Carers Australia s response to the Independent Hospital Pricing Authority s discussion paper: Activity based funding for Australian public hospitals: Towards a Pricing Framework Carers Australia February 2012
About Carers Australia Carers Australia is the national peak body representing the diversity of Australians who provide unpaid care and support to family members and friends with a disability, mental illness, chronic condition or terminal illness or who are frail aged. Carers Australia s members are the eight state and territory Carers Associations. Our Strategic Plan 2009-2012 has a vision that caring is accepted as a shared community responsibility and a mission to lead change and action with and for carers. Carers Australia advocates on behalf of Australia s carers to influence policies, programs and services at a national level and it does so in collaboration with the Carers Associations. Carers Australia believes all carers should have the same rights, choices and opportunities as other Australians. Carers should be able to enjoy optimal health, social and economic wellbeing and to participate in family, social and community life, employment and education. Acknowledgement Carers Australia wishes to thank Donna Turner of Carers WA who drafted this submission on behalf of Carers Australia. Title: Response to the Independent Hospital Pricing Authority s discussion paper Activity Based Funding for Australian Hospitals: Towards a Pricing Framework Date: February 2012 Carers Australia Unit 1, 16 Napier Close Deakin ACT 2600 Telephone 02 6122 9900 Fax: 02 6122 9999 Email: caa@carersaustralia.com.au Copyright 2012 Carers Australia
Summary The identification and inclusion of family and carers in clinical health settings has been recognized as a safety and quality issue for hospitals and therefore impacts on the ability to provide a cost effective health care system. Models of Care describe best practice clinical activities that should be undertaken to ensure safety and quality in health care provision. Several of these Models of Care have now been revised to reflect that carer involvement and assessment is essential to best clinical practice. These clinical activities are not routinely captured in existing lists of services despite being considered best practice activities, and despite the time and skill required of clinical staff to carry out these activities. Recent policy and legislation at both the national and state level have affirmed that carers should be treated as partners of health professionals in the provision of formal care. Carers Australia argues that the full range of activities undertaken by clinical staff to ensure carer identification and inclusion needs to be captured through activity based funding (ABF) processes and added to the general list of services currently under development by the Independent Hospital Pricing Authority (IHPA). If the technical difficulties posed are too great, Carers Australia argues that these activities should be block funded until such time as these activities are adequately described, classified and costed so they can be embedded in ABF accounting.
A carer is a person who provides personal care, support and assistance to another person because that person has a disability, a medical condition (including a terminal or chronic illness) or a mental illness or is frail and aged. i Carers include family members, friends and neighbours. The ABS estimates there are more than 2.6 million carers in Australia. ii The Australian Commission on Safety and Quality in Health Care and several state health services have acknowledge that effective partnering with carers in health care settings can contribute to: reduced length of hospital stays reduction in unplanned hospital readmissions reduction in medication errors better management of chronic conditions in the home reduction in consumer and carer stress levels improved sustainability of the caring relationship improved uptake by consumers and carers in preventative health and selfmanagement programs. iii Recent policies and legislation at national and state level have affirmed that carers should be treated as partners by health professionals in the provision of formal care. The Carer Recognition legislation enacted by the Commonwealth Parliament in 2010 includes a Statement for Australia s Carers. The ten core principles which make up the Statement include (No 7) Carers should be regarded as partners with other care providers in the provision of care, acknowledging the unique knowledge and experience of carers. iv The Carer Recognition legislation also requires each public service care agency to take all practical measures to ensure that its employees and agents take action to reflect the principles of the Statement in developing, implementing, providing or evaluating care supports. v In several states, carer recognition legislation obliges state health authorities to ensure that carers are involved where decisions are made that impact on the carer. At the clinical level, these requirements are contained within Models of Care. In respect of care in the hospital setting, the clear implication of this legislation and policy is that family and friends who are caring for a person in their home need to be identified and involved in the treatment of the person when they enter hospital. Carers Australia argues that the clinical activities required to support the involvement of family carers in hospital settings should be adequately described, classified, costed and funded. This would then provide the opportunity for these activities to be included within performance measures and governance arrangements. We argue for this course of action because we believe it will promote ongoing improvement in the quality, safety and efficiency of health care. We also believe it is consistent with recent policy and legislation, at the national and state level, regarding the place and role of carers in the health and hospital systems.
Please see responses below to select questions. Principles Patient-based, adjustments in price need to be considered from a holistic perspective that encompasses an assessment of the home environment to which the patient who requires ongoing care is returning. The cost to a hospital of safely providing services to a patient can vary significantly due to differences in the ability of family carers to support the patient who requires assistance at home. For example, in the case below of a patient who has experienced a stroke, the cost to a hospital of implementing a care and discharge plan will vary depending on the characteristics of the family carer including their language and communication needs, their familiarity with caring tasks, and their physical and mental well-being. In the case below, the cost to the hospital could be significantly different if the carer required more or less support. Patient based adjustments alone will fail to account for cost variations A husband accompanied his wife who had experienced a stroke to a hospital in Perth. The husband was identified as being his wife s carer by hospital staff when his wife was admitted. As is consistent with the Carers Recognition Act 2004 and WA Department of Health Language Services Policy 2011, at admission, clinical staff determined that the husband had an age-related hearing impairment and moved the husband to a separate quiet room in order to provide him with information, to seek relevant information from him about his wife and to seek his informed consent for procedures to be carried out for his wife. As is consistent with the Stroke Model of Care 2012, in order to develop the care and discharge plan, staff assessed the husband s ability to undertake a range of tasks for his wife when she moved back to her home. After a multidisciplinary team meeting with the husband and wife, referrals were made to the social worker, occupational therapist, physiotherapist, pharmacist and speech pathologist. Each of these staff worked with the husband to train him in a range of tasks including how to communicate with his wife while she remained incapacitated, the administering of medications, the use of mobility aids, transferring his wife from bed to bathroom, how to help her to sit correctly and to transfer her in and out of the car, what to do in the event of a fall, how to identify if his wife was becoming fatigued during feeding, how to clear her throat and mouth, and how to prepare a modified diet. At each clinical handover, staff asked the husband for his input and informed him of his wife s progress and needs. Written instructions were provided to the husband about the care he was required to provide on return to the home. He was referred to appropriate carer support services. Phone contact details were provided in case he needed to ask further questions regarding his wife s care.
As a result of the family carer being identified, assessed, consulted, supported and referred, the discharge plan enacted was effective in supporting the patient s recovery and her return to her home, as well as maintaining the wellbeing of her husband and assisting him to provide care to his wife without putting him at risk. A significant amount of work was undertaken by clinical staff to ensure this outcome, an outcome that has potentially prevented the patient s unexpected readmission to hospital. What public hospital services should be included in new funding arrangements? Activities undertaken by staff to assess and involve family carers, as is required by Standard 1 of the NSQHSS 2011 and embedded in many Models of Care, are not currently identified as hospital services in ABF accounting. Carers Australia argues that the full range of activities undertaken by clinical staff to ensure carer identification and inclusion need to be captured through ABF processes and added to the general list of services currently under development by the IHPA. Failure to fund hospitals for carer assessment and inclusion is a risk to health, safety and efficiency and contradicts state and Commonwealth policy and legislation on carer inclusion in health care. Clinicians, consumers and carers should be consulted to determine if the list of services for ABF is adequate to meeting their needs and reflecting best practice in health service delivery. When should public hospital services be funded on an activity basis or a block grant basis? The technical barriers to including carer related clinical activities may require that these be block funded until they have been adequately described, classified and costed. Recently updated Models of Care vi and NSQHSS Standard 1 provide a sound initial starting point in identifying the full range of clinical activities required to achieve consumer and carer partnership in health care delivery and planning. However, consultation with consumers, carers, community members and clinicians is required to fully identify the range of clinical activities required to be undertaken to ensure safety and quality in health care provision. Additionally, IT systems must be redesigned to capture the identity of the carer (who may not be next of kin) and to create cost codes linked to carer related clinical activity. i National Carer Strategy 2011, Carer Recognition Act 2010, Carers Recognition Act (WA 2004), ii ABS 2011, Catalogue No. 4430.0, Disability, Ageing and Carers, Australia, Summary of Findings, ABS, Canberra. iii For example, NSW Health http://www.health.nsw.gov.au/mhdao/fc_mh_program.asp and Vic Health http://www.health.vic.gov.au/archive/archive2008/discharge/patrans/patrans_all.pdf iv National Carer Strategy 2011: Health and community care professionals should involve carers as partners in the provision of formal care.
Carer Recognition Act 2010, Schedule 1 The Statement for Australia s Carers: Carers should be considered as partners with other care providers in the provision of care. National Safety and Quality Health Service Standards 2011, Standard 1., 1.18.1 Patients and carers are partners in planning for their treatment. Carers Recognition Act 2004 (Western Australia): The views and needs of carers must be taken into account along with the views, needs and best interests of people receiving care when decisions are made that impact on carers and the role of carers. v Under the legislation the Department of Health and Ageing, for example, is a public service care agency. The legislation defines care supports broadly as policies, programs or services directed to carers or the persons for whom they care. Carer Recognition Act 2010, s 4 and s8. vi See for example the Stroke Model of Care http://www.healthnetworks.health.wa.gov.au/modelsofcare/docs/stroke_model_of_care.pdf