Part 5: Risks to the quality of home-based support services

Home-based support services for older people.

In this Part, we examine how well the Ministry and DHBs manage risks to the quality of services by:

Summary of our findings

The performance information collected at a national level is not adequate to ensure that the main risks to home-based support services are mitigated. Performance information needs to be improved to better inform policy and strategy development.

The Ministry is aware of the issue and has work under way to address this. The introduction of the InterRAI tool should help to provide better information.

The Ministry has required DHBs to include a restorative model of care, but has not provided DHBs with any guidance on how or by when this should be achieved. DHBs' progress has therefore been inconsistent.

DHBs have identified the quality of supervision and training of providers' staff as a significant risk to future service delivery. Increased pressures on home-based support services will require better trained and supervised staff. At present, DHBs cannot ensure that this risk is appropriately managed.

Collecting and using performance information

In our view, the Ministry and DHBs cannot be confident that home-based support services are effective and efficient now, or capable of meeting the expected future increase in demand. The Ministry and DHBs need to address the current deficiencies in performance information about home-based support services.

The cost of supporting older people living at home is likely to increase, because older people are living longer and increasing both in number and as a proportion of our population. DHBs will have to continue to decide how to best support older people within the available resources.

In our view, the Ministry and DHBs will need to ensure that the services provided give value for money in terms of effectiveness and efficiency. They cannot do this – or drive improvements and share good practice – without complete, reliable, and comparable performance information on the quality and cost of home-based support services.

Some performance information is collected, but the quality of the information that we reviewed is poor and cannot be relied on.

Provider audits do not give an effective overview of service quality. Providers are not audited regularly or often. When audits do occur, they include, but do not focus on, service quality. The audits identify risks but are mainly focused on compliance. Although contracts allow for satisfaction surveys that are sometimes carried out, surveys allow for improvements at a provider level only. It is difficult for the Ministry to provide leadership and a strategic approach to making improvements without sharing this information.

Service reviews can give a better overview of quality. These reviews provide valuable information for DHB management, identify where changes need to be made, give assurance, and drive improvement. However, the results are not shared with other DHBs or the Ministry to provide useful information to encourage or push improvements across DHBs and providers. Because the results are not shared, there is no comprehensive overview of customer satisfaction or whether services are improving outcomes for older people.

An appropriate number of key performance indicators would help the Ministry oversee the quality of services and allow DHBs to compare and benchmark against each other. Data quality could also be strengthened with regular audits of the information provided.

There have been no national surveys of the views of older people on home-based support services. Such a survey might be expensive but would be useful in informing policy development and ensuring that home-based support services meet current and future demand.

The Ministry needs improved performance information to better inform its development of policies and strategies. Without better performance information, the Ministry and DHBs cannot make informed decisions about service improvements, such as:

  • whether restorative care is yielding benefits in the quality of home-based support services and efficiencies and should be used more widely;
  • whether the cost of home-based support services across DHBs gives value for money in delivering services of a consistent and adequate quality;
  • which practices should be shared and promoted; and
  • whether cultural issues are appropriately understood in delivering home-based support services and what service modifications might be necessary.

Restorative care model

The Ministry has outlined in its Operational Policy Framework 2010/11 that it requires DHBs to include a restorative model of support. It is not clear how DHBs are to implement this model. For example, as at September 2010, nine DHBs (45%) were still delivering a more traditional model of support and eight (40%) were delivering a mix of traditional and restorative care. DHBs are implementing the restorative approach within different timeframes.

Our work has indicated that DHBs have been slow to implement restorative care for a variety of reasons, including not having enough resources, inadequate staff training, uncertainties about the cost of restorative care, and a lack of clear leadership from the Ministry. The inconsistent progress is leading to differences in the approach taken to developing support packages for older people and therefore differences in the quality of support they receive.

The intent of the restorative model of care is that older people will gain improved independence or maintain their level of function for as long as possible. The model relies on a multi-disciplinary team (primarily a registered nurse, physiotherapist, and occupational therapist) to provide an in-depth support plan. The plan sets goals and targets for an individual to restore some function where possible and so increase their independence and reduce their reliance on support.

The benefits of this approach are recognised internationally as reducing the cost of support over time and also increasing the quality of the older person's life, keeping them in their own home for as long as possible. This allows for flexibility to increase or reduce the "package of care"7 according to the older person's needs. This model has been successfully followed in several countries, including the United Kingdom. However, there is recognition that function can be restored only where it is appropriate; some older people's health will not improve.

There is a lack of information from DHBs on the effect of the restorative care model of home-based support services, so it is not clear whether the restorative care model is improving the quality of support that older people are receiving or whether efficiencies are being achieved. The Ministry is therefore unable to assess the success of this policy.

Cost of service delivery

In 2009/10, the cost of providing home-based support services to about 75,000 older people was about $224 million. The annual costs are expected to increase, not only because there will be more older people in future but also because older people's needs are becoming more complex. The proportion of older people receiving less than two hours of service is declining. In 2007/08, 62% of recipients received less than two hours of home-based support services a week. In 2008/09, 57% received less than two hours per week. This declined to 55% for 2009/10. DHBs appear to be focusing their resources on those older people with greater needs who require more than two hours of support each week.

There are inconsistencies in how DHBs purchase home-based support services. These include the amount that DHBs will pay providers, how services are described by providers, how needs are assessed, and various other differences. DHBs need the freedom to negotiate contracts with providers that take into consideration market forces, value for money, and community need. However, they also need to ensure that the outcomes for older people are fair and consistent, and not dependent on which provider delivers the services or where the older person lives.

There are also inconsistencies in thresholds used to access services. Although DHB thresholds can lead to inequity, there is some evidence that DHBs have been successful in directing resources to those with more complex needs. People requiring assistance with only housework generally receive two hours or less assistance each week. The Ministry is aware of the need for better information on the cost and delivery of home-based support services by DHBs to ensure a consistent quality of services and help deliver better value for money. The Ministry is in the early stages of preparing an approach to obtain this information. It is too early for us to comment on the Ministry's approach.

Ensuring that cultural and ethnic differences are respected

The annual Operational Policy Framework and other health policy documents have outlined the need to respect cultural and ethnic differences when home-based support services are delivered. The Ministry specifically expects DHBs to ensure that the cultural values of Māori are respected.

Because of the lack of performance information, DHBs cannot provide assurance that cultural differences are appropriately taken into account when home-based support services are delivered.

The current process of assessing needs and designing each individual "package of care" allows for cultural differences and the level of family and other informal support to be taken account of, together with individual preferences in how services are delivered. In our view, this is an appropriate mechanism for ensuring that services meet individual needs. However, the Ministry and DHBs cannot currently assure themselves that cultural issues are appropriately understood, and modify services if need be, without performance information on the delivery of home-based support services to people in different ethnic groups.

Working with providers to manage risks

DHBs and providers recognise that, as older people's care needs become more complex, the skill levels of home-based support workers need to increase. Providers say that they cannot increase skill levels given the current funding arrangements. In our view, DHBs need to work more collaboratively with providers to resolve this.

Providing home-based support services to older people is an area of potential risk. DHBs have overall responsibility for ensuring that services are provided in a safe and effective way. DHBs manage risks to service delivery through their contract management. Risks that were identified and provided for in the contracts we reviewed included:

  • support workers not providing the agreed services to the older person;
  • support workers providing other services, including services they are not trained to provide;
  • little or no supervision of support workers; and
  • injuries to support workers.

Most contracts between DHBs and providers require appropriate levels of supervision and training of support workers. From our review of provider audits, it appears that DHBs do not always follow up on non-compliance with these criteria. It is clear from our work with DHBs that they consider a significant risk to be whether providers will continue to have enough staff to deliver services.

In our view, DHBs will need to satisfy themselves, through effectively managing their contracts with providers, that those staff are appropriately trained and supervised. There is a large workforce providing home-based support services to older people throughout New Zealand. A 2006 study by DHBs of the community support workforce – of which home-based support service workers are a subset – estimated that there were between 18,000 and 25,000 workers. The report found that, according to providers, staff turnover is high – between 50% and 80% in the first year of their employment. For support workers who stay longer than one year, turnover is still high at about 40% annually. The DHB report commented that "This creates recruitment and retention issues that are significant. This leads to a high level of low-skilled workers."

The report also found that most support workers work part-time, with more than half working less than 10 hours each week, and many have no guaranteed hours. A Ministry study said that providers considered that the lack of guaranteed hours affected the quality and safety of home-based support services.

It is clear that the transient nature of the workforce and its terms and conditions create a considerable risk to the delivery of home-based support services. This was identified as another significant risk when we surveyed DHBs. One DHB identified the problems around workforce development as "erratic standards of employment, orientation, training and supervision, employer attitude to career pathways, staff pay and conditions".

Improving staff training

We looked at whether the Ministry, DHBs, and providers are working together to improve training and supervision for the providers' workforce.

Providers and DHBs believe that the quality of services and staff training are the two major issues that need to be addressed in the home-based support services industry. Appropriate training is important for the safety of the older person receiving the service as well as the support worker. Support workers are generally viewed as unskilled, and better levels of training are required to develop staff and ensure that those staff will be able to provide the increasingly complex support that older people need.

DHBs and providers are investing the additional funding they have received from the Ministry in the workforce to improve the quality of services. Providers are using the funding from DHBs to pay for training in varying ways. Some providers provide internal training, and others pay staff an increased hourly rate depending on training and qualifications.

However, the view of providers is that they cannot, through staff training, improve the quality of services delivered without further funding. Providers consider that, if they do not have the capacity to meet the costs of training or offer pay rates based on training and accreditation, then the skill base of their workforce will not increase.

Some limited progress is being made. The Ministry told us that Health Workforce New Zealand8 has made developing the aged care workforce a priority, and is working with the Tertiary Education Commission and tertiary education institutions to increase the aged care content of core health training qualifications. Health Workforce New Zealand has recently provided 300 training places for nurses working in aged care (including home-based support services).

Staff supervision

DHBs and the auditors of providers share the view that supervision of their staff by providers varies and needs to improve. Many support workers are carrying out their duties in the homes of vulnerable older people with little or no day-to-day supervision. Although there are few complaints about the quality of the work and the conduct of support workers, increased complexity and demand will place further burdens on staff.

Recommendation 5
We recommend that district health boards strengthen management contracts to ensure that home-based support staff provide high-quality services and are well trained and supervised.
Pamela and Keith

Pamela is 85 and has been receiving home-based support services for about four years. Her eyesight is deteriorating. Her husband, Keith, does all the cooking and some general caring for Pamela. They receive three hours of support each week to help them with household tasks, and Keith is provided with 26 days of respite care.

Being involved in services

Pamela and Keith do as much as they can but they do need help with some tasks. Keith said that older people should not be too proud to ask for help. Generally, support workers do a good job and staff are good at communicating with older people. Pamela and Keith think this is an important skill for support workers. If they have concerns about services, they can complain to their case manager. However, they felt they were not at the centre of services and that they did not have a choice in either their provider or their support worker.

7: The funding mechanism for home-based support is on the basis that providers are paid for the delivery of household maintenance services and separate payments for personal care services. A "package of care" combines these payments and allows more flexibility in that the provider can increase or decrease particular services in the package of care.

8: Health Workforce New Zealand is an advisory committee. It was set up in late 2009 to provide national leadership in developing the country's health and disability workforce. Health Workforce New Zealand advises the Minister of Health on all aspects of health workforce planning, within the wider programme of reform of the health system.

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