What’s the deal with Care Coordination?

Have you noticed how much trickier things have become when it comes to client management?

When I started out in the aged care industry in remote communities, we simply received a referral and worked with the local clinic to ensure the person got the care and support they needed – within the limits of our staffing levels and competence.

Our paperwork consisted of a laundry roster and a tick sheet that acted as both the prompt for certain services to be provided and the record of those delivered.

With the introduction of individualised care packages, we did get a little more formal and developed a one-page, image-based care plan which, although checked annually, usually remained in place unless there was a significant change in service needs of the person.

As a small service provider, we were flexible and could adapt to the needs of a person quickly. Our monitoring was usually based on feedback from local staff but was not always documented. Back then, we weren’t asked for evidence of monitoring or for detailed assessments and care plans. After all, the formal home care industry was quite new.

But like all progress, as the industry matured and organisations were asked to be more accountable for where funds were being spent and what care people were receiving, the demands for hard evidence grew.

Now the expectations are much higher, not just for people on Home Care Packages (HCP), but also for those receiving support through the Commonwealth Home Support Programme (CHSP) and the National Aboriginal and Torres Strait Islander Flexible Aged Care Program (NATSIFACP).

We’ve noticed auditors are not only expecting to see a service delivery plan for CHSP consumers (e.g. where, when and how a service will be provided), they also expect providers to:

• develop risk plans based on the client’s known health conditions (where these impact on the service being provided)
• ensure staff are aware of, and trained in, how to respond appropriately to issues that may arise due to these health conditions
• monitor how well the service is meeting the client’s identified goals
• adjust the service plan where necessary and refer the person for additional support if needed.

You also need to maintain clear evidence that this is occurring – this is part of care coordination.

Personally, I view care coordination as case management for entry-level consumers, without the need to create budgets and statements or arrange the purchase of individualised items. Instead of being a separate charge, the costs of care coordination are incorporated into the unit price of each service.

With that in mind – let’s unpack the requirements for effective care coordination.

The Aged Care Quality Standards note that clients have the right to be consulted and respected, receive services that are appropriate, planned, delivered and evaluated regularly and have access to complaints and advocacy information and services. This applies to all aged care clients, irrespective of what program they are on.

Looking through the CHSP Manual, there is an expectation that providers will undertake several assessment functions related to the service being delivered. These may include:

• Home safety checks
• Client safety checks to support both the client and care workers
• Specialised assessments, if providing allied health or nursing care as a service type
• Malnutrition risk assessments by Meals providers (where they have this knowledge and capacity)
• Ongoing monitoring of the client and their home environment
• Regular monitoring on how the service is meeting the person’s needs and goals, as well as a formal reassessment at least annually
• Referring the person back to My Aged Care if the person’s needs change significantly
• Supporting a person to transition to another provider if appropriate

As a provider of CHSP services, you also need to make sure that any services are reflective of the person’s goals and the assessment outcomes identified in their My Aged Care support plan and that they are delivered in a way that is safe and upholds the wellness and reablement approach of the program.

We know that reablement is a key focus of CHSP and this may mean an intensive amount of service provision and monitoring over a short period of time – including a lot of interaction with the person and/or their carer. This can consume considerable care management time, despite being labelled as care coordination. It should be reflected in the higher amount of services being delivered to the person.

Other activities you may find yourself involved in under care coordination are:

• Staff briefing, including explaining any technical aspects of the service plan
• Arranging staff education to meet an individual’s specific needs (e.g. assisting with home dialysis or complex personal care tasks)
• Managing and monitoring any subcontractors you use to deliver services on your behalf
• Alerting the client when a staff member is running late or when the service needs to be rescheduled
• Writing up progress notes and emailing/talking to other agencies who are involved in the care of the person where this impacts on your service delivery.

Whilst we often think of people on CHSP as low care, the reality is that many people with complex care needs are accessing CHSP-level services while they wait for an HCP to be assigned.

If you are a provider operating in a rural and remote area, you may find the person has no one else they can turn to for support, so you end up as the ‘go to’ person and essentially become the person’s case manager.

So how do you make things easier for yourself?

How do you show evidence of your activities? How do you make sure you provide a quality service and be prepared for your next quality review?

In February 2020, CDCS held our first case management training course which was an overwhelming success. Many attendees and those who couldn't initially attend wanted further workshops – but you know what happened then… No face-to-face training during a pandemic, unfortunately.

But now, to meet demand, we are happy to announce the workshops are back! 🙂

We are running two face-to-face workshops in Alice Springs and Darwin in June this year. (For those who can’t attend, you won't miss out – we are developing an online course too.) If you are a case manager, care coordinator, or even a coordinator of supports, click the link below for more information.

Find out more about the Case Management Workshops here.

Hopefully this post has helped you become more aware of the requirements of care coordination and what is expected of you. If you can’t get to one of our workshops, don’t forget you can always go to the CHSP manual to read about your responsibilities. And, if you have any questions on this topic, you can reach out via the contact us page on this website.