The focus of our audit

Before anyone can move to a residential aged care facility (RACF) they must first be assessed according to Commonwealth requirements. This is performed by one of 44 Aged Care Assessment Teams (ACATs) in NSW. ACATs are funded by Commonwealth and state governments, but operate within Area Health Services (AHSs) of NSW Health.

ACATs function in a complex system of aged and other health and social services that are provided by the Commonwealth, state and local governments together with the community and the private sector. As ACATs are part of a Commonwealth Government program, NSW Health is required to confer with the Commonwealth on any changes which may impact on the program in NSW.

ACATs are part of larger teams that provide a range of support services to enable older people to live in their homes and maintain their independence. However if an older person is no longer able to live at home they may need to enter an RACF.

In 2004-05 ACATs assessed 63,000 older people, of whom nearly two‑thirds were living in their homes at the time.

Around 18,000 were assessed while in hospital, and two-thirds of them were recommended for residential care. This represents 41 per cent of the 29,000 people in NSW recommended to enter an RACF.

Most older people approved by an ACAT for entry to an RACF will have to wait for a vacant place to become available. Those who are assessed and approved while in hospital often wait there until a place becomes available.

This audit examines how well NSW Health assists older people to access RACFs. It includes the ACAT assessment, and how those people who have to wait in hospital following an assessment are cared for. We did not review the other services provided to older people by NSW Health.

Audit opinion

Assessment processes for older people needing to go to an RACF vary depending on the processes of the ACAT they see and whether or not they are in hospital.

ACAT members see themselves as advocates for older people. They focus on the welfare of their clients. The staff have specialised skills in dealing with older people, and know what support is available from different service providers.

The time taken by NSW ACATs in 2004-05 to first see clients was slightly slower than the national average. The time taken by individual ACATs to complete assessments varied from one day to several weeks. They also see clients in hospital faster than those with the same priority for assessment living in the community.

The data collected on ACAT performance was significantly revised during 2004 making comparisons with subsequent years problematic.

ACATs use different procedures to clinically assess clients, and there are no formal means of demonstrating that ACATs assess them consistently. However, the Commonwealth’s approval process provides for assurance that the client has received an appropriate assessment and recommendations consistent with the guidelines.

ACATs have more responsibilities than assessing older people for residential care. It is not clear whether they have sufficient resources for this additional workload.

The management of patients waiting in hospital for a place in an RACF depends on the hospital. Some hospitals have dedicated wards with specialised staff to care for these patients. Others accommodate these older patients wherever there is a spare bed, which may include transfer to another hospital.

Recommendations

We recommend that NSW Health:

§         ensure that all clients are assessed and treated in accordance with Commonwealth guidelines whether they are in hospital or living at home (page 20)

§         survey clients, carers, referrers and service providers to gauge satisfaction with services and identify improvement opportunities (pages 21 and 26)

§         clarify the duties that ACATs should perform and ensure they have sufficient resources to meet this workload (page 22)

§         improve the consistency and accuracy of data for performance management (page 25)

§         ensure that consistent assessment approaches are adopted by all ACATs so that assessments completed by different ACATs produce consistent recommendations (page 26)

§         publish ACAT performance (including the number of assessments and waiting times for assessment) in its annual report (page 27)

§         evaluate approaches used by different types of hospitals for managing inpatients awaiting residential aged care to identify better practices and encourage their wider adoption (page 31)

§         review existing data collections to provide more timely information on the number of older people waiting in hospital for entry into residential aged care (page 31).

Key audit findings

Chapter 1:
How does NSW Health assist older people access residential aged care?

Before people can move into a Commonwealth-funded RACF they need to be assessed and approved by an ACAT. Anyone can refer an older person for a residential aged care eligibility assessment.

In 2004-05, around 63,000 assessments were completed by ACATs in NSW. Almost half of those assessed were eligible to go to an RACF.

ACATs are jointly supported by the Commonwealth and the states. The Commonwealth funds ACAT members, but in NSW they are employed through NSW Health and are under the direction of AHSs. The states are required to provide infrastructure and support necessary for ACAT members such as office accommodation, cars and administrative support.

An older person applies for a place in an RACF of their choice after being approved by an ACAT. Each RACF, however, has the right to decide whether it will offer a place to an approved person.

Chapter 2:
How accessible are ACATs for people seeking assessment?

ACAT members assess clients wherever they are located, whether in hospital or at home.

In 2003-04 NSW ACATs were slightly slower to commence assessments than the national average but faster than three other states. Timeliness of individual ACATs varies widely, so clients in different parts of the state may wait longer than others to be assessed.

ACATs see clients in hospital within target times. However this is not always achieved for those living in the community while awaiting assessment.

The data collected on ACAT performance was significantly revised during 2004 and more recent comparable data is not available.

ACATs have more responsibilities than assessing the eligibility of older people for residential care. It is not clear whether they have sufficient resources for this workload, with funding being provided by both the Commonwealth and state governments.

ACATs must prioritise their workloads and competing demands to achieve the best balance between the important functions they perform such as assessing eligibility for RACFs, coordinating care for clients and other aged care duties.

Chapter 3:
Are assessment processes sound?

ACATs use different clinical assessment tools, and there are no formal means of demonstrating that recommendations are consistent across all NSW ACATs. However, the Commonwealth’s approval process provides for assurance that the client has received an appropriate assessment and recommendations consistent with the guidelines.

Based on 2003-04 data, assessments take longer to complete in NSW than the national average, and the performance of individual ACATs varies. However overall NSW timeliness has improved.

ACATs have procedures to advise clients and carers of assessment results and how to appeal. However, they do not all use feedback from clients, referrers and service providers to assess their satisfaction with the ACAT’s service.

ACAT performance is monitored and reported, but not publicly. Performance information is not consistently used for accountability or improvement.

Chapter 4:
How are people looked after in hospital while they wait for residential aged care?

Some hospitals have dedicated wards with specially trained staff for people awaiting a residential aged care place. In other hospitals this is not possible, perhaps due to hospital size and resources. In some cases patients awaiting entry to residential aged care may be moved to different wards or even to different hospitals to make room for new patients.

NSW Health conducts an annual census of the number of older people in hospital which includes those waiting for an RACF place, the reason they were admitted to hospital and how long they wait.

Response from NSW Health

NSW Health acknowledges the contents of the Auditor-General’s Report: Performance Audit: ‘Helping older people access a residential aged care facility’, and appreciates the opportunity to respond to the report.

The audit report reinforces the work that NSW Health has already commenced to improve the overall operation of the Aged Care Assessment Program in NSW and specifically the service provided by Aged Care Assessment Teams to older people in hospital eligible for admission to a residential aged care facility.

Our efforts complement the more recent decision by the Council of Australian Governments (COAG) to contribute significant funding to improve and strengthen the work of Aged Care Assessment Teams in assessing the care needs of frail older people. The audit report will help to inform the improvement processes that NSW Health is currently undertaking.

The attached response confirms NSW Health’s commitment to reviewing and improving practices and systems for helping older people access residential care, and the strategies we will pursue to implement the audit recommendations.

(signed)

Robyn Kruk

Director General

Dated: 7 November 2006

Attached Response from NSW Health

NSW Health appreciates the opportunities highlighted in this audit report to strengthen efforts to maintain and improve the health of the people of NSW. The Audit Office’s acknowledgement of the good practices of NSW Health in the care of older people is welcome.

The intent of the audit by the Auditor-General was to ‘examine how well NSW Health assists older people to access a residential aged care facility’. The audit’s scope was confined to a consideration of those older people waiting in hospital for admission to residential aged care.

NSW Health’s aim is to ensure that older people can access the right care in the right place at the right time. Meeting the needs of older people in hospital awaiting residential care is complicated by a sharing of responsibilities between the NSW and Australian Governments. The care of acutely ill patients in public hospitals is a responsibility of the NSW Government. The residential care of older people is a responsibility of the Australian Government.

In 2004-2005, there were over 500,000 episodes of care for older people in NSW public hospitals, and older people accounted for 48% of total hospital bed days. In the same period Aged Care Assessment Teams (ACATs) assessed over 63,000 older people of whom 18,000 were in hospital.

ACATs, as a key component of the national Aged Care Assessment Program, assess older people for eligibility for residential aged care and community aged care. The Aged Care Assessment Program (ACAP) is funded by the Australian Government and supported by the NSW Government. A funding agreement between the Australian and NSW governments is signed annually and articulates the obligations of both the State Government and ACATs under the Aged Care Act 1997 and associated regulations and guidelines. As part of the agreement, the NSW Government agrees to manage the operations of ACATs in NSW.

Older people in hospital frequently have a multidisciplinary comprehensive assessment, which is not a formal ACAT assessment, in order to access a range of post-hospital care and support services including community health, community nursing, Community Acute/Post Acute Care, ComPacks, Hospital in the Home and Sub-Acute Fast Track Elderly Care. When this range of options does not meet the expected needs of an older person, they may be referred for an ACAT assessment in hospital.

The assessment of older people in hospital is one of a range of functions carried out by ACATs. The primary role of ACATs is to comprehensively assess the physical, medical, psychological and social needs of frail older people and to assist them and their carers to access available services appropriate to their care needs. An ACAT assessment results in completion of an Aged Care Client Record (ACCR) and, when appropriate, delegated approval for a Commonwealth-funded program. Assisting older people to access appropriate care may involve the coordination of aged care and other support services to improve the appropriateness and range of services available to frail older people.

NSW Health supports the approach that ACAT assessments are best conducted in an older person’s home. However, the reality is that there will be some assessments and approvals which need to be conducted in the hospital setting. NSW Health seeks to ensure that older people are medically stable at the time of assessment and are given reasonable choice of residential aged care facility. This process is now being facilitated by the implementation of the Transitional Aged Care Program in public hospitals which provides opportunities for older people to have therapeutic support and time to consider their long term care options.

NSW Health has already identified opportunities for better practice. NSW has commenced improvement strategies, particularly through involvement in the Community Care Review as part of the Commonwealth strategy ‘The Way Forward’ introduced in 2004 and, more specifically, the national ACAP review instigated this year by the Council of Australian Governments (COAG) to strengthen and improve the ACAP nationally.

NSW Health will, with the support of Australian Government funding, undertake a number of projects over the next twelve months:

§          Conduct a statewide survey of key stakeholders, including clients, carers, service providers and general practitioners in order to inform the process of improving the consistency and overall quality of ACAT assessments.

§          Analyse client flows and map existing ACAT systems to better inform both program development and initiatives to improve consistency.

§          Provide training to ACATs to facilitate consistent local implementation of the NSW Aged Care Assessment Program Policy and Practice Guidelines.

§          Gather more appropriate and accurate evidence on which to evaluate ACAT practices, demand management and clinical reviews.

§          Provide support and training to strengthen monitoring and reporting mechanisms as part of improved clinical and corporate governance of the ACAP in NSW.

§          Build on identified opportunities to improve and strengthen the statewide management of the ACAP in NSW through the development and implementation of models of organisation for remote, regional and metropolitan ACATs that make best use of resources and support clinicians in providing timely and consistent assessments to frail older people.

Arrangements for the care and assessment of older people in hospital awaiting residential aged care demonstrates the complexity of managing the interface between the health and aged care systems. The Auditor-General’s report highlights opportunities for NSW Health to work with the Australian Government to further improve the coordination between the two systems so that frail older people and their carers receive appropriate, timely and consistent support. The following table sets out NSW Health’s specific responses to each of the recommendations made by the Auditor-General.

Attachment 1 to Management Response: Recommendations and NSW Health comments

The following table details the response of NSW Health to the Audit Office’s recommendations

Recommendation

Response

1.    Ensure that all clients are assessed and treated in accordance with Commonwealth guidelines whether they are in hospital or living at home

1.1  NSW Health has developed a draft Aged Care Assessment Program (ACAP) Policy and Practice Guidelines manual which will be released for field review by Area Health Services and adoption in 2007. Promulgation of the manual will be accompanied by a training package and on site follow-up sessions with Aged Care Assessment Teams (ACATs). This activity is part of a larger national project aimed at strengthening and improving the Aged Care Assessment Program in all States and Territories.

       Funding support for the above will be available from resources allocated under a bilateral agreement being negotiated with the Australian Government Department of Health and Ageing as part of the Council of Australian Governments (COAG) health reform program.

1.2  NSW Health has undertaken a review of all ACAT delegates across the State to ensure compliance with the national selection criteria introduced in 2005. Delegates are approved by the Secretary of the Australian Government Department of Health and Ageing to have designated authority under the Aged Care Act 1997. Only ACAT members who are Delegates may exercise the authority to approve people to receive residential aged care, including residential respite care, Community Aged Care Packages and, in some circumstances, flexible care. Area Health Services will be reminded of their responsibility to ensure compliance with Delegate appointment processes which in turn will help to ensure that clients are assessed and treated in accordance with Commonwealth guidelines.

2.    Survey clients, carers, referrers and service providers to gauge satisfaction with services and identify improvement opportunities

NSW Health will undertake in the first half of 2007 a statewide survey of key stakeholders of the ACAP, including clients, carers, service providers and general practitioners, in order to inform the process of improving the consistency and overall quality of ACAT assessments. It is intended to repeat this survey annually. Funding support for this work will be available under the bilateral agreement being negotiated with the Australian Government Department of Health and Ageing as part of the COAG health reform program.

3.    Clarify the duties that ACATs should perform and ensure they have sufficient resources to meet this workload

3.1  NSW is an active participant in the national ACAP review being conducted as part of the COAG health reform program. Two of the key areas of work involve analysing the role and functions of ACATs and reviewing ACAT models and business practices. These reviews will assist in identifying the core duties of ACATs nationally. In accordance with COAG’s expectations, significant progress in this area will be demonstrated by December 2007.

3.2  NSW Health together with the NSW Department of Ageing, Disability and Home Care is also an active participant in the Community Care Review which is seeking a more streamlined and efficient approach to the delivery of community care and support services nationally and may impact directly on the future role and functions of ACATs.

3.3  NSW Health will review and implement an improved ACAP infrastructure across NSW as part of the bilateral agreement being negotiated with the Australian Government Department of Health and Ageing. A key objective of this initiative is to determine the best use of resources to support clinicians in providing timely and consistent assessments to frail older people. Significant progress with implementation of change will be achieved by August 2007.

4.    Improve the consistency and accuracy of data for performance management

4.1  NSW Health will take specific action to strengthen data quality and the monitoring and reporting of data by ACATs as part of the bilateral agreement being negotiated with the Australian Government Department of Health and Ageing. Significant progress with implementation of changes and improvements to data collection in NSW will be achieved by December 2007.

4.2  NSW Health will continue to work with the NSW ACAP Evaluation Unit to improve data quality as a basis for performance accountability.

5.    Ensure that consistent assessment approaches are adopted by all ACATs so that assessments completed by different ACATs produce consistent recommendations

5.1  A study of the consistency of ACAT recommendations is another of the key areas of work identified under the COAG health reform program. NSW is contributing to a national project being undertaken by the ACAP National Data Repository to analyse variability in outcomes from ACAP assessments in all States and Territories. This project will assist in identifying national performance measures.

5.2  Statewide implementation of the NSW ACAP Policy and Practice Guidelines is expected to improve consistency of assessment approaches. The development and adoption of nationally agreed performance indicators will assist in monitoring, assessing and improving the performance of ACATs.

6.    Publish ACAT performance (including the number of assessments and waiting times) in its annual report

6.1  NSW Health will include ACAT performance data in its 2007/08 annual report and thereafter. The data reported will take into account the work underway at a national level on the development of performance indicators.

7.    Evaluate approaches used by different types of hospitals for managing inpatients awaiting residential aged care to identify better practices and encourage their wider adoption

7.1  NSW Health will evaluate the AARCS (Acute to Aged Residential Care Service) and similar models which specifically aim to improve the care and management of older people in hospital assessed as requiring admission to residential aged care. This intensive case management model initiated on the Central Coast is being extended across NSW under the COAG health reform program.

7.2  NSW Health will continue to gather and analyse data on older people in public hospitals who have been assessed and approved by ACATs for residential aged care. This work will be undertaken with the aim of identifying and promoting effective and efficient approaches to managing older people’s smooth transition from hospital to residential aged care where this form of care is required.

8.    Review existing data collections to provide more timely information on the number of older people waiting in hospital for entry into residential aged care

8.1  NSW Health will strengthen data quality and the monitoring and reporting of data by ACATs as part of the bilateral agreement being negotiated with the Australian Government Department of Health and Ageing. Priority will be given to obtaining in a timely manner, appropriate, accurate and comprehensive data to support the evaluation of both ACAT practices and hospital demand management strategies. Significant work will be undertaken during 2006-07 with a view to demonstrating improved reporting of ACAT performance data by December 2007.