The Aged Care Quality and Safety Commissioner recently presented on the top 10 complaint issues from consumers which included all of: Fees and Charges, Management of Finances, Financial Statements, Reimbursements and Communication about fees and charges.

A key objective of these reforms should be to provide consumers with straightforward and understandable financial engagement. This would strongly endorse a singular interface for financial interactions. Some financial interactions can only be undertaken by government, meaning the government is the only possible singular interface for all financial interactions. For providers, Government management of customer finance engagement will mean they can focus on care whilst only be required to bill and chase one entity.

Financial engagement with care recipients, including any copayment or means testing, should be undertaken and administered by the Federal Government. 

Guarding innovative practice that sets a provider apart in a tight market may be an unintended consequence of proposed funding mechanisms. This would greatly inhibit smaller or regional providers from having access to, or knowledge of innovations that may provide additional benefits to older Australians in thin markets where skilled workforce, and additional supports are harder to obtain.

Grant funding should be made available to support services in thin markets or with significant infrastructure costs.

We support the proposal that there be supplementary or additional grant funding for key services, acknowledging the additional costs in thin markets:

• Services with considerable infrastructure requirement – cottage respite, centre-based, social groups; especially where the service model relies on fixed minimum staffing regardless of client volumes.
• Short term restorative care – evidence shows the benefit of a care managed, multidisciplinary, short-term and intensive approach (different to just “up front” allied health) – grant funding for this service to be able to continue.
• Additional funding to account for extensive travel requirements/workforce costs in rural areas.
• Grants to support telehealth services in rural regions.

However, the competitive grant process needs to provide sufficient time for application, and implementation, in line with the reform timetable.

Specific grant funding should be made available to encourage investment in innovation and sharing of innovative practice.

The development of a new In-Home Care system should be considered in light of broader discussions about consumer contributions in Aged Care. The objective should be to implement an aged care funding model that balances government funding and equitable consumer contributions. This discussion should include current settings for lifetime contribution caps and means testing of the family home.

The In-Home Aged Care reform process should include consideration of sustainable revenue streams.