My Aged Care Regional Assessment Service Guidelines

June 2015 My Aged Care Regional Assessment Service Guidelines

Contents

2 My Aged Care Regional Assessment Service Guidelines

1 Purpose The My Aged Care Regional Assessment Service Guidelines (Guidelines) inform and guide the implementation of the My Aged Care Regional Assessment Service (RAS) and outline the assessment process and practices the RAS is required to follow when assessing a client’s aged care needs. The Guidelines complement – but not replace – the Deed.

1.1 Other resources The following resources form part of the core documentation RAS should review:  My Aged Care Guidance for Assessors  My Aged Care Assessor Portal User Guide – Parts One and Two  National Screening and Assessment Form User Guide. Resources Purpose The purpose of this document is to help Assessors understand how they will interact with My Aged Care. It provides contextual information My Aged Care Guidance for Assessors about new concepts and functions that Assessors will need to undertake via the My Aged Care Assessor portal. It also outlines activities that Assessors will be expected to complete. The My Aged Care Assessor Portal User Guide outlines how assessors will use the My Aged Care assessor portal (the assessor portal). It is split into two parts:  Part One provides an overview of the portal and describes the functions that an individual My Aged Care Assessor Portal User with the Administrator role in the assessor Guide – Parts One and Two portal will perform.  Part Two provides an overview of the portal and describes the functions that an individual with the Team Leader, Assessor, Delegate or Delegate support role in the assessor portal will perform. The National Screening and Assessment Form User Guide provides detailed information on the National Screening and Assessment principles, inputs, processes and outputs that Form User Guide underpin the use of the National Screening and Assessment Form.

1.2 Document key

3 My Aged Care Regional Assessment Service Guidelines

This is used to highlight a point that assessment organisations need to pay particular attention to. 1.3 Further information Further information to support assessors (including fact sheets, videos and frequently asked questions) is available at: www.dss.gov.au/MyAgedCare. A My Aged Care provider and assessor helpline (1800 836 799) is also available for technical support.

My Aged Care Regional Assessment Service are welcome to provide feedback on these guidelines. Feedback can be provided to [email protected]

4 My Aged Care Regional Assessment Service Guidelines

2 Introduction The My Aged Care vision is to ‘make it easier for older people, their families, and carers to access information on ageing and aged care, have their needs assessed and be supported to locate and access services available to them’.

2.1 Context My Aged Care was introduced on 1 July 2013 and consists of the My Aged Care contact centre (1800 200 422) and website (myagedcare.gov.au). My Aged Care currently provides: Information about aged care to consumers, family members and carers Online service finders that provide information on aged care service providers and assessors Online fee estimators for pricing on Home Care Packages and aged care homes.

After July 2015, people seeking access to aged care services for the first time will need to contact the My Aged Care contact centre to discuss their aged care needs and have a client record created. My Aged Care client interactions are described in the diagram on page 7. Clients receiving services prior to July 2015 do not need to register with My Aged Care unless their needs and/or circumstances change.

My Aged Care Regional Assessment Service Guidelines 2.1.1 My Aged Care client interactions The following diagram describes the interactions people have with My Aged Care.

My Aged Care Regional Assessment Service Guidelines

My Aged Care Regional Assessment Service Guidelines 2.2 Changes to My Aged Care in 2015 My Aged Care will be expanded in 2015. The table below details what is being introduced, and why it is being introduced. What is being introduced Why it is being introduced

Central client record To facilitate the collection and sharing of client information. RAS To conduct face-to-face assessments independent of service provision for clients seeking to access CHSP services. National Screening and Assessment To ensure a nationally consistent and holistic screening Form (NSAF) and assessment process. The NSAF will be used by contact centre staff, the RAS and existing ACATs. Web-based portals for: Client portal – to view their client record and update • clients personal details • assessors Assessor portal – to manage referrals, use the NSAF and • service providers update the client record Provider portal – to manage service information, referrals and update the client record. Service providers will This information will be presented on the service finders self-manage information about the via My Aged Care, and will support accurate referral of services they deliver clients to services.

Enhanced service finders that include To enable the provision of information about non- information about Commonwealth funded aged care services to clients and non-Commonwealth funded services the public.

These changes will result in: A consistent, streamlined and holistic assessment of clients Better access to accurate client and service information (for clients, representatives, carers and family members, service providers and assessors) Appropriate and timely referrals for assessment and services.

2.3 A nationally consistent screening and assessment process The national screening and assessment process has three components:  Screening conducted over-the-phone by My Aged Care contact centre staff.

My Aged Care Regional Assessment Service Guidelines o By asking a broad and shallow set of questions, contact centre staff will be able to facilitate the appropriate client pathway – to home support assessment, comprehensive assessment and/or direct to Commonwealth Home Support Programme services.

 Home support assessment conducted face-to-face by the RAS. o This holistic assessment will determine eligibility for Commonwealth Home Support Programme services and will result in the development of a goal-oriented support plan. This will include the consideration of both formal and informal services that are most appropriate to provide the client with support.

 Comprehensive assessment conducted face-to-face by Aged Care Assessment Teams (ACATs). o This holistic assessment will include the development of a goal-oriented support plan and will determine eligibility for services under the Aged Care Act 1997.

The National Screening and Assessment Form (NSAF) is a form designed to support the collection of information to support the screening and assessment processes. The NSAF ensures that:  A holistic assessment of client needs is undertaken  A wellness approach underpins the assessment process  Appropriate questions are included at each level of screening/assessment, with the assessment building on the information collected at screening  Previously collected information is displayed to assessors so that clients do not have to repeat their story.

My Aged Care Regional Assessment Service Guidelines 3 The My Aged Care Regional Assessment Service The RAS provides assessment services for people requiring either ongoing low intensity services or episodic short term higher intensity services in the community. The RAS will operate in 52 geographical Aged Care Planning Regions across Australia, excluding Victoria and Western Australia. These jurisdictions will continue to retain separate responsibility for the provision of assessment services in those jurisdictions.

3. 1 RAS interactions in the end-to-end business process Assessors will access the My Aged Care assessor portal to:  Create client records (in certain circumstances)  Manage referrals for assessment issued by My Aged Care contact centre staff  Access and update client records  Conduct home support assessments (using the NSAF)  Develop support plans  Refer clients for aged care services or further assessment  Generate reports  Access forms  Update their assessment organisation details and manage the set-up of individual staff members. The following information describes the assessor experience as summarised in the assessor interactions diagram (page 17). Further information is provided in Section 7 of this document.

3.1.1 Inbound referral The My Aged Care contact centre staff will receive inbound referrals from a range of users and participants (e.g. health professionals). Having received an inbound referral, My Aged Care contact centre staff will act on the information, and contact the consumer to discuss their potential aged care needs. Where an inbound referral has been received for a client it will be attached to the client’s record, and made available to assessors.

3.1.2 Registration and facilitated registration An assessor should encourage seeking aged care services to contact the My Aged Care contact centre to register with My Aged Care and in doing so, create a client record. If this is not the person’s preference, the assessor can register the person using the assessor portal, creating a client record. The client needs to provide consent to complete registration.

My Aged Care Regional Assessment Service Guidelines There will be times where an assessor attends a client’s home to conduct an assessment, and finds another person in need (potentially not registered with My Aged Care). The assessor should confirm whether the person is registered before commencing an assessment. Do not assume the person is not registered. If not record exists, register the person with My Aged Care and undertake an assessment (after contacting the My Aged Care contact centre to request that a referral is sent to their organisation). To facilitate registration via the My Aged Care assessor portal, a RAS should:  Determine if the client has an existing client record, by using the ‘find a client’ function  If it is determined that the client does not have an existing client record, seek the consent of the client and/or their representative for the following: o To be registered with My Aged Care and have a client record created o To the sharing of information with the Department of Human Services for identity verification.  Where the client does not have a client record, enter and submit the client’s personal information (name, date of birth and Medicare number) which will then be verified with information held at the Department of Human Services to ensure duplicate records on My Aged Care are not created  Provide the client with the Aged Care User ID generated when the client is registered. Following this process, the assessor must contact the My Aged Care contact centre to have the client referred to the organisation. The assessor will also need to ensure that a Team Leader (in the assessor portal) accepts this referral for assessment, and assigns the referral to the relevant assessor. An assessment should be undertaken only where appropriate to the circumstances, including information available in the client record if available.

Assessors should refer to the My Aged Care Guidance for Assessors document for more information about this process.

3.1.3 Receive referral All referrals for home support assessment are sent to the RAS via the My Aged Care assessor portal. Upon receipt of a referral, a team leader can access the client record that contains information gathered during client registration, screening and previous assessments (if applicable). A priority rating is also available to assist in identifying the urgency for response required and to assist in managing assessor workloads and schedules. After acceptance of the referral, a team leader can assign a client to a particular assessor. The assessor must have the necessary skills and capacity to undertake the assessment.

My Aged Care Regional Assessment Service Guidelines In some cases, the referral may be sent back to the My Aged Care contact centre such as in the instances that the RAS does not have the capacity; it is out of the assessment region; or an ACAT assessment is required.

My Aged Care Regional Assessment Service Guidelines 3.1.4 Assessment An assessor arranges an appointment with the client for the assessment. If possible the face-to-face assessment should be conducted in the client’s usual accommodation setting. This does not mean that the assessment cannot take place in other settings, such as a carer’s home. Assessment in a client’s usual accommodation setting assists the assessor to complete the environmental, physical and social components of the assessment by observing the level of independence and functioning and existing support arrangements in familiar surroundings. Upon commencement of the assessment, an assessor should introduce themselves to the client, display their identification and explain:  The role of the assessor and the overall assessment service  The assessment, support planning and referral process  Review or further assessment procedures. The assessor should sight two types of the client’s identification documents at the beginning of the assessment. Once the client’s identity has been verified, this information should be updated on the client’s record (by completing the ‘wallet check’).

My Aged Care Regional Assessment Service Guidelines

It is expected that whoever has face-to-face contact with the client in the first instance (i.e. an assessor or service provider) will sight client identification and record this information in the client record. The wallet check only needs to occur once. The assessment itself will be conducted using the NSAF which is available via the My Aged Care assessor portal, via the myAssessor app, or a printed version. As part of the assessment, the assessor will work with the client to explore their current level of support (including formal and informal forms of support), family and community engagement, health and lifestyle considerations, functional ability, cognitive or psychosocial considerations, and any issues relating to home and personal safety. The assessment will build on the previous screening or assessment information collected (where applicable). When conducting the assessment, the assessor is to:  Verify and update the pre-populated information that is provided from previous screening or assessment events, and  Complete information that has not been addressed. A copy of any previous screening and/or assessment and action/support plan will also be available on the client record so there is a record of each screening and/or assessment event from each interaction. Assessors will have several options for recording assessment information, including:  Online/real time – information is recorded during the assessment process via a mobile device (such as a laptop or tablet) connected to the internet  Offline – information is recorded on a mobile device that is not connected to the internet. Data is transferred when the device is connected to the internet at a later time  Manual – information is written on a paper form during the assessment and subsequently, when online, can be keyed into the NSAF via the Assessor Portal at the first available opportunity for the assessor. The assessor may also gather information from other sources such as the client’s GP or carers, with the consent of the client.

3.1.5 Support plan During and following the face-to-face visit(s) with the client, the assessor will work with the client to establish and document their strengths, goals and motivations in the form of a support plan. The plan contains the agreed recommendations for support which address the needs identified during the assessment, and may include reablement or restorative care

My Aged Care Regional Assessment Service Guidelines interventions. An assessor is responsible for ensuring that the client understands all aspects of the support plan, including the implications of recommended actions. Assessors should have a strong understanding of Commonwealth funded services and non- Commonwealth funded service providers that operate locally and provide services to meet client’s needs. Information on Commonwealth-funded services will be available on the My Aged Care assessor portal (see Match and refer below). Where a non-funded service may be best placed to meet the needs of the client, assessors should record relevant information in the support plan about the non-funded service, and provide information to the client about how they can contact the non-funded service. This can be recorded as a general recommendation in the client’s support plan. An assessment is considered finalised when the support plan is completed and the client has acknowledged the support plan. That is, the client is aware of the findings of the assessment and how their needs and goals will be addressed. An assessor may provide a hard copy of the support plan to the client and/ or their representative. It may also be viewed via the My Aged Care client portal.

3.1.6 Match and refer If the client’s support plan contains recommendations for Commonwealth funded aged care services, the assessor helps the client identify service providers in their region. The service finder available on the My Aged Care assessor portal contains information on the service provider’s services, availability, price (if available) and specific services for people with diverse needs. An assessor must ensure that clients are matched with service providers according to the client’s preferred area/location of service delivery, needs and preferences, and that proposed service options are discussed with the client. Assessors may send referrals electronically to one or more Commonwealth-funded service providers of the client’s choice, or provide the client with a referral code for the client to self-manage the referral. If a client has a preference for a particular service provider who does not have availability, the client can elect to be referred to that service provider’s waitlist on the system (if a waitlist is available). Clients may be on a number of waitlists at any one time. Where a service is not available to meet the needs of the client and the client does not want to be put on a waitlist, the assessor should have a further conversation with the client in order to consider other alternative options for support. Other options may include:  A different Commonwealth-funded service that could meet the need (on an interim or ongoing basis)  Non-Commonwealth funded services  The client and/or their carer/representative being able to address part of their need. An assessor may also refer a client for comprehensive assessment (with the client’s consent) where it is identified the client has more complex needs that may better be met by services under the Aged Care Act 1997.

My Aged Care Regional Assessment Service Guidelines Where required, the assessor is to provide short-term assistance to the client for the purpose of implementing the support plan. This may include monitoring referrals or discussing options with service providers for the provision of alternative services if necessary. The role of the assessor is finalised when an effective referral has been made or where the client has made a choice not to proceed with aged care services or to manage their own referrals. An effective referral is where:  A referral is accepted by a service provider;  The client has accepted responsibility for managing their own referral; or  The outcome of the Assessment is that no further action is required by the RAS. 3.1.7 Review and new assessment Changes in a client’s circumstances may result in the need for a review to be undertaken. Where there is a significant change in circumstance, a new assessment may also need to be undertaken. Review Review refers to a check of the effectiveness and on-going appropriateness of the services a client is receiving. There are two types of review:

My Aged Care Regional Assessment Service Guidelines Type of review Scope

Review by a service A review by a service provider relates to the way in which they deliver provider services(s) to the client. It may be requested by a client or an assessor (as identified in the client’s support plan), or initiated by the service provider. It is expected that a service provider will continue to undertake reviews in line with relevant programme guidelines. A review can be completed over- the-phone with the client. A review by a service provider will look at the following aspects of service delivery:  The frequency and/or intensity of services  The service sub-type(s) delivered  The appropriateness of setting another review date or an end date for service delivery  Comments relating to the provision of services to the client. The result of the review is recorded on the client record. Where the service provider identifies that there is a change to the client’s needs or goals, or that they may benefit from a different service, they can request a review by an assessor. This request can be facilitated from the provider portal which will provide details of the assessment organisation that originally assessed the client, for the service provider to contact over- the-phone. Service providers can also ring My Aged Care to request a review. Depending on the change to the client’s needs or goals, the assessor may undertake a review or new assessment. Review by an assessor A review by an assessor relates to the effectiveness and appropriateness of the client’s support plan. An assessor may set a review date of the support plan at the time of the assessment. A review may also be requested by a client or a service provider. It may be completed over-the-phone with the client. A review by an assessor will look at the following aspects:  The reason a review has been requested and its impact on the client’s existing assessment information and support plan  The appropriateness of the services in meeting the client’s goals  Any new goals for the client, and associated referral(s) for service  The appropriateness of setting another review date or an end date for service delivery. The outcome of a review by an assessor may be no change or an increase or decrease in services. Where the results of a review by an assessor affects the current delivery of services to the client, the assessor is to 17

My Aged Care Regional Assessment Service Guidelines Type of review Scope

contact the service provider and discuss the results of the review and the recommendations as it relates to the delivery of the service. Where changes to the support plan no longer reflect the outcomes on the assessment, a new assessment is to be undertaken. New assessment Where there is a significant change in a client’s needs or circumstances which affect the objectives or scope of the existing support plan, a new assessment may be undertaken. A new assessment can be requested by a client, or following a review by a service provider or assessor. This new assessment will be pre-populated with the previous assessment information and is to be updated to reflect the changes in needs and circumstances. Should the client’s needs have become more complex, a referral can be made for comprehensive assessment.

My Aged Care Regional Assessment Service Guidelines My Aged Care Assessor Interactions An overview of how Assessors interact with My Aged Care .

Assessment Organisation Assessor An organisation engaged by the Assessors undertake assessments in Commonwealth to conduct Aged Care accordance with the national assessment Assessments (RAS and ACATs). framework. y y r r i i

u myagedcare.gov.au My Aged Care Contact Centre u

q Inf ormat ion about q Computer Tablet / Phone aged care Phone Email Mail Fax Interpreter Mult iple Channels n n E E

Website that contains information about Contact centre that assists with aged care. This site is publicly available general enquires, registration, and access is anonymous. screening and referrals to services.

Assessment Organisation n n

o An organisation engaged by the o i i

t Commonwealth to conduct Aged Care t Assessments (RAS and ACATs). a a r r t t s s i i n n i Administrator and Team i m Leader Roles m d Assessor Staff d Administrator manages the Add, Remove or A Staff who have access to the My Aged Care A Organisation's outlets and allocates Updat e Users

r staff access to the portal. system to view referrals assigned by the r

e Team Leader. e

s Team Leader accepts referrals and AUSKEY s Data Entry

U assigns them to individual staff who U Administrator / Assessor can then access the client 's record Team Leader

d and undertake assessment. d n n AUSKEY a a

s s s s e e Assessor Portal c c Assessor Portal Assessor Portal (Login) c (Login) (User Management) c A A

l l a a t t r r o o

P Assessor P Portal

l Assessment Referral l

a A request to conduct an Assessment of a Client a r r

r is created by the My Aged Contact Centre and r

e allocated to the Assessment Organisation . e f f e e

Assessor Portal R R

(Assessment Work List )

e Allocate Assessor e v v

i Team Leader or i

e Administrator accepts e

c the referral and allocates c

e to an Assessor to e conduct the R Assessment. R

Assessor Portal (Client Details) Phone Contact n (Typical) Assessment Appointment n a a l An appointment is arranged l

P for the Assessor to undertake P

t the assessment. t r r

o Assessor Appointment o Interpreter

p Assessors undertake assessments in accordance p with the national assessment framework, using p p the National Screening and Assessment Form. Client u u Assessment Outcome S S

Assessment and Clients are notified with the

d Assessor discussion about outcome of the Assessment and d needs and

n preferences. this information is recorded in n

a Assessment their client record. a

Support Plan Outcome Letter t The Assessor and Client work together to t n establish a support plan that reflects the Client’s n e needs, goals and preferences. The Assessor e records this information in the client record. m Approval m s Comprehensive assessments s s s Assessor Portal require a Delegate to review and e (Support Plan) approve the assessment when e s complete. s

s Support Plan Delegate s A A r r

e e f f h Service Finder Service Referral h e e

c Assessor Portal c

t Find services that meet the (Service Finder) Electronic referral to a t R R

a Client’s needs using a Commonwealth Funded a

d national repository of aged Service Provider. d M M

n care services. n a a

My Aged Care Regional Assessment Service Guidelines 4 Assessor Requirements and Training Assessors must be trained and credentialed before they can access the My Age Care system and undertake assessments. The Department engaged CIT Solutions, a Registered Training Organisation (RTO) to deliver this nationally recognised training and CIT Solutions are being assisted by partner RTO’s to achieve this delivery by 1 July 2015.

4.1 Assessor Requirements All Client-facing RAS personnel must be credentialed before they are provided access to the My Aged Care system and are able to undertake assessment. The RAS must ensure that:  police checks are undertaken for all personnel;  all personnel are fit and proper persons to perform their designated roles;  all personnel are not "prohibited persons" under child protection legislation in a State or Territory;  all personnel have the necessary experience, skill, knowledge, qualifications and competence to perform the Assessment Services in an efficient and professional manner; and  all personnel hold and maintain such licences, permits, approvals, insurances and registrations as are required under any State, Territory or Commonwealth legislation to perform the Assessment Services. The RAS must also ensure that its personnel receive the ongoing training and professional development they require to maintain their credentials and appropriate skills to deliver the Assessment Services, as appropriate to their respective role. The following sections explain the training requirements for RAS personnel, including Home Support Assessors and Team Leaders. This includes a requirement to:  undertake competency-based training;  complete and submit competency assessment tasks to the Department’s Registered Training Organisation (RTO) for evaluation, within a timeframe of 4 weeks;  receive an academic pass upon successful completion of the competency assessment tasks, which will be evaluated by the RTO. The process of evaluation and approval of assessment tasks typically takes between five and ten working days depending upon the quality of the assessment tasks;  commence assessment and complete a third-party assessment report for evaluation by the RTO; and  receive a statement of attainment and certification from the RTO following the approval of third-party reports, which typically takes ten to twenty working days.

4.2 Mandatory Training Statement of Attainment 2 and Statement of Attainment 3 represent the mandatory training assessors will need to undertake. RAS assessors are required to complete Statement of Attainment 2 which includes the following units of competency:  Work effectively with older people 20

My Aged Care Regional Assessment Service Guidelines  Operate referral procedures  Conduct individual assessment  My Aged Care and NSAF system training. RAS team leaders are required to attend, participate, undertake units of competency under Statement of Attainment 3. Where they are able to complete the activities associated with the unit of competencies (i.e. attend a comprehensive assessment and develop a support plan) a Statement of Attainment will be issued. Statement of Attainment 3 includes the following units of competency:  Work effectively with older people  Undertake advanced client assessment  Implement goal directed care planning  My Aged Care and NSAF system training. Where a RAS team leader cannot complete the activities associated with the unit of competencies, they are required to complete a Statement of Attainment 2 including the following units of competency:  Work effectively with older people  Operate referral procedures  Undertake advanced client assessment (attendance required)  Implement goal directed care planning (attendance required)  Conduct individual assessment  My Aged Care and NSAF system training.

Assessors should contact their RAS organisation for more information on the Statement of Attainments.

My Aged Care Regional Assessment Service Guidelines 4.3 Elective units Elective units are also available to assessors and/or team leaders upon completion of Statement of Attainment 2 or 3. Elective units are not delivered by Workplace Trainers. Elective units can either be completed online or in a self-paced mode by the participant using materials provided by the RTO. The RTO will be responsible for evaluating assessment tasks and certifying that an assessor or team leader has successfully completed the elective modules. Elective units include: AQF Unit of Competency Prerequisite Training Level AQF 4 Work Effectively with Culturally Diverse Statement of Attainment 1, 2 or 3 Clients and Co-Workers (HLTHIR403C) AQF 4 Work Effectively with Aboriginal and Torres Statement of Attainment 1, 2 or 3 Strait Islander people (HLTHIR404D) AQF 4 Use targeted Communication Skills to Build Statement of Attainment 1, 2 or 3 Relationships (CHCCOM403A) AQF 5 Develop, Facilitate and Monitor all Aspects Statement of Attainment 2 or 3 of Case Management (CHCCM503C) AQF7 Work Effectively with Carers and Families in Statement of Attainment 3 Complex Situations (CHCCM705C)

4.4 Mode of delivery of training From July 2015, the Department, through CIT Solutions, will be providing two modes of training for all assessors. Mode One: Online Learning Assessment Mode One ensures accessibility for participants across Australia at any time. In this online mode, RAS participants enrol via CIT Solutions e-learn system. Individual participants at any time can:  Enrol with CIT to complete their online training  Use the integrated online submission for all assessment items  Where appropriate, be awarded nationally recognised qualifications (i.e. Statement of Attainment). In addition to completing the online training, participants will need to attend the one day My Aged Care and NSAF system training. This component of the training can be delivered by RAS workplace trainers or team leaders.

My Aged Care Regional Assessment Service Guidelines Mode Two: RAS Workplace Trainer-led delivery with E-learning environment Under mode two, for each individual unit comprising a Statement of Attainment:  RAS workplace trainers will deliver the content under each unit to participants in a face-to-face training environment.  Participants access the CIT Solutions assessment portal, where the workplace trainer delivered content is placed in context and competency is assessed via online assessment activities  CIT Solutions also assesses submitted activities and issues qualifications where the participant has completed assessment tasks correctly and demonstrated competency  The RAS workplace trainer delivers a one-on-one (or one-to-many) review session to: o Assess the application of skills in the workplace; and o Validate participants learning. As part of the one-on-one review session, workplace trainers may wish to dive deeply into content related to the workplace and provide any coaching or additional support to participants as required. Please note that for both modes of training there is a distinction between the receipt of an Academic Pass and a Statement of Attainment. The Academic Pass is awarded upon successful completion of training activities and assessment tasks, and verification of this completion by CIT. This enables assessors and team leaders to commence the provision of assessment. The Statement of Attainment is the issuing of a nationally recognised qualification to assessors and team leaders. After the training and assessment tasks are successfully completed, assessors and team leaders are required to complete and submit a third party report. CIT will review the report for completeness, quality assure the participant and then issue the Statement of Attainment directly to them.

My Aged Care Regional Assessment Service Guidelines 5 The National Assessment Framework The purpose of the National Assessment Framework is to ensure a nationally consistent approach to assessing people’s aged care needs and eligibility for government-funded services. The National Assessment Framework provides assurance that the aged care assessment workforce, funded by the Commonwealth Government to conduct the processes involved in assessing a person’s aged care needs, is supported appropriately, and that reporting requirements by and for organisations and government are enabled. A governance structure will be in place to support the implementation and delivery of the National Assessment Framework. The National Assessment Framework includes the following components:

Overview – National Assessment Framework Workforce Staff in the My Aged Care contact centre My Aged Care Regional Assessment Service Aged Care Assessment Teams Funding Commonwealth funding to operate the Workforce Processes Nationally consistent assessments Complaints Compliance Quality Assurance Support ICT platform that operationalises My Aged Care, including the Assessor Portal User Guides (NSAF User Guide, Assessor Portal User Guide, Data Dictionary) National Training Strategy Departmental Administration Reporting Mandatory reporting Business reporting Organisation reporting Governance Legislation The Aged Care Act 1997 Workforce contracts and agreements Internal governance within the Department of Social Services focussing on operational control, policy, clinical guidance and engagement with other government agencies External governance including with consumers, stakeholders and peak bodies Engagement with delivery partners

My Aged Care Regional Assessment Service Guidelines 6 The National Screening and Assessment Form (NSAF) The NSAF has been designed to support the collection of information for the screening and assessment processes conducted under My Aged Care. It has been developed by the Department of Social Services based on existing best practice assessment processes from around Australia, and through significant consultation with stakeholders, particularly the Assessor User Group (made up of representatives from Access Points, Home and Community Care assessors and service providers and ACATs). The NSAF ensures that questions are appropriate to each level of assessment; that there is no duplication which would result in the client having to repeat their story; and that the appropriate client pathway can be facilitated through the completion of an action plan or support plan. A RAS must undertake home support assessment using the NSAF. The NSAF is built into the My Aged Care system and can be accessed through the assessor portal. The home support assessment component of the NSAF includes questions on a client’s current level of support (including formal and informal forms of support), family and community engagement, health and lifestyle considerations, functional ability, cognitive or psychosocial considerations, and any issues relating to home and personal safety. The following areas may be addressed as part of home support assessment:

Profile Overview of questions Reason for Contact Key circumstances triggering contact Current Support Services and support currently being received Carer Overview Type of care provided/being provided, difficulties or concerns with the caring relationship, sustainability of the caring relationship, client as a carer Family, Community Personal and family support networks, involvement in activities and client Engagement and interests, engagement with family and social/community groups, recent Support changes to family/cultural/social situation Health Health conditions, medication, recent hospital discharge, weight loss, oral health concerns, vision/hearing/speech, falls, pain General observations, health and wellbeing challenges, allergies/sensitivities, skin conditions, continence issues, sleep difficulties, appetite concerns, fluid intake, alcohol consumption, physical activity, health literacy Function Transport, shopping, meals preparation, housework, medicine management, money management, walking, showering, dressing, eating, transfers, toilet use – assistance received, assistance required Cognitive Memory problems or confusion, behavioural problems, decision making Changes in memory and thinking, changes in personality, psychological symptoms associated with memory loss 25

My Aged Care Regional Assessment Service Guidelines Profile Overview of questions Psychosocial Being nervous, depressed or lonely Stressful events, change in mental state, social isolation Home and Personal Risks, hazards and concerns in the home, concerns with living arrangements Safety Self-neglecting of care, equipment/modification required to maintain independence, personal and smoke alarms, personal emergency plan, driving ability, concerns with financial situation, safety concerns, legal issues Complexity Indicators Complexity indicators, risk of vulnerability, impact on ability to live independently Support Plan Client strengths and abilities, areas of difficulty, satisfaction with level of independence, hopes for change, areas of concern, goals, motivation, agreed action to be taken, referral information Questions in black text are questions that may be asked as part of the screening process and are to be verified or completed as part of the home support assessment process. Questions in green text are additional questions that may be addressed as part of home support assessment. Mandatory questions are underlined. Supplementary Assessment Tools are included as part of the NSAF and may be used by an assessor to inform a holistic assessment of a client’s needs. The use of these clinically- validated assessment tools is not mandatory, but should be used if a need is identified that requires a greater level of assessment. An assessor may also choose to use other clinically- validated tools at their discretion, but should record within the NSAF the name of the assessment tool used, the result of the assessment and also upload the assessment to the client’s record. The NSAF also includes a set of decision support rules that assists the RAS to make recommendations for the type of support a client requires. There are five types of decision support rules: Pathway and eligibility (e.g. this client should be referred for comprehensive assessment) Priority (e.g. access to assessment or service is a high priority) Recommended actions (e.g. the client should visit a GP) Complexity indicators (e.g. the client is living in inadequate housing or with insecure housing or is already homeless) Needs identification (e.g. behavioural concerns). It is important to note that the NSAF is not a decision-making tool nor is it designed to recommend particular service types a client should access. This will be the role of a trained assessor who, when developing the support plan with a client, considers their needs holistically, and recommends support most appropriate to their needs and circumstances.

My Aged Care Regional Assessment Service Guidelines This may include referral to Commonwealth-funded services or provision of information about non-Commonwealth funded services the client may wish to approach. 7 Home Support Assessment This section contains information as it related to the assessment process undertaken by the RAS.

7.1 Assessment principles The following principles apply at screening and face-to-face assessment (home support assessment and comprehensive assessment):  Holistic assessment of client need  Flow of information from screening and assessment events  Provision of support in line with the client’s goals  Promotion of consumer direction  Awareness of cultural and/or religious values, beliefs, gender identity or sexual preferences Further information on these principles is available in the National Screening and Assessment Form User Guide. It is important that assessors maintain professionalism in all interactions they have, both with clients and when recording information on the client record. Assessors should: Utilise information collected at screening Conduct the assessment with an open mind Withhold from having preconceived ideas about a client’s capability or the service pathways they may require Respect the client’s personal values and beliefs, health and lifestyle preferences, goals and privacy Impart knowledge to ensure the client is making informed decisions Record assessment information in an accurate, appropriate and sensitive manner.

The following principles apply to RAS when conducting home support assessment.

7.1.1 Preparation for assessment When scheduling an assessment with the client, an assessor should:  Confirm the client’s contact details and address/location of where the assessment is to take place

My Aged Care Regional Assessment Service Guidelines  Enquire if anyone else will be present at the assessment and whether the client is comfortable with the arrangement  Ask questions pertaining to work, health and safety in accordance with local policy and procedures.

My Aged Care Regional Assessment Service Guidelines Prior to the assessment, an assessor should:  Review relevant information pertaining to the client. This includes the client’s details, information collected during screening, and any other referral information provided  When relevant, talk to people who provide the client with support (following client consent)  Organise any assessment support such as an interpreter (e.g. Translating Interpreting Service), National Relay Service, Aboriginal Liaison Officer or advocate. An assessor should also be aware of the client’s willingness to participate in an assessment; their language abilities; and aspects of cultural importance, including any cultural practices that may need to be observed.

7.1.2 Client-centred approach to assessment A client-centred approach to assessment will enable the best outcomes to be achieved for the client. It involves: Conducting an assessment ‘with’ the client – taking into consideration the client’s needs, values, goals and choices, and not just the issues they present with Building a client’s confidence of their own abilities and acknowledgement of their areas of difficulty Empowering the client to make decisions about the type of support they wish to receive Generating a support plan that reflects the client’s goals and the type of support they wish to receive.

7.1.3 Involvement of family and carers Where possible, and with the client’s consent, an assessor should involve the client’s carer, family or other nominated representative as part of the assessment process, as they play an integral role in developing the most suitable support plan. Clients have a right to privacy and confidentiality, and their consent must be sought before other parties, including family members, become involved in the assessment support planning process. In circumstances where family and carers are not able to be physically involved, the assessor should (with a client’s consent) contact them to gain an understanding of the client’s needs and their capacity to continue in a caring role.

7.1.4 Assessor observations

My Aged Care Regional Assessment Service Guidelines Assessor observations are an essential component of assessment. Observations can verify or contradict information that has been obtained from informal and formal reports. They can help the assessor communicate with the client about their concerns and possible solutions in a practical way. Observations can be opportunistic, for example noticing how the person moves about the home, their facial expressions, the interpersonal dynamics between the client and others present. Observations can also be more overt and intentional, for example asking the person to demonstrate how they transfer, manage the stairs, open the medicine bottle etc.

7.1.5 Importance of developing a support plan in line with the client’s goals Goal setting is a key component of the assessment process and is facilitated through the development of the support plan. Asking clients to think about what their goals are allows an assessor to understand where the client’s priorities may be. These may be priorities in relation to support, or other goals the client may have in mind, such as leading a healthy and active lifestyle or reconnecting with the community. The goals outlined in the support plan do not have to be actioned through service provision, rather it is encouraged that clients and assessors think more broadly about ways to address the client’s goals, through formal and informal services. It is also important that the support plan is considered as an ongoing document that can be updated as needs change.

7.2 Wellness, reablement and restorative care Assessment and service provision is founded on a wellness approach that is embedded at all levels of the client’s journey through aged care. The provision of reablement and restorative care services are complementary methods of interventions. Wellness aims to promote independence and autonomy. The terms reablement and restorative care may be used to describe specific and time limited interventions and supports, with reablement aimed at adaption to changed circumstances and restorative care aimed at measurable improvements in an individual's capacity or function.

7.2.1 Wellness Wellness is a philosophy based on the premise that even with frailty, chronic illness or disability, people generally have the desire and capacity to make gains in their physical, social and emotional wellbeing and to live autonomously and as independently as possible. A wellness approach in aged care services therefore aims to work with individuals and their carers, as they seek to maximise their independence and autonomy. A wellness approach draws on the wellness philosophy to inform a way of working with people. It therefore involves assessment, planning and delivery of supports that build on the strengths, capacity and goals of individuals, and encourages actions that promote a level of independence in daily living tasks, as well as reducing risks affecting the ability to live safely at home. It avoids 'doing for' when a 'doing with' approach can assist individuals to 30

My Aged Care Regional Assessment Service Guidelines undertake a task or activity themselves, or with less assistance, and to increase satisfaction with any gains made. The wellness approach underpins all assessment and service provision and applies even when the need for assistance is episodic, fluctuates in intensity or type over time, or is of an ongoing nature. As the wellness approach becomes embedded in service delivery practices, Commonwealth Home Support Programme providers will be expected to:  Interpret the support plan with a wellness approach in mind and in consultation with the client  Work with individuals and their carers, as they seek to maximise their independence and autonomy  Build on the strengths, capacity and wishes of individuals, and encourage actions that promote self-sufficiency  Embed a cultural shift from 'doing for' to 'doing with' across service delivery  Be alert to changing circumstances and goals of the client and consult with the My Aged Care Regional Assessment Service where appropriate to review the client's support plan  Consult Living well @ home: Commonwealth Home Support Programme Good Practice Guide to assist in the development or good practices within a wellness approach (www.dss.gov.au/chsp)

7.2.2 Reablement Like wellness, reablement aims to assist people to reach their goals and maximise their independence and autonomy. However, reablement involves time-limited interventions that are more targeted towards a person's specific goal or desired outcome to adapt to some functional loss, or regain confidence and capacity to resume activities. Supports could include training in a new skill, modification to a person's home environment or having access to equipment or assistive technology. As part of the assessment process, RAS will need to work with the client to identify whether they would benefit from a reablement approach to home support services, based on their preferences and needs. It is anticipated that 10% of assessed clients will be referred to short-term reablement support services. If the client agrees that short-term reablement support is appropriate and beneficial to them, the assessor must include service solutions within the support plan which promote their independence. The support plan must include services which assist the client to maintain and/or strengthen their capacity to continue to undertake daily activities, and maintain social and community connections. For clients receiving reablement support, assessors must include review dates on the client’s support plan for the purposes of reviewing the client’s progress, requirement for ongoing 31

My Aged Care Regional Assessment Service Guidelines services, or whether to adjust the level of services required. The Review process is explained in section 3.1.7 of these Guidelines.

My Aged Care Regional Assessment Service Guidelines 7.2.3 Restorative care For a smaller sub-set of older people, restorative care may also be appropriate, where assessment indicates that the client has potential to make a functional gain. Restorative care involves evidence-based interventions led by an allied health worker or professional that allows a person to make a functional gain or improvement after a setback, or in order to avoid a preventable injury. Restorative care interventions implemented through the Commonwealth Home Support Programme will be coordinated by providers of allied health and therapy services that will help clients set (functional) goals and review their progress after a defined period.

7.3 Assessment of people with special and significant needs To assist in achieving more equitable access to all assessment services, the following groups of people are identified as having special needs (Note: Section 11-3 of the Aged Care Act 1997 identifies these groups of people with special needs):  people from Aboriginal and Torres Strait Islander communities  people from culturally and linguistically diverse backgrounds  people who live in rural and remote areas  people who are financially or socially disadvantaged  veterans  people who are homeless or at risk of becoming homeless  care-leavers  parents separated from their children by forced adoption or removal  lesbian, gay, bisexual, transgender and intersex people. In conducting assessments of people from these groups, all assessors should be aware of their special needs and be familiar with any information, materials, or expertise in the organisation to help meet this requirement. People from these groups can benefit from a service that links vulnerable people with particular services that are relevant to them; however, this identification with special needs is not always an indication of vulnerability. Care should be taken assuming vulnerability. Vulnerable older people are those who, due to the complexity and nature of their needs, may be unwilling or unable to access services they require to support them to live in the community in safety and with dignity. Where an older person’s complex circumstances may impede their access to aged care services, linking support will assist in linking the client to various services they require in order to live in the community with dignity, safety and independence.

My Aged Care Regional Assessment Service Guidelines 7.3.1 Aboriginal and Torres Strait Islander people Assessments of Aboriginal and Torres Strait Islander people should be carried out in a culturally appropriate manner by people who are acceptable to both the client and their community and who are qualified to carry out such assessments. Assessors should observe local protocols and create a culturally safe environment. It is desirable that RAS develop a good understanding of the communities in which they operate. This will ensure that advice and assistance provided to clients is appropriate for their needs. RAS should be aware of culturally safe services for frail older people in their region and establish links with Aboriginal and Torres Strait Islander community and health services. If it is not possible for assessors to fulfil this requirement, RAS should seek advice from Aboriginal health workers based in local clinics, who are known and accepted by their clients and would be willing to assist the RAS in undertaking the assessment. RAS operating in areas with established Aboriginal or Torres Strait Islander communities should consider engaging suitably qualified staff or subcontractors from relevant backgrounds. RAS are encouraged to explore ways of facilitating culturally safe assessments and engaging with local communities.

7.3.2 People from culturally and linguistically diverse backgrounds RAS should identify, facilitate and promote culturally sensitive forms of assessment for people from culturally and linguistically diverse backgrounds. To ensure an accurate exchange of information, independent, qualified interpreters should be used to assist people who do not speak English as their main language. Client or carer consent regarding the use of an interpreter must be sought in all cases. RAS in areas with culturally diverse populations should consider engaging liaison workers from relevant backgrounds. RAS should be aware of culturally appropriate services for older people in their region. It would be appropriate to establish links with culturally diverse organisations, services and welfare officers in the region. RAS may also utilise the services of specialised workers for older people from culturally diverse backgrounds, such as contacting a local migrant resource centre or refer to the Federation of Ethnic Communities’ Councils of Australia for information on specific support groups. The National Ageing and Aged Care Strategy for People from Culturally and Linguistically Diverse (CALD) Backgrounds is designed to inform the way the Australian Government supports the aged care sector to deliver care that is appropriate and sensitive to the needs of older people from CALD backgrounds. The Strategy is available through the My Aged Care website.

My Aged Care Regional Assessment Service Guidelines

7.3.3 People from rural and remote areas A RAS may work in areas which cannot be routinely visited due to geographical isolation. In these cases, assessments may be conducted by telephone where no other options are available. A suitably skilled person from within the local health or community care environment should be present to support the client and to facilitate the assessment under direction from the assessor. Broadband internet connectivity in remote areas should be used wherever possible to facilitate the provision of assessment services to clients in such areas through a virtual face- to-face assessment.

7.3.4 People who are financially or socially disadvantaged Financial or social disadvantage can often create a significant barrier to a wide range of services in the community. RAS should ensure that they develop and promote links with other organisations in their area which attempt to overcome these barriers, and provide assessments to people who may benefit from aged care services regardless of their financial or social circumstances. People who are financially or socially disadvantaged may also experience difficulties in accessing services after their assessment. RAS should be prepared to engage in linking support activities on behalf of these clients to ensure that they receive the care which they need. A person’s access to care must not be affected by their ability to pay consumer fees, but should be based on the need for care, and the capacity of the service provider to meet that need.

7.3.5 Veterans and war widows and widowers The Australian Government recognises the special aged care needs of the veteran community. RAS should develop a sound understanding of the services (and eligibility for services) offered by the Department of Veterans’ Affairs; establish links with relevant veterans’ organisations in their communities; and foster links between veterans and aged care services. They should aim to facilitate an understanding of veterans’ particular needs and to improve integrated care and access.

7.3.6 People who are homeless or at risk of becoming homeless Assessors have a responsibility to recognise people who are homeless or at risk of becoming homeless and ensure that they are able to access an assessment and any aged care services for which they are eligible. Liaison between RAS and support services for homeless people is particularly important for this cohort because of their extreme vulnerability. 35

My Aged Care Regional Assessment Service Guidelines Where the client has insecure housing arrangements or is homeless, RAS must work with Commonwealth Home Support Programme providers of Assistance with Care and Housing in order to provide clients with the supports they need. Where there is no provider of Assistance with Care and Housing, RAS must provide linking support to the client to address areas of vulnerability. Assessors should also be aware that homelessness is not automatic grounds for a client to be eligible for Commonwealth Home Support Programme services. Assessors should make appropriate referrals and work with states and territories and housing and homeless services to assist these clients.

7.3.7 Care-leavers The DSS website provides information on care leavers, including a description of the term “care-leaver”. This term refers to children who were in institutional and other out of home care through the last century, including:  Forgotten Australians – people who spent a period of time as children in children's homes, orphanages and other forms of out-of-home care in the last century; and  Former Child Migrants – children who arrived in Australia through historical child migration schemes and who were subsequently placed in homes and orphanages. Assessors should be particularly sensitive to the effects of care-leavers’ childhood experiences with government officials and other authority figures and in residential institutions. Assessors should emphasise that clients are not obliged to take up care; that care can be provided in a community setting if that is the client’s preference; and that the wishes of the client are taken into account throughout the entire assessment process.

7.3.8 Parents separated from their children by forced adoption or removal The DSS Website provides information on forced adoption practices, including a description of the term: “parents separated from their children by forced adoption or removal”. This term refers to:  The policies and practices that resulted in forced adoptions and the removal of children throughout Australia, particularly during the mid-twentieth century. Assessors should be particularly sensitive to those who have been adopted or impacted by past adoption practices as these experiences can have significant personal and psychological impacts. Assessors should be particularly sensitive to the effects of forced adoption or removal and interactions with government officials, authorities and institutional care. Assessors should emphasise that clients are not obliged to take up any care; that care can be provided in the client’s home if that is their preference, and that the wishes of the client are taken into account throughout the assessment process.

My Aged Care Regional Assessment Service Guidelines 7.3.9 Lesbian, Gay, Bisexual, Transgender and Intersex people Assessors should not make assumptions about the sexual orientation or gender identity of clients, nor the nature of the relationship between lesbian, gay, bisexual, transgender and intersex (LGBTI) clients and members of their support network. LGBTI people may be more inclined to disclose their sexual orientation or sex/gender identity to assessors if a non-judgemental, supportive and LGBTI inclusive environment is provided for the client and their support network during assessment. The choice to disclose or not disclose is entirely one for the client. Where a client does disclose this information, the assessor should assure the client that the personal information they provide is subject to the provisions of the Privacy Act 1988. In the case of transgender and intersex clients, where specific medical history may need to be communicated to service providers, it is important to discuss the way this information will be made available to the providers. RAS should also be aware of service providers who provide LGBTI specific services and those that are LGBTI inclusive and be prepared to advocate for LGBTI clients with other service providers as necessary. The National Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) Ageing and Aged Care Strategy has been released by the Australian Government. The Strategy informs the way the Australian Government supports the aged care sector to deliver care that is sensitive to and inclusive of the needs of LGBTI people, their families and carers. The Strategy is available through the My Aged Care website.

7.3.10 Other groups with significant needs People with dementia The Australian Government recognises the special needs of people with dementia and their carers. RAS should develop contacts with dementia specific services and where relevant, include this expertise in the assessment process. Fostering links between RAS and dementia specific services will facilitate an understanding of the needs of ageing people with dementia and their carers and assist with improving linkages, integrated care and access.

People with psychiatric disorders RAS are encouraged to make links with mental health services which will assist in understanding of the needs of older people with mental illness and improve linkages, integrate care and assist these clients to access appropriate aged care and other support services. In most jurisdictions, the majority of people who receive specialist mental health services are in a community setting. In these circumstances, specialist mental health care is often provided as acute treatment, but individuals who receive treatment are sufficiently stable to be managed in the community.

My Aged Care Regional Assessment Service Guidelines Clients with a mental illness may require access to a range of supports including Commonwealth funded services. As with all assessments, it is important to obtain informed consent (either from the person if they have the capacity to do so or if not, a decision maker consistent with state guardianship legislation who is able to make decisions regarding health, accommodation and daily living care) prior to an assessment.

7.4 Sensitive clients A registered client or representative may be considered a “sensitive client” if the client or representative requests that access to their information is limited, and the client or representative:  Is a member of the My Aged Care contact centre; or  Has a conflict of interest with a member of the My Aged Care contact centre; or  Has provided Commonwealth or state government documentation that their identity and contact information is to be protected. The client or representative or member of the My Aged Care contact centre will submit a request in writing to My Aged Care. If the request is based on a legal requirement, it must be submitted as a letter or fax and accompanied by the relevant supporting documentation. The request will be assessed by contact centre team leaders and if appropriate the client or representative’s record will be flagged as “Sensitive”. Sensitive client details will still be available to assessors and service providers who are working with the client.

7.6 Priority A referral for home support assessment will include a priority rating by which the RAS must manage the referral, undertake the assessment and refer the client to services. Priority also relates to the urgency in which services should be delivered to a client.

7.6.1 Priority for Home Support Assessment There are three priority categories within which a referral for assessment may be classified, based upon the client’s needs:  High priority – the client requires an urgent assessment  Medium priority – the client is not at immediate risk of harm, but an assessment will be required in the short to medium term  Low priority – the client has sufficient support available at present, but they require an assessment in anticipation of their future care requirements.

My Aged Care Regional Assessment Service Guidelines The three priority statuses for completing actions associated with home support assessment are outlined below. The RAS are expected to complete 90% of required actions within the timeframes outlined.

Priority status Required action and timeframe Manage referrals (accept, reject) Undertake face-to-face assessment (including finalising the support plan and matching and referring clients for services) High 3 calendar days 10 calendar days after acceptance Medium 3 calendar days 14 calendar days after acceptance Low 3 calendar days 21 calendar days after acceptance

Where a RAS refers a client to comprehensive assessment, the definitions of high, medium and low priority apply. Different timeframes associated with priority apply for comprehensive assessment.

7.6.2 Priority for services A priority category is also assigned when a client is referred to services. The priority rating is based on a client’s level of function, the level of risk in relation to the care situation, and any other concerns that are relevant to the client’s presentation. It is the role of the assessor to agree with or change the recommendation based on the client’s needs and urgency for services.

My Aged Care Regional Assessment Service Guidelines 8 Linking support Where an older person’s complex circumstances may impede their access to aged care services, linking support will assist in linking the client to various services they require in order to live in the community with dignity, safety and independence. Linking support activities are aimed at working with the client to address areas of vulnerability that are preventing access to receiving mainstream aged care support, to the extent that the client is willing or able to access aged care services. Issues leading to vulnerability include homelessness, mental health concerns, drug and alcohol issues, elder and systems abuse, neglect, financial disadvantage and cognitive decline. For the purposes of linking support ,’vulnerable’ is defined as the outcome of complex interactions or discrete risks that present a threat to a person’s wellbeing. Taking into account this definition, the process to determine need for linking support will be based on a person’s complexity, whether the client belongs to a cohort that is at risk of vulnerability, as well as consideration of the urgency of the situation and the barriers that impede access to aged care services. The NSAF includes indicators which will assist assessors to identify vulnerable clients with complex needs who require linking support. Specific responses to assessment questions will trigger the indicators, which will assist in identifying whether the client is at risk of vulnerability. Ultimately it is a matter of assessor judgement as to whether a person may require linking support based on:  The client has any complexity indicators  The client belongs to a cohort that is at risk of vulnerability  The risk or issues warrant urgent intervention and/or support to minimise deterioration  The client’s complexity impedes access to the delivery of aged care services. No Complexity Indicator . 1 Person is living in inadequate housing or with insecure tenure or is already homeless which compromises their health, well-being and ability to remain living in the community. 2 There is a risk of, or suspected or confirmed abuse. 3 Person has emotional or mental health issues that significantly limits self-care capacity, requires intensive supervision and/or frequent changes to support. 4 Person is experiencing financial disadvantage or other barriers that threaten their access to services essential for their support. 5 Person has adverse effects of institutionalisation and/or systems abuse (e.g. spending time in institutions, prison, foster care, residential care or out of home care) and is refusing assistance or services when they are clearly needed to maintain safety and well-being. 6 Person is exposed to risks due to drug and/or alcohol issues and is likely to cause harm to themselves and others. 7 Person is exposed to risks or is self-neglecting of personal care and/or safety and likely to cause harm to themselves and others. 8 Person has a memory problem or confusion that significantly limits self-care 40

My Aged Care Regional Assessment Service Guidelines No Complexity Indicator . capacity, requires intensive supervision and/or frequent changes to support.

Through the NSAF, the following cohorts will also be identified as potentially being at risk of vulnerability:  Aboriginal and/or Torres Strait Islanders  Veterans  Lesbian, Gay, Bisexual, Transgender and Intersex people  Culturally and linguistically diverse population  Those who have experienced family and/or carer changes  Refugees  Socially isolated. The level of linking service support offered in My Aged Care is time limited, and is not designed to provide ongoing support services. If linking support is required, the assessor must determine which pathway is most appropriate for the client:  Short term case management – where there is an aged care requirement and barriers to accessing services have been identified. The RAS must provide short term case management to address these barriers until effective referral. Effective referral is defined in section 3.1.6 of these Guidelines.  Assistance with Care and Housing (ACH) programme – where the client has insecure housing arrangements or is homeless, the assessor must refer the client to ACH for linking support. Where there is no ACH coverage, the RAS must provide this assistance to the client  Non-aged care support – if vulnerability is identified and there is no aged care requirement, this could trigger a recommendation that the client access support service(s) outside of aged care. If appropriate, this may include a support service which provides a coordination or case management function. This is dependent on the client’s individual needs, preferences or circumstances, and the level of case management required to connect the client to further support outside of aged care.

8.1 Short term case management The requirements, preferences and circumstances of vulnerable clients may be complex. Assessors involved in the provision of short term case management should possess a strong understanding of different service pathways and local services for supporting vulnerable clients, both within and outside the aged care sector. The activities that an assessor chooses to undertake when providing short term case management will be dependent on the needs, circumstances and preferences of the client, and may include one or more of the following:

 Information provision and tailored advice – provision of clear, reliable, up-to-date and relevant information and advice to clients regarding service options and pathways. The information is to be offered in a variety of formats to promote 41

My Aged Care Regional Assessment Service Guidelines equitable access (e.g. paper-based, electronic, face-to-face, over-the-phone etc) and may include information for consumers and/or service providers to self-refer (e.g. referral code) to the identified services and supports  Guided referral – the RAS facilitates and manages the process of linking a vulnerable client to appropriate service pathways within or outside the aged care system. This includes monitoring the success of the referral process, and ensuring that linking to the appropriate services is achieved  Service coordination – where a client’s needs are complex and require a range of services spanning a number of sectors, the RAS must oversee the coordination of these services. This includes: o Intensive and close interaction with the client in the short term to ensure that they are linked to all of the required services, and that an adequate support structure is in place o Ensuring that adequate communication is established between the different agencies providing services to the client o Ensuring that the timing of service provision is coordinated in order to avoid overlap and duplication. It is anticipated that the RAS will have more intensive and interactive involvement in service coordination with the client over the short term. This coordination is expected to end once the client is effectively linked to the nominated services, or to a service that can assume responsibility for the client  Advocacy activities – in order for the vulnerable client to gain access to the identified support services, the RAS is to provide advocacy activities on behalf of the client. These include speaking, acting and writing to the identified service providers on behalf of the vulnerable client  Case conferencing/multidisciplinary service coordination – the RAS is to provide comprehensive, integrated service coordination for clients with high intensity needs. The RAS is to utilise a case conferencing/multidisciplinary service coordination approach which brings together a number of team members and a suite of services across sectors in order to meet the client’s needs at different levels  Establish local knowledge base and networks – the RAS is to build and maintain a database of the service providers which support vulnerable people in each region in which it provides assessment services, which includes service information and contact details  Administrative tasks – the RAS is to establish and undertake the administrative functions necessary to support the smooth and seamless progression of the vulnerable client through the required services. This includes:

o Contact the relevant service providers on behalf of the client (e.g. legal services, health services, housing services etc.) o Obtaining the necessary client information from various sources and organisations o Compiling and completing the necessary forms on the client’s behalf 42

My Aged Care Regional Assessment Service Guidelines o Organising relocation services for the client, if required (e.g. removalist and utility services) o Organising cleaning services for the client’s place of residence, if required o Documenting the client’s progress.

My Aged Care Regional Assessment Service Guidelines

9 Commonwealth Home Support Programme The provision of home support assessment by the RAS is to be separate from the delivery of home support services. This includes a requirement by the RAS not to engage or use any related body corporate to provide home support services without the prior written approval of the Department. The Department may, from time to time, ask the RAS to demonstrate that it has the mechanisms, processes and procedures in place to ensure that this separation is maintained. The Department recognises that in some cases, the type of home support service provided by the RAS is the only service of that type provided within a Client’s Region. In this situation, self-referral may be acceptable. The following information is subject to the finalisation of the Commonwealth Home Support Programme (CHSP) Programme Manual. The Programme manual is the primary source of information on the Commonwealth Home Support Programme including interactions with My Aged Care and should be considered in the first instance. The Programme Manual will be available at www.dss.gov.au/chsp.

9.1 Vision The Commonwealth Home Support Programme will help frail, older people living in the community to maximise their independence. Through the delivery of timely, high quality entry-level support services taking into account each person’s individual goals, preferences and choices – and underpinned by a strong emphasis on wellness and reablement – the Commonwealth Home Support Programme will help frail older people stay living in their own homes for as long as they can and wish to do so. In recognition of the vital role that carers play, the Commonwealth Home Support Programme also supports care relationships through providing respite care services for frail, older people which allows regular carers to take a break from their usual. 9.2 Key features The Commonwealth Home Support Programme will:  Provide streamlined entry-level support services  Be supported by My Aged Care in providing access to information and services through: o A central client record to allow client information to be appropriately shared with assessors and service providers o A consistent, streamlined assessment process

o Better access to relevant and accurate information (for clients, carers and family members, service providers and assessors)

My Aged Care Regional Assessment Service Guidelines o Appropriate referrals for assessments and services.

 Deliver services and support with a strong focus on wellness, reablement and restorative care  Provide targeted sector support and development activities  Promote equity and sustainability through a nationally consistent fees framework.

9.3 Target groups All new Commonwealth Home Support Programme clients will access services through My Aged Care. Target groups for the Commonwealth Home Support Programme are:  Frail, older people (aged 65 years and over or 50 years and over for Aboriginal and Torres Strait Islander people) and who need assistance with daily living to remain living independently at home and in the community  Frail, older Commonwealth Home Support clients aged 65 years and over (50 years and over for Aboriginal and Torres Strait Islander people) will be the direct service recipients of planned respite services, which will allow regular carers to take a break from their usual caring duties  People aged 50 years and over on a low income who are homeless or at risk of homelessness as a result of experiencing housing stress or not having secure accommodation  Grant recipients funded under the Commonwealth Home Support Programme and their service delivery client base.

The Commonwealth Home Support Programme is structured around the target groups identified above. Specific eligibility will apply for each Sub-Programme that targets these groups. Chapter 2 of this Programme Manual provides more detail on Sub-Programmes and eligibility.

9.4 Commonwealth Home Support Programme services The Commonwealth Home Support Programme builds on the strengths of home support programmes which came before it and from 1 July 2015 consolidates the following programmes to create a streamlined source of support for frail, older people living in the community and their carers:  The Commonwealth Home and Community Care (HACC) Program  Planned respite under the National Respite for Carers Program (NRCP)  The Day Therapy Centres (DTC) Program  The Assistance with Care and Housing for the Aged (ACHA) Program.

The following service types, including the activities or sub-types under each, are available under the Commonwealth Home Support Programme:

My Aged Care Regional Assessment Service Guidelines Sub-programme: Community and Home Support Service type Service sub-type

Domestic Assistance General House Cleaning

Unaccompanied Shopping (delivered to home)

Linen services

Personal Care Assistance with Self-Care

Assistance with client self-administration of medicine

Social Support Individual Visiting

Telephone/Web Contact

Accompanied Activities, e.g. Shopping

Other Food Services Food Advice, Lessons, Training, Food Safety

Food Preparation in the Home

Nursing N/A

Allied Health and Therapy Podiatry Services Occupational Therapy

Physiotherapy

Social Work

Speech Pathology

Accredited Practising Dietitian or Nutritionist

ATSI Health Worker

Psychologist

Ongoing Allied Health and Therapy Services

Restorative Care Services

Diversional Therapy

Exercise Physiologist

My Aged Care Regional Assessment Service Guidelines Service type Service sub-type

Allied Health and Therapy Other Allied Health and Therapy Services Services Social Support Group N/A

Home Modifications N/A

Home Maintenance Minor Home Maintenance and Repairs

Major Home Maintenance and Repairs

Garden Maintenance

Goods, Equipment and Self-care aids Assistive Technology Support and mobility aids

Medical care aids

Communication aids

Other goods and equipment

Reading aids

Car Modifications

Meals At Home

At Centre

Transport Direct (driver is volunteer or worker)

Indirect (through vouchers or subsidies)

Specialised Support Services Continence Advisory Services

Dementia Advisory Services

Vision Services

Hearing Services

Other support services

Client Advocacy

Carer Support

My Aged Care Regional Assessment Service Guidelines Sub-programme: Assistance with Care and Housing Service type Service sub-type

Assistance with Care and Assessment - Referrals etc. Housing Advocacy - Financial, Legal etc.

Sub-programme: Care Relationships and Carer Support Service type Service sub-type

Flexible Respite In-home Day Respite

In-home Overnight Respite

Host Family Day Respite

Host Family Overnight Respite

Community Access - Individual respite

Other planned respite

Mobile Respite

Cottage Respite Overnight Community Respite

Centre-based Respite Centre Based Day Respite

Community Access - Group

Residential Day Respite

In addition, under the Commonwealth Home Support Programme’s Service System Development Sub-Programme, Sector Support and Development activities will be funded. However the target group for these services is grant recipients funded under the Commonwealth Home Support Programme and their client base. These services do not support clients, and accordingly, My Aged Care will not refer clients to these services. Negotiations for transitioning Home and Community Care services for older people are underway with the Victorian and Western Australian governments. HACC services for older people in Victoria and Western Australia will continue to be provided under the Commonwealth-State jointly funded HACC Program until these are transitioned to the Commonwealth. Older people in Victoria and Western Australia will also be able to access services under the Commonwealth Home Support Programme that were previously delivered through the NRCP (planned respite services), DTC and ACHA programmes.

My Aged Care Regional Assessment Service Guidelines Commonwealth Home Support Programme services will not be offered:  To permanent residents of residential aged care facilities (except under grandfathering arrangements or a full-cost recovery basis)  Where a resident's accommodation contract provides for similar services to those under the Commonwealth Home Support Programme. Services can be offered to people in retirement villages and independent living units, where a resident’s accommodation contract does not include Commonwealth Home Support Programme-like services. The My Aged Care screening process will help identify what existing services a client is receiving including accommodation services subsidised by Government.

8.5 Programme Framework Sub- Community and Home Care Relationships and Assistance with Service System Programme Support Carer Support Care and Housing Development

Objective To provide entry-level To support and maintain To support To support the support services to assist care relationships vulnerable clients development of frail, older people to live between carers and to remain in the the community independently at home clients, through community aged care service and in the community providing good quality through accessing system in a way respite care for frail, appropriate, that meets the older people so that sustainable and aims of the their regular carer can affordable housing programme and take a break and linking them broader aged where appropriate, care system to community care and other support services Frail, older people aged Frail, older clients aged People aged 50 Grant recipients 65 years and over 65 years and over years and over Target Group funded under (or 50 years and over for (or 50 years and over for who are on a low the Aboriginal and Torres Aboriginal and Torres income and are Commonwealth Strait Islander peoples) Strait Islander peoples) homeless or at risk Home Support who need assistance will be the recipients of of homelessness as Programme and with daily living to planned respite services a result of their client base remain living experiencing independently at home housing stress or and in the community not having secure accommodation

My Aged Care Regional Assessment Service Guidelines Sub- Community and Home Care Relationships and Assistance with Service System Programme Support Carer Support Care and Housing Development

Service types  Meals Flexible Respite:  Assistance with  Sector funded  Other Food Services o In-home day Care and Support and  Transport respite Housing Development  Domestic Assistance o In-home activities  Personal Care overnight respite  Home Maintenance Community  Home Modifications o access – individual  Social Support- Individual o Host family day  Social Support-Group respite (formerly Centre- o Host family Based Day Care) overnight respite  Nursing  Allied Health and o Mobile respite Therapy Services o Other planned  Goods, Equipment respite. and Assistive Centre-based respite: Technology o Centre based day  Specialised Support respite Services o Residential day respite o Community access- group respite Cottage respite (Overnight community)

Commonwealth Home Support Programme services are funded under specific Sub- Programmes based on the Commonwealth Home Support Programme target groups. In certain circumstances services may be provided to people outside the identified target groups for the Commonwealth Home Support Programme.

My Aged Care Regional Assessment Service Guidelines

10 Additional processes and procedures

Assessors should contact their RAS organisation for more information on the additional processes and procedures.

10.1 Standard Operating Procedures RAS are required to maintain standard operating procedures that address, but are not limited to:  Client contact procedures (including instances where client cannot be contacted or are not present at the scheduled appointment time)  Work, health and safety procedures  Hazard and incident management  Managing clients /carers displaying concerning behaviours (e.g. violence, threatening behaviour).

10.2 Data, reporting and performance management Reports which will be available to the RAS from July 2015 include:  Assessment Management Report (Assessor) – lists all current assessments for each individual assessor. This report can be generated by assessors  Assessment Management Report (Outlet) – lists all current assessments for assessors within the outlet (Region). This report can be generated by Team Leaders  RAS End of Month Preparation Report – outlines completed assessments for the month for the RAS organisation  RAS End of Month Invoicing Report – allows RAS to view the completed assessments which have been reconciled for payment by the Department.

10.3 Collection, storage and protection of information Assessors have access to a great deal of information about clients and their families as part of the assessment process. This information needs to treated confidentially. It is important that RAS have the systems, protocols and processes in place to ensure the safety of client records from loss, damage or misuse.

10.3.1 Privacy RAS are required to comply with the legislative requirements under the Privacy Act 1988 (Privacy Act), including the Australian Privacy Principles. The Privacy Act regulates the handling of personal information about individuals, including the collection, use, storage and disclosure of personal information, and access to and correction of that information.

My Aged Care Regional Assessment Service Guidelines The Office of the Australian Information Commissioner has resources on its website (http://www.oaic.gov.au) that assist in the process of ensuring compliance with the Privacy Act. RAS must ensure that they only release information which they have appropriate authority to release. In cases where there is any doubt about the release of information, the assessor should discuss the situation with the organisation manager. The manager may also consult the assessment organisation’s auspice organisation the state or territory government, the Department or obtain independent legal advice if any doubt remains, before releasing information.

10.3.3 Freedom of information The Freedom of Information Act 1982 (Cth) gives members of the public rights of access to official documents of the Commonwealth and its agencies. The Freedom of Information Act 1982 (Cth) extends, as far as possible, the right of the Australian community to access information (generally documents) in the possession of the Commonwealth, limited only by considerations of the protection of essential public interest and of the private and business affairs of persons in respect of whom information is collected and held by departments and public authorities.

10.4 Complaints RAS must maintain systems, protocols and processes for dealing with complaints, as required under the Deed and Statement of Requirement. It is important that consumers, clients and their representatives are made aware of the complaints and review pathways, and that the RAS adopt a system which is:  simple for complainants to understand and follow;  fair;  free of charge for complainants; and  documented and available to any person upon request at no charge. The RAS must notify the Department of complaints made. All complaints must be documented by the RAS in a complaints log. This log is to be provided to the Department as part of the bi-annual reporting requirement or upon request by the Department. Each complaint must be recorded with sufficient detail (e.g. name, contact details, details of complaint, proposed action, and resolution) and indicate one of the following classifications:

Complaint Classification Definition Staff behaviour A complaint where a stakeholder believes a staff member has acted unprofessionally. Timeframes Not meeting a timeframe perceived by a stakeholder to be reasonable. Privacy breach Personal information was released without appropriate permissions. Assessment process This type of complaint may relate to a question(s) asked in the

My Aged Care Regional Assessment Service Guidelines Complaint Classification Definition assessment process. Assessment outcome This type of complaint relates to recommendations from the assessment outcome. Out of Scope The complaint relates to matters beyond the influence of the RAS or the Department and cannot be adequately addressed.

Each complaint must also be assigned an urgency category.  Significant – these are complaints which are considered serious in terms of their potential to impact the client’s well-being or to generate referral to another body e.g. Police, Australian Health Practitioner Regulation Agency, Ombudsman. The Department must be notified of complaints in this category as soon as is practicable, and no more than 24 hours after the RAS is made aware of the complaint. This category of complaint should be addressed as a priority.  Other – all complaints which do not fall in to the ‘Significant’ category. This does not diminish the RAS responsibility to resolve the matter efficiently and effectively. Complainants may address their concerns directly to the RAS or may choose to use the My Aged Care contact centre. In the majority of cases, complainants will be directed back to the RAS for resolution in the first instance. In cases where the complainant does not feel comfortable approaching a RAS, the matter will be referred to the Department. If a RAS determines that a complaint is significant and potentially impacts a client’s well-being or requires referral to another body (e.g. Ombudsman), the Department should be notified as soon as practicable via [email protected] The resolution process need not be a formal one depending on the nature of the complaint. Where a suitable resolution can be achieved using informal means (e.g. telephone call) this approach is sufficient. All complaints, regardless of the process used to resolve it them, must be recorded in the complaints log.