Part 3: Accessing home-based support services

Home-based support services for older people.

In this Part, we examine how well older people are able to access home-based support services when needed. We look at whether:

Summary of our findings

Information that DHBs produce about home-based support services is generally in plain English, comprehensive enough, and available in a range of places. Services appear to be available for older people who are referred and assessed as requiring support. The level of unmet needs – of older people who are not aware of the services available to them or are not referred to have their needs assessed after accessing health services – is not known.

Our review of the limited information available suggests that needs assessments are improving in timeliness and broadly adequate. However, further improvements are required to ensure that all older people receive effective and consistent assessments. Progress with the introduction of a consistent needs assessment tool (InterRAI) in all DHBs is on target. However, the allocation of services to needs once they are assessed can still be inequitable. The Ministry and DHBs need to do more work to ensure that services are appropriately allocated based on need. The Ministry is developing a framework that it expects will ensure a more consistent process for allocating services according to need and provide information to improve value for money.

Contact with older people, assessment, service delivery, and reassessment appear to be largely carried out in a timely way.

Accessibility of information about home-based support services

DHBs appear to be effectively informing older people about the availability of home-based support services.

Older people can access home-based support services through various means. Most older people are referred to the DHB's needs assessment service (which could be within the DHB or funded by it) by their general practitioner (GP) or another health professional. Older people can refer themselves to the needs assessment service, and can also be referred to the service by staff in their local council or in organisations such as Grey Power or Age Concern.3

Written information about home-based support services

In our view, DHBs have produced useful written information about home-based support services. Pamphlets and the other written material we looked at were generally written in plain English and gave a good overview of the referral and assessment processes and range of services available. The information was available in several places, including GPs' practices and public libraries.

However, feedback we received from one stakeholder suggested that a small number of DHBs needed to improve the quality and accessibility of this information. Providing useful and up-to-date information in places where older people can easily find it is important; it increases the ability of older people to make informed choices about the type and level of services they might need.

Website information about home-based support services

We reviewed the information available on most DHBs' websites about how to access home-based support services and what those services were. Generally, the web-based information was helpful, but several DHBs could improve the information they provide. Most websites had appropriate links to other services, and the information was easy to find and easy to read. However, several DHBs were redeveloping their websites and a small number had information on home-based support services that was not very easy to find.

In our view, some DHBs need to improve their web-based information. Access to information through the Internet is increasing and is particularly important for older people living in rural areas.

It appears that, when older people know about the availability of home-based support services and are assessed as needing support, their access to services is generally timely. Overall, healthcare professionals we spoke with were satisfied that services were effectively and quickly delivered to these people. Our review of a selection of provider audit results and DHBs' files supports this view.

Not enough clarity about the extent of unmet need

Although DHBs have plans and strategies that include some analysis of gaps in their service provision, it is not entirely clear whether there are older people who need home-based support services but are not able to access them or are unaware of the services' availability.

DHBs have tried to estimate the level of need for home-based support services by comparing their level of service provision with that of other DHBs. There is a national client-level data collection, but it has been managed primarily as a payment system. In the view of at least one DHB, it provides only limited data that is neither nationally consistent nor reliable, particularly for non-residential services.

In our view, wider use of the InterRAI assessment tool (see paragraph 3.18) should produce a nationally consistent set of data about needs assessment. This will enable DHBs to more accurately compare the level of services provided and the extent to which there may be unmet need in their community. However, it will not provide DHBs with any better information about the needs of older people who remain outside the primary health care system.

Effectiveness and consistency of needs assessments

The Ministry and DHBs are making progress with ensuring that needs assessments are carried out consistently.

DHBs have a degree of autonomy in how they allocate services to older people. Any older person wishing to receive home-based support services funded by a DHB must first have their needs assessed by the DHB's Needs Assessment Service Co-ordination agency (NASC).

Generally, assessment involves the following steps. After a person is referred to it, the NASC carries out an initial screening assessment, either by telephone or face to face. If appropriate, the NASC then carries out a detailed assessment, normally face to face. After this assessment, and if the older person qualifies for support, the NASC plans a support package. Ideally, this support is co-ordinated with any other health care the older person is receiving to ensure an integrated approach.

Different DHBs have been using different assessment systems. The Ministry's view is that these were non-specialist, non-validated, and opinion based. Older people have sometimes been subject to multiple assessments, which duplicated the information gathered. Also, there was no mechanism for detecting risks to an older person's health early. InterRAI could introduce a more rigorous and standardised approach, which could include detecting health risks at an earlier stage.

There are also differences in how DHBs allocate services to individuals after their needs have been assessed. It is likely that the differences in allocation will mean some inequity in older people's access to services. The scale of inequity is largely unknown because there is a lack of national information about the level of services provided. That said, the Ministry is concerned about inequity. DHBs will need to have ways to assess equity as demand for services increases as the population ages and as budgets become more strained as a result of pressures on public spending.

The Ministry and DHBs are implementing a more consistent assessment process. In 2003, the Ministry and DHBs began work to introduce InterRAI, an assessment tool for older people likely to require home-based support services. The intention is to have, in all DHBs, a single approach that consistently assesses the needs of older people. This is expected to provide a basis for effective and equitable allocation of services to meet needs. The InterRAI assessment covers matters such as mobility, personal care, health conditions, and nutrition.

The Government has supported the introduction of InterRAI with $19 million in additional capital and operating funding for DHBs. The Ministry recognised that DHBs had differences in their progress with implementation and their capacity to fully implement the system. As a result, DHBs had a staggered timeframe for implementing InterRAI. The funding was spread over four years, from 2008/09 to 2011/12, with the expectation that all DHBs would be fully using InterRAI within the four years.

The Ministry is confident that all DHBs will be using InterRAI to achieve nationally consistent needs assessment by 2012. In our view, the Ministry needs to use the information it will produce about the level of need and service allocation to guide further policy development.

Although Ministry data and our interviews with DHBs indicate that further training is needed, progress is being made. This is an improvement on the previous widely varied approaches to needs assessment.

Timeliness of assessments and reassessments

The information available about assessments suggests that they are timely and responsive to older people's needs. The information about reassessments is less clear, but DHBs recognise the importance of reassessments and this aspect of home-based support services appears to be improving.

Health services can involve a period of waiting. We wanted to check that older people did not have to wait an overly long time after applying for home-based support services.

We reviewed 100 randomly chosen files from three DHBs. Our review showed that, in most instances, older people received services that were timely and responsive to their needs. Adjustments were made to services to reflect changing needs. It was more difficult to assess whether reviews and reassessments were done in a timely way.

It appears that most older people are contacted within five days after they have been referred to an NASC to have their needs assessed. Most contracts between DHBs and providers, and standards outlined in the Ministry's Operational Policy Framework 2010/11, require providers to contact older people within five working days of a referral. Providers are required to report to DHBs on their performance against criteria and standards, including reporting on the time taken to contact people. We reviewed a sample of provider reports for a six-month period in 2010 to check compliance with this requirement. In all instances, providers reported that the assessments were completed within five working days.

Some DHBs have specified higher levels of performance. For example, some contracts require providers to contact people within two working days of a referral. Again, we found that these requirements appear to have been met in the sample of reports that we looked at.

Although assessments are generally timely, there is some duplication in the assessment process. After an assessment by the NASC, older people are referred to a provider. The provider creates an individual support plan for the person and a health and safety plan for the home. The provider will repeat much of the NASC assessment. Some DHBs have recognised this and have reduced duplication in the initial assessment process, which makes the process easier for the older person.4

Reassessing the needs of older people

The needs of individuals change over time. To ensure that the services delivered match these changing needs, DHBs need to ensure that older people are reassessed at least every 12 months. In the past, DHBs have struggled to ensure that older people have been regularly reassessed. In the view of the Ministry, this was partly because of co-ordination difficulties between health care support and home-based support, particularly when older people were discharged from hospital. DHBs also started to deliver support for more complex cases, which took up more resources and put more strain on the DHBs' ability to reassess people in a timely way.

We note that reassessments can be carried out by the NASC or by the provider of the home-based support service, who has an apparent conflict of interest.

Overall, DHBs recognise the importance of regular reassessments. The regularity of reassessments has improved in recent years, according to our limited review of DHBs' audit reports and the views of DHBs. Improvements in the reassessment of older people can be attributed to several factors, including DHBs recognising that they need to use resources more effectively to ensure value for money and that resources are available for more complex care cases. DHBs also recognise that people's needs change and that reassessment is essential to appropriately meet those needs.

There were problems in recent years with untrained staff in some DHBs using telephone reassessments to reduce or remove services for "business" rather than health or service co-ordination reasons, and without telling the older person what the purpose of the telephone call was. The Ministry has written to all DHBs to remind them of the appropriate use of telephone reassessments.

Recommendation 2
We recommend that the Ministry of Health, through district health boards, evaluate by June 2013 whether the use of a standard approach to assessment and reassessment is improving the way needs are assessed and home-based support services are allocated.

Ngaire is 88 and lives alone in her own home. Her mobility is fairly limited and she uses a walker to help her move around. She has used home-based support services for about three and a half years. She receives three and a half hours of support each week to help her with household tasks. This time is split so that a support worker visits her twice a week.

Support to remain at home

Overall, Ngaire is very happy with the support she gets. The DHB provided a ramp for better access to her house, which she says is excellent for her. The people who provide her services are hard workers and are very good. Ngaire enjoys having her support worker sometimes sit and have a cup of coffee and a chat with her. Socialising is important.

Ngaire's aim is to live at home safely and independently. Home-based support services are important to her because the support helps her to do this. Ngaire felt she could not stay in her home without the support she gets.

3: Grey Power is a lobbying organisation that promotes the welfare and well-being of New Zealanders aged over 50. Age Concern He Manaakitanga Kaumātua is a registered charitable organisation. A national office (Age Concern New Zealand He Manaakitanga Kaumātua Aotearoa) and a network of 34 member councils, branches, and associates provide information and advocacy services to older people.

4: For example, at one DHB, older people are referred to a central assessment facility before their needs are formally assessed. Based on information about the person's circumstances, people likely to have low- or medium-level needs are referred to a provider who will assess the person in their home. Because providers are legally responsible for the safety of their workers, the assessment can take place at the same time as the assessment of any safety issues for the support worker.

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