Direct to Service Referral for Clients in Need of Immediate Support

As you are aware, access to aged care services is via a My Aged Care referral and formal assessment.

However, what happens when a person requires emergency support because their health and safety are at risk?

Perhaps they no longer have a carer and they can’t carry out personal care tasks, or an illness has left them unable to cook for themselves anymore.

In recognition of these sorts of situations, provision has been made for a person to commence receiving basic, essential support through the Commonwealth Home Support Programme (CHSP), before being formally assessed and approved by My Aged Care.

This is called a Direct to Service Referral. It allows people to access essential support in four specific categories: Meals, Transport, Personal Care and Nursing. The Australian Government and My Aged Care have created a useful fact sheet on Direct to Service Referrals, which you can view by clicking here.

A referral may come directly from the My Aged Care call centre, the Aged Care Assessment Team, a health professional, or even the person themselves or their carer.

Just remember, this is an interim arrangement only. The person still needs to be referred to My Aged Care and undergo a formal assessment by either the Regional Assessment Service (RAS) for on-going CHSP support or the Aged Care Assessment Team (ACAT) if they are seeking a Home Care Package.

While the expectation in mainstream is that the person will be formally assessed within a couple of weeks, in a remote context it is often longer than this due to the logistics of the assessors getting out to complete the assessment.

So how might this look in a rural or remote setting?

Janie

Janie is returning home after having emergency heart surgery and subsequent rehabilitation. It has been determined that she will need some basic essential care support to aid her recovery, including assistance with personal care tasks and meals. Janie is keen to get out of hospital and go home as soon as possible, however the Aged Care Assessment Team (ACAT) are unable to complete a full assessment of her needs while she is in hospital and will need to complete her assessment at her home. The community where Janie lives is located on the edge of the Tanami Desert, a four-hour drive from the nearest major town, and the ACAT are not scheduled to visit for another six weeks.

To assist Janie in the interim, the ACAT contacts the aged care service provider on the community and makes a direct referral for CHSP level services for Janie; these include assistance with showering and daily meals on wheels, as well as transport to the shop on a weekly basis. The service provider is able to continue to provide this support until the ACAT are able to visit the community and complete the full assessment.

Of course we know that assignment of a Home Care Package is something that takes time. The ACAT is able to approve on-going CHSP-level support for Janie until she is assigned a Home Care Package.

Fred

The clinic nurse notices that Fred, an older man living on the community, has been losing weight. She refers Fred to the local aged care service for meals.

The aged care coordinator talks to Fred about receiving meals on wheels, letting him know that he will need to be formally assessed by the Regional Assessment Service (RAS). The coordinator assists Fred to complete the online My Aged Care referral to start the assessment process. A Regular Representative form is also completed as Fred would like the coordinator to talk to My Aged Care on his behalf. After talking to Fred and receiving his permission to discuss his needs further with the clinic nurse, the coordinator determines that Fred needs to start receiving meals immediately; this will prevent him from deteriorating further.

My Aged Care contacts the aged care service and after an initial screening conversation with the coordinator, they forward a referral to the RAS for a full, face-to-face assessment. While waiting for the formal assessment visit by the RAS, the service commences delivering meals to Fred to meet his dietary needs.

Reporting Requirements

The service provider records all services delivered to Janie and Fred as CHSP clients in the DEX reporting for the period.