Community Aged Care e-Waitlist Priority of Access POA Tool May 2010

1. Community Aged Care e-Waitlist Priority of Access (POA) Tool May 2010 National Ageing Research Institute Xiaoping Lin, Betty Haralambous, Kirsten Moore

3. Overview Background Methods Literature review Scoping survey Consultation The POA tool and pilot findings Implementation Future considerations

4. 1. Background

5. I would like to begin the background of the current referral process in Victoria. Of course, this is a simplified flow-chart. The process begins when the ACAS receive a client referral, which might be from the client, their family, their GPs or local councils. The ACAS then conducted a comprehensive assessment on the client to decide their eligibility for the packaged care and their individual needs. After an client is determined as eligible and been approved for the packaged care, the ACAS staff add the client to the Electronic Referral and Waiting List system. Relevant documentation (such as ACCR) are uploaded and the priority level of the client is also set up in the waitlist. The service providers then choose clients from the waitlist based on the clients’ priority level, the service provider’s target group, their resources and then made contact with clients or their carers. If everything goes smoothly, then the service providers will offer a package to the client. So you can see the electronic waiting list play a central role in this process.I would like to begin the background of the current referral process in Victoria. Of course, this is a simplified flow-chart. The process begins when the ACAS receive a client referral, which might be from the client, their family, their GPs or local councils. The ACAS then conducted a comprehensive assessment on the client to decide their eligibility for the packaged care and their individual needs. After an client is determined as eligible and been approved for the packaged care, the ACAS staff add the client to the Electronic Referral and Waiting List system. Relevant documentation (such as ACCR) are uploaded and the priority level of the client is also set up in the waitlist. The service providers then choose clients from the waitlist based on the clients’ priority level, the service provider’s target group, their resources and then made contact with clients or their carers. If everything goes smoothly, then the service providers will offer a package to the client. So you can see the electronic waiting list play a central role in this process.

6. ACAS Electronic Waitlist Web-based Accessed through secure online portal Clients registered on waiting list with appropriate providers Information is stored in a secure client data repository The Electronic Waitlist and Referral System is an innovation in Victoria ACAS. This e-waitlist system replaced the previous system where ACAS was required to refer clients individually to multiple providers, using multiple referral methodologies. The electronic waitlist is a web based system and is accessed through a secure online portal. Once approved, clients are registered with appropriate providers and referral information stored in a central and secure client data repository. The service providers then can log to the website through secure online portal. The Electronic Waitlist and Referral System is an innovation in Victoria ACAS. This e-waitlist system replaced the previous system where ACAS was required to refer clients individually to multiple providers, using multiple referral methodologies. The electronic waitlist is a web based system and is accessed through a secure online portal. Once approved, clients are registered with appropriate providers and referral information stored in a central and secure client data repository. The service providers then can log to the website through secure online portal.

7. This is what the e-waitlist look like and the information here is from the demonstration website.This is what the e-waitlist look like and the information here is from the demonstration website.

8. Priority in the E-Waitlist Priority decided using different approaches Some using locally developed priority tool Some using clinical judgment No consistency of decision making in regards to prioritisation The waitlist has a priority level, however, priority was decided using different approaches. Some ACAS used a priority tool and some use clinical judgement instead of the tool. Further, these tools were developed locally, they differed in what factors they used in deciding the priority. They also differ in how they decide the priority, some used tick box, some use checklist, some used a score. Therefore, there is no consistency of decision. There is obvious an need for a statewide priority tool. The waitlist has a priority level, however, priority was decided using different approaches. Some ACAS used a priority tool and some use clinical judgement instead of the tool. Further, these tools were developed locally, they differed in what factors they used in deciding the priority. They also differ in how they decide the priority, some used tick box, some use checklist, some used a score. Therefore, there is no consistency of decision. There is obvious an need for a statewide priority tool.

9. HACC POA NARI developed the original HACC POA in 2002 (Current version 2006) Feedback from staff Quick and easy to use Systematic process for allocating priority A means for confirming staff judgments Provides a transparent process for potential clients and referring agencies Provides a tool for measuring and recording demand for services NARI developed the original HACC POA in 2002.. In 2004 and 2006, the tool was revised in to align with the introduction and revision of the (SCTT). NARI developed the original HACC POA in 2002.. In 2004 and 2006, the tool was revised in to align with the introduction and revision of the (SCTT).

10. HACC POA4 The latest version is the HACC POA 4. There are 14 indicators to be completed. Half of the indicators were weighted. Once all 14 indicators have been completed, a total score can be calculated to determine the priority. The latest version is the HACC POA 4. There are 14 indicators to be completed. Half of the indicators were weighted. Once all 14 indicators have been completed, a total score can be calculated to determine the priority.

11. Aim: to develop, pilot and finalise a statewide priority of access tool for the CACPs/EACH Electronic Waitlist Governance Committee and ACAS Victoria This tool would promote consistency of decision making in regards to prioritisation of client need, benefiting clients by ensuring services are targeted appropriately

12. 2. Methods

13. Methods A literature review A scoping survey of current approaches Consultation with ACAS teams and service providers Pilot and revision of the draft tool

14. 3. Literature Review In the finding section, I will first report on the finding from the literature reIn the finding section, I will first report on the finding from the literature re

15. Draft Guidelines of Community Packaged Care Programs Purpose ‘provide individually planned and coordinated packages of community aged care services; meet the needs of frail older people with complex care needs assessed as eligible for low or high level residential care; and enable those who have expressed a preference to live at home to do so with the assistance of a package of care including residents of retirement villages” (DoHA, 2007) How do we define who is most in need? So the task of the priority tool is how to define who is most in need?How do we define who is most in need?So the task of the priority tool is how to define who is most in need?How do we define who is most in need?

16. Literature review - methods An update of the 2002 HACC POA literature review Search in medline and grey literatures Search relevant websites Key words: indicators of needs, aged care assessment, needs & aged care, risk & aged care, CACPs, EACH, EACHD, community packaged care Limited to English language, and articles after 2000

17. Limited evidence on which factor/factors are most important Who most urgently needs services Which combination of factors increase the urgency for services Some evidence that dependency level, carer availability and financial situation were important predictors of use of service Needs commonly assessed using measurement tools Literature review - findings Therefore, we focus on studies on needs and indicator of needs. The literature review found that there is limited evidence on which factor/factors are most important Who most urgently needs services Which combination of factors increase the urgency for services Even though, there is some evidence that Dependency level, carer availability and financial situation were important predictors of use of service. The review also found that needs commonly assessed using measurement tools. This links to another focus of our literature reivew. Therefore, we focus on studies on needs and indicator of needs. The literature review found that there is limited evidence on which factor/factors are most important Who most urgently needs services Which combination of factors increase the urgency for services Even though, there is some evidence that Dependency level, carer availability and financial situation were important predictors of use of service. The review also found that needs commonly assessed using measurement tools. This links to another focus of our literature reivew.

18. Literature review - findings Why a measurement tool? Evidence suggests different clinicians use different approaches to decision making Reduce individual styles/judgments Increase objectivity in assessment and service allocation Increase transparency for clients Here I also want to discuss why using a measure tool in determining priority. Evidence suggests different clinicians use different approaches to decision making. Therefore, a measurement tool will help to reduce individual styles/judgements and increase objectivity in service allocation. Furthermore, Importantly, The use of a tool in determining priority assists in creating a transparent process where clients can see that their priority is assessed the same way as others. Here I also want to discuss why using a measure tool in determining priority. Evidence suggests different clinicians use different approaches to decision making. Therefore, a measurement tool will help to reduce individual styles/judgements and increase objectivity in service allocation. Furthermore, Importantly, The use of a tool in determining priority assists in creating a transparent process where clients can see that their priority is assessed the same way as others.

19. 4. Scoping Survey In the finding section, I will first report on the finding from the literature reIn the finding section, I will first report on the finding from the literature re

20. Scoping survey - methods Aim: to gain information on current assessment and prioritisation practices among Victorian ACAS and CACPs/EACH/EACHD service providers Distributed to/through ACAS managers Returned by 11 ACAS teams (61%) and 42 providers

21. Scoping survey - findings Assessment tools used: Aged Care Client Record(ACCR), Victorian Service Coordination Tool Templates (SCTT) Various approaches in determining priority Locally developed POA tools based on client’s need The most common assessment tools include ACCR (Aged Care Client Record), SCTT (Victorian Service Coordination Tool Templates), ACR We examined current priority setting approaches used by Victorian ACAS. There are different approaches used in Victoria ACAS. Some of the ACAS used a priority tool, some did not use a priority tool. Instead, they set the priority based on clinical judgment or discussions at group meetings. Some refer to relevant guidelines to decide priority. Of the ACAS teams that used a priority tools, the tools are different in what indicators are included in the tool and how these indicator are assessed. The common indicators in these tools are dependency level (physical, mental, function), risk of abuse, carer availability/state, social, psychosocial, demographic factors, need for case management, other risk. We also examined factors providers considered when choosing clients: target groups, needs of the client, resources of the agency. It is important to highlight that the needs of the client, the priority of the clients in the waitlist, is just one of the factors the agency consider when they choose a client. This is important when we interpret the report of the waitlist. The most common assessment tools include ACCR (Aged Care Client Record), SCTT (Victorian Service Coordination Tool Templates), ACR We examined current priority setting approaches used by Victorian ACAS. There are different approaches used in Victoria ACAS. Some of the ACAS used a priority tool, some did not use a priority tool. Instead, they set the priority based on clinical judgment or discussions at group meetings. Some refer to relevant guidelines to decide priority. Of the ACAS teams that used a priority tools, the tools are different in what indicators are included in the tool and how these indicator are assessed. The common indicators in these tools are dependency level (physical, mental, function), risk of abuse, carer availability/state, social, psychosocial, demographic factors, need for case management, other risk. We also examined factors providers considered when choosing clients: target groups, needs of the client, resources of the agency. It is important to highlight that the needs of the client, the priority of the clients in the waitlist, is just one of the factors the agency consider when they choose a client. This is important when we interpret the report of the waitlist.

22. Scoping survey - findings Common indicators: dependency level, risk of abuse, carer availability/state, social/psychosocial factors, need for case management Factors providers considered when choosing clients: Client’s need, target group, resources of the agency The most common assessment tools include ACCR (Aged Care Client Record), SCTT (Victorian Service Coordination Tool Templates), ACR We examined current priority setting approaches used by Victorian ACAS. There are different approaches used in Victoria ACAS. Some of the ACAS used a priority tool, some did not use a priority tool. Instead, they set the priority based on clinical judgment or discussions at group meetings. Some refer to relevant guidelines to decide priority. Of the ACAS teams that used a priority tools, the tools are different in what indicators are included in the tool and how these indicator are assessed. The common indicators in these tools are dependency level (physical, mental, function), risk of abuse, carer availability/state, social, psychosocial, demographic factors, need for case management, other risk. We also examined factors providers considered when choosing clients: target groups, needs of the client, resources of the agency. It is important to highlight that the needs of the client, the priority of the clients in the waitlist, is just one of the factors the agency consider when they choose a client. This is important when we interpret the report of the waitlist. The most common assessment tools include ACCR (Aged Care Client Record), SCTT (Victorian Service Coordination Tool Templates), ACR We examined current priority setting approaches used by Victorian ACAS. There are different approaches used in Victoria ACAS. Some of the ACAS used a priority tool, some did not use a priority tool. Instead, they set the priority based on clinical judgment or discussions at group meetings. Some refer to relevant guidelines to decide priority. Of the ACAS teams that used a priority tools, the tools are different in what indicators are included in the tool and how these indicator are assessed. The common indicators in these tools are dependency level (physical, mental, function), risk of abuse, carer availability/state, social, psychosocial, demographic factors, need for case management, other risk. We also examined factors providers considered when choosing clients: target groups, needs of the client, resources of the agency. It is important to highlight that the needs of the client, the priority of the clients in the waitlist, is just one of the factors the agency consider when they choose a client. This is important when we interpret the report of the waitlist.

23. 5. Consultation After the literature review and the scoping study, we developed a draft POA tool, I won’t go into details of the draft tool because it has been revised substantially, I would instead focused on the main themes in the consultationAfter the literature review and the scoping study, we developed a draft POA tool, I won’t go into details of the draft tool because it has been revised substantially, I would instead focused on the main themes in the consultation

24. Consultation - methods 4 focus groups 2 with ACAS staff (one in metropolitan, one in rural area, 20 staff from 13 ACAS teams) 2 with service providers (one in metropolitan, one in rural area, 28 staff from 20 providers) Email survey for those unable to attend focus groups 3 ACAS teams 9 providers 89% response from ACAS89% response from ACAS

25. Consultation – findings Acceptance of need-based tool Welcome the idea of a statewide POA tool Revise some of the indicators Mixed ideas about weighting indicators No separate tool for each package Simplicity of the tool In the consultation, we Based on the literature review and the scoping survey, we developed a draft tool and seek feedback from the ACAS staff and service providers through focus groups and survey. I will discuss the tool later on and here I want to mention some issues that has been raised in the consultation. Raised some issues that are related to the electronic waitlist but beyond the scope of the current project, eg clients being eligible but not able to get a package due to long waiting list, clients on the waitlist not willing to accept a packageIn the consultation, we Based on the literature review and the scoping survey, we developed a draft tool and seek feedback from the ACAS staff and service providers through focus groups and survey. I will discuss the tool later on and here I want to mention some issues that has been raised in the consultation. Raised some issues that are related to the electronic waitlist but beyond the scope of the current project, eg clients being eligible but not able to get a package due to long waiting list, clients on the waitlist not willing to accept a package

26. 6. The POA tool and pilot finding So, based on the consultation, we develop a draft POA tool that went for pilotSo, based on the consultation, we develop a draft POA tool that went for pilot

27. POA Pilot Two options developed Guidelines and training materials developed Piloted for four weeks Training/information session Each team asked to complete 5-10 assessments Survey to collect general feedback De-identified copies collected So, basically, after the literature review, the scoping survey and consultation with ACAS staff and providers, we developed a draft POA tool that went to pilot. Two options developed (same indicators, but differ in how the indicators are assessed. I will present the option that had been selected later on, otherwise it is too confusing., Guidelines and training materials provided, Piloted for four weeks, Training/information session provided Each team asked to complete 5-10 assessments, De-identified copies collected. So, basically, after the literature review, the scoping survey and consultation with ACAS staff and providers, we developed a draft POA tool that went to pilot. Two options developed (same indicators, but differ in how the indicators are assessed. I will present the option that had been selected later on, otherwise it is too confusing., Guidelines and training materials provided, Piloted for four weeks, Training/information session provided Each team asked to complete 5-10 assessments, De-identified copies collected.

28. Need based tool 12 indicators on a single side page Each indicator is assessed on three levels: high/medium/low Priority was determined by total score of the indicators Here is the final POA tool we developed, Here is the final POA tool we developed,

29. The POA Tool There are some tick box on the topThere are some tick box on the top

30. List of indicators

31. Examples of indicators 1) Instrumental Activities of Daily Life (IADL): Consider whether the client has any difficulty at home with domestic activities, e.g. doing his/her housework and laundry, preparing meals for himself/herself, shop for food and household items. High-Mostly dependent; Medium-Partially dependent; Low-Independent We developed a detailed guidelines to help the assessor in filling the POA tool. We developed a detailed guidelines to help the assessor in filling the POA tool.

32. Examples of indicators 9) Informal carer or client status (coping) This question is not about availability of someone to provide care, but how well the informal carer supports are coping with this care. This question should also consider the sustainability of the informal carer (e.g. are they available for the long term?). If carer available High-Significant impact on carer; Medium-Moderate impact on carer; Low-Minimal impact on carer

33. Examples of indicators 9) Informal carer or client status (coping) If carer not available High-Can’t manage at home without additional support; Medium-have impact on the client’s general well being; Low-Client coping well

34. What the POA tool does not do Identify individual needs Specify levels or types of service provision for clients Provide a comprehensive assessment tool Determine eligibility for CACP, EACH and EACHD Replace clinical judgment and common sense

35. Who & When ACAS staff who conduct assessments of potential clients of CACP, EACH or EACHD Can be completed during the assessment with the client and/or carer or in the office after the assessment

36. Pilot findings 150 assessments by 12 ACAS teams (67%) 72% assessors found the tool easy to use Average time taken to complete the tool was 4.9 minutes 61% assessors felt confident about the results of the POA tool 61% assessors reporting agreement between POA and clinical judgment Assessments were completed for 150 potential clients by 12 ACAS teams (response rate: 67%). Of these 150 assessments, 132 have completed data and was used in data analysis. Most assessors (72%) found the tool easy to use Average time taken to complete the tool was 4.9 minutes. It is important to note that this is the time used for completing both options. Also, it take much longer to complete the tool for the first time, so the actual time will be less than 4 minutes. 54% assessors felt confident, 27% felt about the results of the POA tool Agreement between POA and clinical judgment was investigated and modifications were made to the tool to reduce mismatches. Assessments were completed for 150 potential clients by 12 ACAS teams (response rate: 67%). Of these 150 assessments, 132 have completed data and was used in data analysis. Most assessors (72%) found the tool easy to use Average time taken to complete the tool was 4.9 minutes. It is important to note that this is the time used for completing both options. Also, it take much longer to complete the tool for the first time, so the actual time will be less than 4 minutes. 54% assessors felt confident, 27% felt about the results of the POA tool Agreement between POA and clinical judgment was investigated and modifications were made to the tool to reduce mismatches.

37. Pilot findings You can also see the spread of the three priority levels are very similar in POA tool and the clinical judgementYou can also see the spread of the three priority levels are very similar in POA tool and the clinical judgement

38. Pilot findings Agreement between clinical judgment and POA tool in completed assessments We also investigate the agreement between clinical judgment and POA tool in the completed assessments. Of those, again 60% of the assessments is consistent with clinical judgment. We also want to make sure there is few big discrepancies between the POA and clinical judgment, as you can see only 4% of the assessment is very different from clinical judgment. And overall, there seems to be a tendency in the POA tool to put clients on a lower priority level than the clinical judgment. In summary, we think the agreement between POA and the clical judgement is acceptable. We also investigate the agreement between clinical judgment and POA tool in the completed assessments. Of those, again 60% of the assessments is consistent with clinical judgment. We also want to make sure there is few big discrepancies between the POA and clinical judgment, as you can see only 4% of the assessment is very different from clinical judgment. And overall, there seems to be a tendency in the POA tool to put clients on a lower priority level than the clinical judgment. In summary, we think the agreement between POA and the clical judgement is acceptable.

39. Pilot findings Explanations for disagreement: Four levels of priority (critical/urgent/routine/low) in old system Training Atypical clients/factors outside the tool Client extremely high on one indicator Clients tends to be on lower priority level on the POA tool than on clinical judgment. Explanations for disagreement: four levels currently (critical, urgent, routine and low) in the old system. Clinical judgment might use the old system and there is some problems in matching them with the three priority level in the POA tool Training: understanding of each indicator Atypical clients Client extremely high on one indicator, low on others, for example, depression, however, what we want to emphasize here is priority is relative, for the client who is depressed but otherwise well function, when compared the the clients who is high on most indicator, depressed and not functioning well, the latter should be on high priority than the one only high on depression Priority is relative Clients tends to be on lower priority level on the POA tool than on clinical judgment. Explanations for disagreement: four levels currently (critical, urgent, routine and low) in the old system. Clinical judgment might use the old system and there is some problems in matching them with the three priority level in the POA tool Training: understanding of each indicator Atypical clients Client extremely high on one indicator, low on others, for example, depression, however, what we want to emphasize here is priority is relative, for the client who is depressed but otherwise well function, when compared the the clients who is high on most indicator, depressed and not functioning well, the latter should be on high priority than the one only high on depression Priority is relative

40. Some suggestions: Longer trial Space for summary/comments Consider extra score outside the listed factors/indicators

41. In Summary Promote consistency in prioritisation Easy to use Most assessors were confident about results from the tool Acceptable agreement with clinical judgment Requires further testing

42. 7. Implementation

43. Implementation Implemented in late 2009 All ACAS teams who use the E-waitlist are using the tool No major issues in implementation A survey in April 2010 Response from both ACAS (n=49) and providers (n =30)

44. Findings from the survey ‘I find the tool satisfactory and easy to use’ ‘Quick and easy to use’ ‘I really like the tool ‘ ‘I find the tool sufficient’ ‘Happy with current format’

45. Findings from the survey 72% respondents received enough training and support when the tool was implemented 61% respondents found the scoring useful 68% respondents felt confident about the results 43% respondents found results from the tool consistent with clinical judgment

46. Findings from the survey Explanations for disagreement: Circumstance changed No weighting for indicators Factors outside the tool Same tool for CACP/EACH Urgency for service Circumstance changed: As client's are scored at the time of ax, by the time they are in contact with package provider, their score has often changed anyway. This scoring does not reflect in any way how we recruit clients at our organisation. I recently had an experience where the husband of a deceased CACP client was assessed as eligible for a CACP and was considered the highest priority. At the time he was grieving and awating foot surgery. 3 months post assessment, he has recovered from his surgery and reconciled greif and loss to a managable level and taken himself caravaning aruond Australia for 6 months - he is still listed as a high priority on the waitlist - he would have been an inappropriate CACP recipient. No weighting for indicator: Dementia behaviours and associated increased priority, carer coping.Generally to do with dementia and carer stress for which weighting can not be increased if someone is otherwise relatively independent. Clients with extremely high needs that have high level of informal support in the community will score high due to their needs but low priority is requested by family. Factors outside the POA tool Same tool for CACP/EACH All EACH recipients come up automatically as high priority merely because of their extensive care needs. Perhaps there needs to be separate tools for EACH & CACP The fact that CACP clients are scored on the same tool as EACH client applications puts CACP clients at a disadvantage. Urgency for service: the tool did not specify urgency for serviceI assessed a palliative care client last week who scored as medium on the POA but I felt she should've been marked as 'high'. Despite being predominantly bed bound, & in high need of services she scored well on cognition, behaviour, communication, sensory & environmental hazards which resulted in a good score despite the urgent need for services. On the other hand, well supported by the carer, but the carer is going to have a surgery, so, is low on needs, but high on urgency. Circumstance changed: As client's are scored at the time of ax, by the time they are in contact with package provider, their score has often changed anyway. This scoring does not reflect in any way how we recruit clients at our organisation. I recently had an experience where the husband of a deceased CACP client was assessed as eligible for a CACP and was considered the highest priority. At the time he was grieving and awating foot surgery. 3 months post assessment, he has recovered from his surgery and reconciled greif and loss to a managable level and taken himself caravaning aruond Australia for 6 months - he is still listed as a high priority on the waitlist - he would have been an inappropriate CACP recipient. No weighting for indicator: Dementia behaviours and associated increased priority, carer coping.Generally to do with dementia and carer stress for which weighting can not be increased if someone is otherwise relatively independent. Clients with extremely high needs that have high level of informal support in the community will score high due to their needs but low priority is requested by family. Factors outside the POA tool Same tool for CACP/EACH All EACH recipients come up automatically as high priority merely because of their extensive care needs. Perhaps there needs to be separate tools for EACH & CACP The fact that CACP clients are scored on the same tool as EACH client applications puts CACP clients at a disadvantage. Urgency for service: the tool did not specify urgency for serviceI assessed a palliative care client last week who scored as medium on the POA but I felt she should've been marked as 'high'. Despite being predominantly bed bound, & in high need of services she scored well on cognition, behaviour, communication, sensory & environmental hazards which resulted in a good score despite the urgent need for services. On the other hand, well supported by the carer, but the carer is going to have a surgery, so, is low on needs, but high on urgency.

47. Further consideration Priority is relative Weighting indicators Separate tool for CACP/EACH Urgency for service Further data collection

48. Thank you!