ACCNA Field Trial Final Report CHSD June 07 - UOW · study ... Level 1 – a Technical Field Trial...

The Australian CommunityCare Needs Assessment

(ACCNA): towards anational standard

Centre for Health Service Development

June, 2007

CHSDCentre for Health Service Development

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UNIVERSITY OF WOLLONGONG

Peter Samsa

Louise Ramsay

Alan Owen

Tara Stevermuer

Peter Siminski

Pam Grootemaat

Kathy Eagar

Suggested citation:

Samsa P et al (2007) The Australian Community Care Needs Assessment (ACCNA):towards a national standard. Centre for Health Service Development, University ofWollongong.


The ACCNA: towards a national standard

Table of Contents

EXECUTIVE SUMMARY.........................................................................................................................1

1 STATUS OF THIS REPORT ............................................................................................................5

2 SUMMARY OF THE ACCNA MODEL THAT WAS FIELD-TESTED...................................................5

3 METHODS......................................................................................................................................6

3.1 Field testing the ACCNA model at four levels -----------------------------------------------------------------------------6

3.2 Opportunistic information sessions and conferences ------------------------------------------------------------------8

3.3 Data sources and key questions------------------------------------------------------------------------------------------------8

3.4 Profile of the participating Level One agencies and assessors-----------------------------------------------------9

3.5 Agencies that responded to the web site----------------------------------------------------------------------------------10

4 RESULTS..................................................................................................................................... 13

4.1 Types of assessments undertaken ------------------------------------------------------------------------------------------13

4.2 Time taken to complete the ACCNA ----------------------------------------------------------------------------------------14

4.3 Completion of screens within the ACCNA --------------------------------------------------------------------------------15

4.4 Analysis of client assessments collected at Level One--------------------------------------------------------------16

4.5 Assessments triggered-----------------------------------------------------------------------------------------------------------29

4.6 Feedback on assessment triggers -------------------------------------------------------------------------------------------33

4.7 Priority rating -------------------------------------------------------------------------------------------------------------------------34

4.8 Feedback from the Level One agencies -----------------------------------------------------------------------------------36

4.9 Feedback from the Level Two agencies -----------------------------------------------------------------------------------39

4.10 Feedback from the Level Three agencies --------------------------------------------------------------------------------39

4.11 Combined Levels Two and Three feedback including written submissions ---------------------------------40

4.12 Level Four - Foc us Group Feedback ---------------------------------------------------------------------------------------43

4.13 National Aboriginal and Torres Strait Islander consultations ------------------------------------------------------44

4.14 Culturally and Linguistically Diverse (CALD) Focus Group --------------------------------------------------------47

4.15 Consumer Focus Group----------------------------------------------------------------------------------------------------------48

4.16 Summary of evaluation results ------------------------------------------------------------------------------------------------50

5 DISCUSSION................................................................................................................................ 52

5.1 The need for the ACCNA --------------------------------------------------------------------------------------------------------52

5.2 Relationships between rehabilitation potential, function and other factors-----------------------------------52

5.3 Priority Rating------------------------------------------------------------------------------------------------------------------------53

5.4 Interoperability -----------------------------------------------------------------------------------------------------------------------55

5.5 Inter-relationship between the ACCNA and next version of the CENA----------------------------------------55

5.6 The interface with the Aged Care Assessment Program------------------------------------------------------------56



5.7 Triggers for comprehensive assessment ---------------------------------------------------------------------------------58

5.8 Key implementation issues -----------------------------------------------------------------------------------------------------59

5.9 Other issues raised in the field-testing -------------------------------------------------------------------------------------60

5.10 Towards a national assessment system ----------------------------------------------------------------------------------61

6 RECOMMENDATIONS ................................................................................................................. 63

6.1 The ACCNA Version 1 national assessment system ----------------------------------------------------------------63

6.2 National protocol--------------------------------------------------------------------------------------------------------------------68

6.3 Products -------------------------------------------------------------------------------------------------------------------------------69

6.4 Inter-relationship issues----------------------------------------------------------------------------------------------------------69

6.5 Implications for ‘The Way Forward’ agenda -----------------------------------------------------------------------------70

ATTACHMENT 1 FURTHER ASSESSMENTS TRIGGERED BY THE ACCNA.................................... 72

ATTACHMENT 2 RECOMMENDED ACCNA DATA ELEMENTS........................................................ 75

ATTACHMENT 3 CHANGES TO THE ACCNA FROM THE VERSION USED IN THE FIELD TRIAL..... 92



List of Tables

Table 1 Participating agencies ............................................................................................................9

Table 2 Agencies responding to the CHSD web site........................................................................... 10

Table 3 Number of assessments by mode of administration ................................................................ 13

Table 4 Number of assessments by ACCNA version .......................................................................... 14

Table 5 Average time for first contact assessment by assessment type ............................................... 14

Table 6 Completion of ACCNA screens ............................................................................................. 15

Table 7 Financial and legal items completed ...................................................................................... 16

Table 8 Assessment type by source of referral ................................................................................... 20

Table 9 Services requested by number of clients................................................................................ 21

Table 10 Services requested............................................................................................................... 21

Table 11 Profiles triggered.................................................................................................................. 23

Table 12 Profiles attempted................................................................................................................ 23

Table 13 Caring for another person ..................................................................................................... 24

Table 14 Distribution of functional profile scores................................................................................... 26

Table 15 Types of assessments triggered............................................................................................ 29

Table 16 Number of assessments recommended based on the triggers used in the field trial .................. 33

Table 17 Recommended triggers and assessor feedback ..................................................................... 34

Table 18 Priority rating scores............................................................................................................. 35

Table 19 Assessor judgements about the priority rating........................................................................ 36

Table 20 Assessor satisfaction with the ACCNA by mode of administration............................................ 36

Table 21 Assessor satisfaction with the ACCNA by agency .................................................................. 37

Table 22 Assessor confidence about the outcomes of the assessment .................................................. 37

Table 23 Was any important information missing?................................................................................ 38

Table 24 Rating of the ACCNA domains by the focus groups ................................................................ 43

Table 25 Proposed ACCNA layers ...................................................................................................... 64

Table 26 Data elements in the ACCNA ................................................................................................ 75

Table 27 Triggers in ACCNA Version 1................................................................................................ 90

Table 28 Changes from the field trial version........................................................................................ 92

Table 29 An example of inconsistencies in current code sets - source of referral codes for HACC andNRCP.................................................................................................................................. 95



List of Figures

Figure 1 Domains in the ACCNA .......................................................................................................... 5

Figure 2 Time taken to complete first contact assessment with the electronic ACCNA ........................... 15

Figure 3 Age distribution of people assessed using the ACCNA ........................................................... 17

Figure 4 Client goal ........................................................................................................................... 19

Figure 5 Circumstances triggering client contact ................................................................................. 19

Figure 6 Source of referral ................................................................................................................. 20

Figure 7 Functional profile ................................................................................................................. 26

Figure 8 Functional profile of clients in the ACCNA field trial compared to the 2001 functional dependencystudy................................................................................................................................... 27

Figure 9 Numbers of triggered assessments for Care Recipients with rehabilitation potential ................. 28

Figure 10 Assessments triggered by the ACCNA .................................................................................. 30

Figure 11 Number of recommended assessments................................................................................. 32

Figure 12 Relationship between the number of assessments recommended and key circumstancestriggering contact ................................................................................................................. 32

Figure 13 Priority rating model ............................................................................................................. 54

Figure 14 Relationship between the ACCNA and the CENA................................................................... 55

Figure 15 Specialist assessments that are relevant to comprehensive assessment ................................. 58

Figure 16 Comprehensive assessments triggered by the assessments listed in Figure 15 ....................... 58

Figure 17 Proposed ACCNA Re-design................................................................................................ 65

Figure 18 Proposed module for first contact by phone ........................................................................... 66

Figure 19 Proposed module for reassessment and face to face assessment ........................................... 67

Figure 20 The overall assessment system............................................................................................ 69

Figure 21 Algorithm for the ACCNA priority rating system...................................................................... 91


The ACCNA: towards a national standard Page 1

Executive Summary

This is the Final Report on the development of Version 1 of the Australian Community Care NeedsAssessment (ACCNA) instrument. This report presents the results of a four level national field trialconducted in 2006 and outlines a series of recommended next steps. Previous reports havecovered the results of a national practice and international literature review, development optionsfor the ACCNA and technical issues in its development. These issues are not repeated in this finalreport.

Levels of field testing

The four levels of the field trial were:

Level 1 – a Technical Field Trial with selected service providers in South Australia and New SouthWales, commencing in July 2006 and covering an 8-9 week period. Service agencies used bothan electronic and a paper version of the ACCNA tool for assessment and data collection. Thislevel of the trial specifically set out to test the functionality and the useability of the ACCNA. Thetechnical performance of the tools was evaluated using de-identified data from each site.

Level 2 – a General Useability Trial that involved the full version of the trial software beingprovided to interested service provider agencies to test its acceptability and compatibility with theircurrent systems.

Level 3 – a General Acceptability Trial that allowed interested agencies and individuals toparticipate in the field testing on the CHSD web site and provide feedback on the acceptability ofthe tools. Users at this level had access to the training manuals and relevant documentation.

Level 4 - Focus Groups with selected service providers and agencies who assessed clients withspecial needs, and with a group of consumers from one agency.

The results from all 4 levels of the field trial were generally (but not always) positive, withacceptability and useability of the data elements being confirmed. At the technical trial level, 1,247detailed client assessments using the ACCNA were received and analysed. The profile of clients inthe technical trial indicates that they were a representative sample of those known to be in receiptof community care.

There were 67 requests for the CD version and 232 people registered on the trial website toinspect the tools. A total of 200 people attended the focus groups and participated in thediscussions and feedback on what was presented.

Feedback from the field test

Feedback from participants in levels 2 and 3 was mostly positive and included constructivesuggestions for modifications. Taking the necessary time out of routine work to understand theACCNA and to give a response was an issue for many participants. The content of the feedbackreceived has implications for training as it indicates the variability as well as the complexity ofarrangements in the assessment environment.

The feedback from assessors in the field trial was highly consistent. Where feedback was morenegative, it was from agencies whose assessors were less experienced in using the tools due tolow volumes in the agency and where there were delays between training and using the tools.Many of the problems raised were process concerns rather than content, where the assessors hadtechnical problems in printing paper forms, accessing the Internet or where there was a lack oftraining support at the agency-level.

There was clear recognition that the ACCNA was a sophisticated tool that could still be used in astraightforward way with those clients whose needs were less complex, and that the information itgathered was of higher quality than much of what is routinely collected. It was also seen to bemore ‘interactive’ with assessor judgements than what is (mostly) routinely being used. The Level


Page 2 The ACCNA: towards a national standard

1 data give a very detailed picture of the clients who were assessed and the way that the dataelements captured that detail showed the ACCNA did what it was designed to do. Analysis of thedata collected in this level suggests that the type of data collected by the ACCNA, if routinely used,would be a powerful tool for understanding need and unmet need, for managing demand andorganising both simple and sophisticated service responses. Some examples of these data areincluded in this final report.

The majority (82%) of assessments were conducted over the phone, with the remaindercomprising face to face (16.5%) assessments and assessments that involved elements of both(1.8%). 79.3% of all assessments involved only one contact with the client while 12.9% ofassessments involved two contacts and 4.5% involved three. There were no differences inuseability reported between the different modes of contact.

The average time taken to complete a first contact assessment in the technical level was 29minutes, with the actual time taken dependent on the type of agency practice, the experience ofthe assessors and the complexity of the client contact. The useability for experienced assessorsin Level One of the field test increased over time and the amount of time taken for eachassessment decreased with familiarity with how the data elements worked together.

Many initial assessments take place in stages, with other phone calls or home visits incorporatedinto the overall client assessment episode. The expandable design was found to be useful andexperienced assessors reported that after sufficient exposure they could complete an ACCNA in20 minutes, but sometimes took over an hour. This represents an acceptable overall result andone that is in line with how tools with a similar purpose are commonly used.

In spite of the emphasis on the design being for electronic systems, the trial included moreassessments than expected that were completed on paper. For some agencies this reduced theutility of the tool because they did not have the advantage of using the electronic prompts andauto-populating functions that were built into the design. However, the evaluation sessions withthe technical testing sites indicated that experienced assessors liked the logic and ‘feel’ of the tool.Further, assessors indicated that they could use the appropriate domains and the priority rating atthe client level and that they found the ACCNA, as a whole, to be a useful way of categorisingclients’ relative needs.

The results of the technical testing in the trial demonstrated the numbers and types of profiles andrecommended further assessments that were triggered and the trial database was used as part ofthe evaluation to refine how those triggers worked. Many suggestions were made for changes atthe detailed technical level such as the sequencing and wording of questions. The consensusview is that the next version of both the ACCNA should build on the ability to follow the ‘flow’ of aconversation by the explicit ‘layering’ of items.

Feedback from the field test was that the ACCNA and the parallel carer assessment instrument(the CENA) should be designed so that they can ‘inter-relate’. Agencies indicated interest in usingboth instruments in the future if the two assessments could be linked in a way that enablesinformation to be ‘pulled through’ rather than be re-asked or re-entered. This assumes thatinformation about the carer and care recipient is consistent in both instruments.

Using the results

These more complex aspects of the ACCNA design can be further refined in work on subsequentversions, including work that could refine the priority rating for different service types and theprediction of rehabilitation potential. Other areas with potential for development by the Eligibilityand Assessment Working Group include using the ACCNA to explore unmet need on a regionalbasis and using it for re-assessment. This would represent a significant step towards routineoutcome measurement in community care.

None of the substantive issues arising in the field trial were unexpected. Planning for anysubsequent implementation stages must give detailed attention to the level, the strategies and thecontent of the necessary training and support, as well as the ‘technical’ preparation time needed



for agencies to adapt new national and standard data elements into their existing systems. Thefeedback about the electronic version at all levels of the trial has, overall, been very positive. Thespeed of broadband access obviously affects the useability of the web version.Splitting the assessment process into layers as described in the recommendations willaccommodate a wider diversity of users and address the scale and size issues that have beenraised during the field trial. This design change should improve useability by a split of the pool ofdata elements into broad layers that represent different depths of inquiry, as well as modulescorresponding to the purposes of the assessment tasks (such as initial phone contact orreassessment). Recommendations to achieve this refined model are included in Section 6.1 (page63).

In summary

Experienced assessors in both the focus groups and the technical trial found the electronic versionuseful to assist decision-making by making it easier to access, summarise and analyseinformation, and the referral prompts and derived data items were well received. The findingsshow the acceptability and also the useability of the ACCNA in relation to issues such as the timetaken to complete, the number of items that can be completed for different assessment purposesand the contribution it can make to organise a service response. On that basis, the ACCNA can,after some modifications suggested in this report, be confidently promoted as a practical outcomefor assessment standardisation arising from the national The Way Forward strategy.

The areas for improvement in the design of the ACCNA that now need to be incorporated intoVersion 1 of the ACCNA are:

1. More ‘layering’ of the information to achieve a better ‘flow’ of the conversation

2. Refinement of the items and derived data elements that are used as triggers for referral andfurther assessment

3. Extra information for CALD clients, adding ethnicity and religion

4. Aboriginal communities (and others) need better links between the carer and care recipientinformation, and links to greater depth of inquiry on medical and health issues

5. Better consistency between the electronic and mobile versions should be developed insubsequent work, by using mobile applications to avoid the double data entry inherent in areliance on paper forms

6. Resolution of the inconsistencies and a reduction in the reporting burdens in the HACC MDSitems

7. To encourage interoperability with existing systems at the level of the jurisdictions, encouragea gradual resolution of inconsistencies with similar items in existing tools in common use injurisdictions i.e. SCTT (Vic), ONI (Qld) and HNI (WA).

8. Build in the ability to inter-relate with the Carer Eligibility and Needs Assessment (CENA)instrument.

These changes have been incorporated into the recommended Australian Community Care NeedsAssessment (ACCNA) Version 1 instrument that is set out in diagrammatic form in Section 6.1,with the ACCNA data elements included as Attachment 2.

Agencies in the field test have sophisticated systems in place or significant investments in the nearfuture on their work programs. They are representative of many other agencies in the field anddecision making at the next stage has to take this into account. The ability to provide a greaterdegree of certainty for agencies that want to take the national agenda forward is crucial.

The analysis undertaken for this final report has been limited to that necessary for the testing andrefinement of the ACCNA instrument. This analysis suggests that the relationships between thedata elements were clear and in the expected directions. The database collected from the Level 1sites now has the potential to produce rich information through further analyses should it be



required. For example, there is the potential for further exploration of priority rating and therelationships between rehabilitation potential, function and other factors. There is also potential tofurther analyse the database to form a rich picture of the needs of different types of communitycare clients. These could form a practical staring point for further research and development incommunity care in some jurisdictions.

The real test of the ACCNA will be when the actual outcomes of further assessments can be usedto check on the accuracy of the initial contact information and the reliability of therecommendations that were made. Such system-level testing may lead to Version 2 of theACCNA, with potentially further refinements to the recommended data elements and to the triggersfor further assessment and referral. Consideration of the Final Report findings in the context ofwork now being undertaken on the development of a continuous client record and local areanetworking to allow information sharing should now inform the scale and pace of therecommended next steps.

Recommendations

1. The Australian Community Care Needs Assessment (ACCNA) Version 1 instrument, includingthe layered structure included in diagrammatic form in Section 6.1 and the ACCNA dataelements included in Attachment2, be adopted as a generic and multi-layered collection ofstandard national data items.

2. Jurisdictions and agencies be given flexibility in adopting various combinations of these dataelements for use in different circumstances:

§ in the initial assessment of those seeking community care services.

§ in the periodic re-assessment of those in receipt of community care services.

3. Protocols for routine reassessment be developed and implemented by each jurisdiction.

4. Jurisdictions and agencies be given flexibility in adding any data elements they require for theirown purposes and in building in the ACCNA as the front end of their existing assessment tools(eg, the ONI and the SCTT).

5. All consumers in the community care system undergo an ACCNA within 6 weeks of the receiptof first services if such an assessment was not undertaken at the initial point of entry.

6. Different versions of the ACCNA be developed with jurisdictions and agencies being given thechoice of which version to adopt:

§ A public domain stand alone ACCNA software program

§ A set of data specifications to allow agencies to include the ACCNA data elements in theirinformation systems

§ Paper form version

§ Hand held application version

§ Web based version.

7. A training strategy be developed that builds on existing models such as the QueenslandOngoing Needs Identification Tool training model. This model has been reported as beingeffective and has the potential to provide generalisable lessons.

8. In addition to implementing the ACCNA as part of the proposed access points trials, a plan bedeveloped for the progressive implementation of the ACCNA on a national basis. This couldbe either progressive implementation on a jurisdiction by jurisdiction basis or progressiveimplementation on an agency by agency basis.

9. The data elements in the ACCNA and the Carer Eligibility and Needs Assessment (CENA)instrument be combined to form Version 1 of a national Community Care Data Pool of dataelements for information sharing across programs, service types and agencies.

These recommendations are discussed in some detail in Section 6 (page 63).



1 Status of this report

This is the Final Report on the field trial of the Australian Community Care Needs Assessment (theACCNA) undertaken between July and October 2006. The purpose of this Final Report is to givea description of the field-testing and the results of the field trial evaluation, provide a discussion ofthe implications, draw out conclusions and make recommendations for subsequent national workto be carried out in this area of community care reform.

The Final Report covers a description of the trial, its levels and settings and agencies, the resultsof the evaluation of field testing, analyses of the findings from the data, and a synthesis of thefindings to support the conclusions and recommendations. The appendices contain tables of thedata collected and analyses of the data that are relevant to the conclusions and for planningsubsequent national and jurisdiction-based work on assessment reform.

Previous reports have covered the results of a national practice and international literature review,development options for the ACCNA and technical issues in its development. These issues arenot repeated in this final report.1

2 Summary of the ACCNA model that was field-tested

Preliminary work to establish the design and content of the ACCNA included field consultations, anational survey, feedback from jurisdictions on their current range of assessment tools, andagreement through the Eligibility and Assessment Working Group on a national typology ofassessment.

The ACCNA was then tested as a “Type 3 broad and shallow” assessment of a client’s needs.The ACCNA model included a number of domains that assess a client’s need (see below) withthese domains being covered at a shallow level. The ACCNA was designed to collect otherrelevant information, such as demographic information, and the information needed for services torespond to the client’s needs, which are identified in the development of an Action Plan.

Figure 1 Domains in the ACCNA

Eligibility Living arrangements

Reason for referral Carer profile

Functional dependency profile Self reported health conditions

Client goal Social, emotional & mental health issues

Financial and legal profile

.The ACCNA was designed to determine eligibility for clients, as well as stream (potential) clients to:

§ other assessments as required

§ direct to service provision, including any service-specific assessments required

§ exit / referral to other more appropriate services

1 Owen A, Marosszeky N, Ramsay L, Rix M and Eagar K (2005) The Australian Community Care Needs Assessment Project:

Consultation Paper. Centre for Health Service Development, University of Wollongong. Eagar K et al (2005) National Intake Assessment Project - progress report on the development of the Australian Community Care

Needs Assessment instrument. Centre for Health Service Development, University of Wollongong. Ramsay L, Owen A, Eagar K, Marosszeky N, Samsa P, Rix M, Fildes D, Willmott L (2006) An Australian Carer Needs Assessment

Instrument: The Recommended Approach. Centre for Health Service Development, University of Wollongong. Samsa, P. et al (2006) Australian Community Care Needs Assessment (ACCNA) Progress report No. 2: the tools, the field test and

the evaluation. Centre for Health Service Development, University of Wollongong. Samsa P, Ramsay L, Owen A, Siminski P, Stevermuer T, Grootemaat P and Eagar K (2006) The ACCNA Field Trial Interim Report.

Centre for Health Service Development, University of Wollongong.



An important aspect of the design that had implications for later ‘system-level’ trials was that itshould assess client needs in a way that can feed relevant care recipient information into carerassessments.

The revised ACCNA model is the result of examining the evidence from the field testing and thecomments received on the project’s interim report. This revised model, including therecommended layered structure is included in diagrammatic form in Section 6.1. The refinedACCNA data elements are included in Attachment.

3 Methods

The tasks involved in the field-testing and the evaluation framework were set out in previousdocuments2 and will not be repeated here. This section summarises the data sources used acrossthe four levels and the key questions that were examined.

The field trial covered a variety of agency types from large to small, from basic to complexservices, and across a variety of service types and a range of competencies of assessors. Thetraining highlighted the practical concern to collect only the level of data required according to theclient’s need. This was the most important issue for assessors and the people consulted in thefield trial – given the potential scale of a full assessment, how to moderate the amount ofinformation that should be collected, at different points, for each assessment?

As summarised in the evaluation framework, the field trial involved a mix of qualitative andquantitative methods. Prior to collecting data, ethical approval was required from both theUniversity of Wollongong Human Research Ethics Committee (UoW HREC). The UoW HRECapproved the study to begin in July 2006.

The ethical approval included constraints on the level of identification and attribution that would beincluded in the final report. The intention was to protect the confidentiality of participants in order tomaintain an evaluation environment where full and frank feedback would be encouraged.

‘This information will be used in a confidential and aggregated way to add to the resultsof a literature search of tools used for intake and needs identification. The intention isnot to make comparisons between jurisdictions, agencies or current systems, but touse this survey to build efficiently on detailed knowledge of existing systems andapproaches.’(extract from Ethics Application)

This necessarily limits comparisons being made between jurisdictions, agencies, teams andassessors. Those levels of comparison are best used when all comparisons are against somenational standard, with an ability to compare like with like, rather than between disparatecomponents of a diverse system.

The type of control of variability used in the field test was primarily to establish therepresentativeness of the sample of agencies and the assessors, and use that to judge thegeneralisability of the findings and the strength and validity of the conclusions.

3.1 Field testing the ACCNA model at four levels

The ACCNA and the Carer Eligibility and Needs Assessment (CENA) trials were linked and usedin parallel where possible, incorporated a similar methodology in the evaluation design and usedsimilar methods for their useability testing.

The field trials were comprised of four distinct levels.

2 Samsa, P. et al (2006) Australian Community Care Needs Assessment (ACCNA) Progress Report No. 2: The tools, the field test

and the evaluation. Centre for Health Service Development, University of Wollongong.Samsa P, Ramsay L, Owen A, Siminski P, Stevermuer T, Grootemaat P and Eagar K (2006) The ACCNA Field Trial Interim Report.Centre for Health Service Development, University of Wollongong.



Level 1

The technical field trial was a high-volume trial with selected service providers in South Australiaand New South Wales, commencing in July 2006 and covering an 8-9 week period. Serviceproviders used an electronic version of the ACCNA and CENA tool for assessment and datacollection and a paper-based version was also used.

Service providers in the technical trial of the ACCNA were selected in consultation with stategovernment officials in SA and NSW and local Department of Health and Ageing representatives.Some of these services also trialed the CENA. CENA technical trial participants were selected onthe basis of their readiness and interest, the potential volume of assessments during the trialperiod and to achieve a mix of respite services and Commonwealth Carer Respite Centres(CCRCs).

This level of the trial specifically set out to test the functionality and the useability of both thesetools in the agencies’ information systems. The technical performance of the tools was evaluatedusing de-identified data from each site.

Level 2

The General Useability Trial was designed to promote an inclusive approach to the trial and toencourage transparency about what had been developed to date and what was being tested. Itinvolved the full version of the trial software, in CD format, developed for the technical field trial ofthe ACCNA and/or CENA that was provided to interested service providers to test its acceptabilityand compatibility with their current systems.

Training manuals on using the ACCNA and CENA were provided to the service providers whoregistered to participate in this aspect of the trial, but on-site and hotline support was not provided.Participating service providers were asked to provide feedback on the tools and how they wereused in local systems and how data could be transferred into their information systems.

Level 3

The General Acceptability Trial was a further level to promote an inclusive approach andencourage transparency. Any interested service providers could participate in the field testing onthe CHSD web site and provide feedback on the acceptability of the tools. Users at this level hadaccess to the training manuals and relevant documentation.

This version did not enable the tools to be used for assessments or for data collection, but offeredthe opportunity to provide feedback to improve the tools and get access to the backgroundinformation on the CHSD website.

Level 4

CHSD met with selected service providers for clients with special needs in Focus Groups. Theseincluded client groups from culturally or linguistically diverse backgrounds (CALD) in Victoria,service providers with predominantly indigenous clients in the Northern Territory (Alice Springsand Darwin), Queensland (Townsville and Thursday Island) and in Sydney (regional/rural andmetropolitan, and service providers in Canberra, Launceston and Hobart. A consumer focusgroup was held in Sydney.

The one-day focus group workshops were attended by a total of about 200 people who discussedthe appropriateness of the ACCNA and CENA tools to assess the different client groups.Participation at the focus groups for the ACCNA were organised in conjunction with state andterritory government officials. The State and Territory Program Managers of the National Respitefor Carers Program invited NRCP services to participate.



3.2 Opportunistic information sessions and conferences

In the course of field-testing a number of jurisdictions and organisations took the opportunity toinvite the CHSD team to deliver presentations on the background and current status of field testingof the ACCNA and CENA. This presented an opportunity to get less structured feedback as wellas being a useful addition to the communication strategy around the field trial. There werepresentations and/or meetings in Sydney, Perth, Adelaide, Brisbane and Melbourne.

Members of the CHSD team presented to the NSW Aboriginal HACC Gathering executive meetingand the NSW HACC Issues Forum, both convened by the NSW Council of Social Service.Invitations to speak were accepted at State and regional level conferences conducted by the Agedand Community Services Association and its affiliates in Queensland at Noosa and the GoldCoast, in NSW at Wagga and Coffs Harbour, Caulfield in Victoria and Perth WA.

In addition to the formal and informal presentations, the team also made use of opportunities forwritten communication with articles in State and local newsletters (Aged Care Queensland, Agedand Community Services Association national and NSW and ACT newsletters) and provided draftsand written feedback on letters, articles, fact sheets and website content for the Department ofHealth and Ageing.

3.3 Data sources and key questions

The 1,247 de-identified client assessments received for analysis from agencies was sufficient forthe evaluation purposes. There was a 25% refusal rate at the level of the client consent forparticipating in the evaluation.

The key question asked was ‘Did the ACCNA do what it was designed to do?’

The data sources were:

§ Databases consolidated from the Level 1 participating sites

§ Feedback forms from Level 2 and Level 3 users

§ Feedback given at Focus Group meetings in Level 4 of the Trial

§ Feedback given in Evaluation Sessions with Level One agencies

§ Feedback from presentations and opportunistic information sessions.

Other data sources include:

§ Information from participants through hotline support, emails and phone contacts

§ Website usage statistics

§ Documentation received from national, state and territory and regional bodies

§ Direct observation and information collected from site visits.

The key design components being tested were how the derived data items (the triggers andpriority rating) worked and in particular how acceptable and useable the profiles were, whether thetrigger questions made sense and how the priority rating worked. The analysis is mostlydescriptive.

The level one data represent a single snapshot of client characteristics and the data do notaggregate over time and nor do they form a continuous client record. The end point of theassessment is the recommendations made for additional assessments and for referrals in theAction Plan. Because this is not a system level or longitudinal field trial, there is limited scope forcommenting on client outcomes and there is no capacity to comment on the impact of the ACCNAon client well being or the appropriateness of the referrals that were actually made.



The discussion (Section 5) synthesises the findings and draws together the results from thedifferent sources of data, including specific elements of the ACCNA design. It is used to highlightthe lessons from the trial for any subsequent assessment system development or work on accesspoints, the continuous client record and referral pathways in community care.

3.4 Profile of the participating Level One agencies and assessors

More information on the Level One agencies can be found on their web sites, which are includedin the table.

Table 1 Participating agencies

Agency Location Assessmentsin data base

IT and InteroperabilityStatus

Description of Service

NSW HomeCare Service

Referral andAssessmentCentreParramatta,NSW

464 Sits within NSW DADHCclient system (in roll-outphase) that includes basicassessment items and theHACC CIARR. Referralsare also made by fax andemail.

DADHC has plans for usingHSNet for e-referral.

Single point of entry fordomestic assistance,personal care and respite. In2005/06, the RAC receivedapproximately 28,500referrals and assessedapproximately 18,000 clients.Approximately 84% ofassessments were conductedby phone and 16% in thefield.

http://www.dadhc.nsw.gov.au/dadhc/Older+People/Home+Care+Service.htm

Central Coast Gosford ACATCCRC andCare Link,Wyoming,Central Coast,NSW

140 Parallel systems in ACATand carer assessments.Participates in the CentralCoast local referral andinformation system (4CN)

Co-located CCC/CCRC andACAT with AHS links, alsoinvolved in CENA trial

http://www.4cn.org.au/

BaptistCommunityServices

HarringtonPark, NSW

20 Integration of informationwithin BCS is wellunderway, with a focus ontele-health pilots.

Used a combination ofpaper and web-basedsystem for the trial

HACC funded personal careservices for a new estate andsurrounding areas

CareLink/CCRC (in differentarea) involved in CENA trial

http://www.bcs.org.au/

Community Care

NorthernBeaches

NorthernBeaches,Sydney, NSW

47 Established local servicenetwork with in-house ITsupport and establishedintake function.

Comprehensive communitycare agency

Also in CENA trial

http://www.ccnb.com.au/

Health E-link

WakefieldRegional HealthService

Gawler, SA 359 Wakefield Regional Healthnetwork – widely known inand used by community

Single Point of Entry servicefor Wakefield Regional HealthServices

http://www.wakefieldhealth.sa.gov.au/

MetropolitanAccess Team,MetropolitanDomiciliary Care

Netley, SA 101 Currently using ONI+ forclients.

Adelaide wide service -Single Point of Entry foraccess to domiciliary care

Also in CENA trial

http://www.domcare.sa.gov.au/

Helping Hands Adelaide, SA 32 Multi-sites spread over SA,used a central serverversion

NGO provides broad range ofresidential and communityservices



Agency Location Assessmentsin data base

IT and InteroperabilityStatus

Description of Service

Also in CENA trial

www.helpinghand.org.au/

Aged Care &Housing Group

Adelaide, SA 84 Developing single point ofentry for range of currentservices

NGO range of residential andcommunity resources, IncDVA

Also in CENA trial

http://www.ach.org.au/

Eight agencies, four in NSW and four in SA, were included in level one of the field testing. EachState included a large agency with a central phone-based system, small agencies or small outletsof a multi outlet organisation, and integrated multi-program organisations operating as part of anestablished regional network.

In total the participating agencies used 60 different assessors with varying amounts of assessmentqualifications, experience and competencies. There were 1247 de-identified client assessmentsreceived for analysis from agencies using the ACCNA at Level One of the field trial.

The aggregate data and feedback from assessors is covered in Section 4 below. The cooperationand goodwill at the agency and assessor level was a key factor in achieving sufficient quality andquantity of data in the technical level of the field trial.

3.5 Agencies that responded to the web site

The alphabetical list in Table 2 includes those that also requested a CD version of the database.

Table 2 Agencies responding to the CHSD web site

Agency Name

ACROD Inner South Community Health Service

ACT Health Inner West Community Transport

Adamas Corporate Solutions Ipswich Hospice Care Inc

Alzheimer's Australia ACT ISRCSD

Anglicare Sydney Kiama Council

Aputula Aged Care Kiama Shellharbour

Australian Red Cross Kimberley Aged & Community Services

Ballina District Community Services Association KinCare Community Services

Barwon Health Knowledge Base Systems Pty Ltd

Bayside Community Options Latrobe Community Health Service

Belconnen Community Service Launceston General Hospital

Best of Care LINC

Bethanie Community Care Lincoln Centre for Ageing

Blue Care Macarthur Community Options

Broken Hill City Council Marrickville Council - Tom Foster Community Care

Brotherhood St Laurence Mater Respite Services

Bucketts Way Neighbourhood Group Inc. Mecwa

Campbell Town Health & Community Service Mercy Care Centre

Care for Children with Disabilities Inc Mersey Community Care

Carers ACT (CCRC) Mid North Coast Commonwealth Carer Respite



Agency NameCentre

Carers NT Inc. Mildura Rural City Council

Carrington Centennial Care Ltd Moreland City Council

CCRC and Carelink Hunter Moreland Community Health Service

Centacare Community Support Services Murray Mallee Community Health Service

Central Coast Case Management Services Mutijjulu Community Health Service Inc.(AC)

CHAP Narellan Congregational Community Service s

Chinese Community Social Services Centre Inc. Narrabri Meals On Wheels Inc

Churches of Christ New England HACC Development Inc

CISS Northern Community Care

City of Belmont HACC Services Northern Health

City of Canning Multicultural Respite Novacare

City of Greater Dandenong Oak Lifestyle Options

City of Greater Geelong Ozcare

City of Port Adelaide Enfield Perth Home Care Services

Co.As.It. Pilbara Community and Aged Care Services

Commonwealth Carelink Centre North WesternTAS

Polish Welfare Office

Community Connections Inc Portland District Health

Community Ventures and Alliances Port Pirie Community Health

Concord Community Options Port Pirie Regional Health Service

Coolibah Community Care Primary Health Services

Country Home Advocacy Project Queanbeyan City Council

DAART Resthaven

DADHC Riverland Regional Health Service Inc

Department of Health and Human Services Tas RSL Care

Department of Human Services, Vic Shellharbour City Council

DHHS Silver Chain

Diversicare Snowy Respite Service

Eastern Regional Collaboration Project South Eastern Community Care

Eastside Care SSWAHS

ECH Inc St Carthage’s Community Care

Enable Home Care Services St George Community Services Inc

Eurobodalla Shire Council St Hedwig Village

Family Based Care (North) Sunnyfield Association

Family Based Care Association North West Inc Tablelands Community Support Options

Friends of Woodstock Disability Services TASCOSS

Gippsland Lakes Community Health The University of Queensland

Glenview Titjikala women's centre

GOC Care TOCAN

Greenways Toowoomba Health service district

Gunnedah Oxley Community Options Town of Cambridge Cambridge Senior Services



Agency Name

H.N. Mclean Memorial Retirement Village Uniting Care Community Options

Handyhelp ACT Inc Uniting Care Lithgow

Hills Community Care UPA

Hills Community Support Group University of Sydney

Holbrook Meals On Wheels Service Inc. Villa Maria

Illawarra Retirement Trust Villaggio Sant' Antonio

Indochinese Respite Care Service WACHS-Midwest Aged and Community Care

Ingkerreke Outstations Resource Services Warialda HACC Multi Service Outlet

Wesley Mission



4 Results

The profile of the eight agencies that participated in technical field-testing was described in Section3.4. Approximately 60 assessors provided data on 1,247 ACCNA assessments.

Other levels of the evaluation allowed a measure of transparency about the tools and theirevaluation to be available to the wider community care sector. This was achieved through thedata base version sent on request, the web version and through the demonstrations in focusgroups. The key point of the evaluation was to use the feedback at all levels to assess whetherexperienced assessors found the data elements useful and acceptable to their agencies and withtheir particular client groups.

The results of the evaluation are described below under the four levels of the field trial. Thedetailed data from the technical level of the trial forms the major part of this section with additionalresults and some interpretation included in Attachment 1. Results from the web version and theCD database version are included in this section and the Level Four focus groups results are alsopresented along with the feedback received from the various presentations and informationsessions.

4.1 Types of assessments undertaken

Table 3 shows the numbers and types of assessments undertaken in the field trial and the numberof contacts that the assessor had with the client. The top section shows the raw data. The modeof administration was not recorded for 316 assessments, with over 200 of these coming from oneagency. The majority of these were also missing data on the number of contacts.

The middle section shows the results as a percentage of those with both the mode ofadministration and the number of contacts recorded. The majority (82%) of assessments wereconducted over the phone, with the remainder comprising face to face (16.5%) assessments andassessments that involved elements of both (1.8%). 79.3% of all assessments involved only onecontact with the client while 12.9% of assessments involved two contacts and 4.5% involved three.

The bottom section shows the percentage of contacts for each mode of administration. 88.4% ofphone assessments involved only one contact with the client while 11.6% involved two or threecontacts. This compares to face to face assessments, where nearly half involved two or morecontacts.

Table 3 Number of assessments by mode of administration

Mode of administrationNumber ofcontacts withclient Over the telephone Face to face Both Not specified

All

1 653 83 0 28 764

2 68 43 9 2 122

3 18 20 4 42

Not specified 22 7 4 286 319

All 761 153 17 316 1247

As a percentage of total valid responses re mode of administration and number of contacts:

1 70.4% 8.9% 0.0% NA 82.3%

2 7.3% 4.6% 1.0% NA 12.9%

3 1.9% 2.2% 0.4% NA 4.5%

All 82.0% 16.5% 1.8% NA 100.0%

As a percentage of valid responses re mode of administration:

1 88.4% 56.8% 0.0% NA 82.0%



Mode of administrationNumber ofcontacts withclient Over the telephone Face to face Both Not specified

All

2 9.2% 29.5% 69.2% NA 13.4%

3 2.4% 13.7% 30.8% NA 4.7%

All 100.0% 100.0% 100.0% NA 100.0%

* Over 200 of these were from one agency

Agencies had the choice of using either the electronic or the paper version of the ACCNA, withsome agencies beginning the trial with the paper version and subsequently moving to theelectronic. If the paper version was used, the information was subsequently entered into theelectronic version. The version used was recorded for three quarters of assessments. Of these,60% used the electronic version and 40% the paper version (see Table 4).

Table 4 Number of assessments by ACCNA version

ACCNA version No. Percentage of total Percentage of those recorded

Electronic 548 43.9% 60.6%

Paper 356 28.5% 39.4%

Not recorded 343 27.5% NA

Total 1247 100.0% 100.0%

4.2 Time taken to complete the ACCNA

As described above, 548 assessments were completed using the electronic version. For theseassessments, the time spent on the assessment was automatically recorded by the software. Notime data were collected for assessments using the paper form.

As reported above, 82% of assessments were completed at first contact while 18% took place instages. Figure 2 on page 15 summarises the time taken to complete only the first contactassessment for the 548 electronic assessments. The average time taken at first contact was 28.7minutes but 6.4% of first contact assessments took more than one hour. In interpreting thisfinding, it is important to note that this time includes not only the assessment, but also the timetaken to complete the registration and the action plan. It excludes any subsequent contacts withthe client or other agencies.

As shown in Table 5, the majority (89%) of electronic assessments took place by phone. Therewere no differences in the time taken for the first assessment between the modes ofadministration.

Table 5 Average time for first contact assessment by assessment type

Assessment type Number Average time taken

Phone 485 29.3

Face to face 23 31.1

Both 16 30.0

Not recorded 24 11.9

All 548 28.7



Figure 2 Time taken to complete first contact assessment with the electronic ACCNA

4.3 Completion of screens within the ACCNA

The majority of the ACCNA is optional and one of the goals of the technical field test was toevaluate which components assessors found to be most useful. This is assessed in two ways.One way is simply to identify how often each section was used on the basis that assessors wouldnot have asked questions at the assessment unless they found them useful. Table 6 shows theresults of this aspect of the evaluation.

The other way that usefulness was assessed was in an analysis of assessor feedback, which isdiscussed in Section 4.8.

It will be seen that the rate at which sections of the ACCNA were used ranged from 100% (initialcontact, registration details and functional screen) to 7.3% (action plan for referrals not alreadybuilt into the ACCNA). As expected, not all questions were necessarily answered in each section.

Table 6 Completion of ACCNA screens

Profile Screen used Percentage

Initial contact 1247 100.0%

Contact reasons 1209 97.0%

Provisional eligibility 1008 80.8%

Registration 1247 100.0%

Functional profile – functional screen 1247 (913 fully completed) 100.0% (73.2% fully completed)

Functional profile – extra ADLs 959 76.9%

Information for services response - page 1 1122 90.0%



Triggers 1012 81.2%

Financial and legal 788 63.2%

Health conditions profile 1109 88.9%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

< 10 mins 10-19 mins 20-29 mins 30-39 mins 40-49 mins 50-59 mins 60 mins or more

% o

f ass

essm

ents



Profile Screen used Percentage

Health conditions profile - diagnostic aids 1027 82.4%

Social and emotional profile 681 54.6%

Social and emotional profile – K10 574 (510 fully completed) 46.0% (88.9% fully completed)

Carer profile - page 1 461 37.0%

Carer profile - page 2 288 23.1%

Pre-action summary plan - extra questions 409 32.8%

Action plan - referral needs 362 29.0%

Action plan - other referrals 91 7.3%

Action plan - other 129 10.3%

One interesting finding relates to the financial and legal profile. Two thirds (62.2%) of all assessorswho asked the trigger questions answered the question that triggers the financial and legal profile.Of these, only 15 (or 2.4%) clients were triggered to the financial and legal screen and only oneassessment triggered for this profile did not attempt it. Yet 788 assessments recorded informationin the financial and legal screen, equivalent to 98.2% using a screen that was not required for thepurpose of assessment (as determined by the trigger question). This begs the question of exactlywhat items in this screen assessors found useful.

To help answer this, Table 7 lists the items in this screen and their individual completion rates. Itwill be seen that most questions were answered in about two thirds of assessments, withemployment status being the most common question answered. But questions about decision-making are also clearly important for inclusion in a broad but shallow screen.

The issue of what screens were triggered and what screens were completed is discussed furtherin Section 4.4.3.

Table 7 Financial and legal items completed

Screen item %completed Relevant results

Employment status 94.4% 89.1% retired for age or disability

Decision status 85.9% 71.3% self

Financial decisions 82.7% 69.6% self

Financial resources 69.8%

Mental Health Act status/score 66.0%

Capable of decisions 65.4%

Financial assistance 45.9%

Financial trade offs 24.5%

4.4 Analysis of client assessments collected at Level One

This analysis is based on the full data of 1,247 ACCNA client assessments received as at 22November 2006 from sites participating in the Level 1 trial. This was fewer than the initialestimates by participating agencies due to the higher than expected number of clients who did notagree to give consent to the evaluation component of the trial assessment. There is no exactfigure available for the number of client refusals, which varied between agencies, but based on theevaluation feedback sessions with assessors, a 25% refusal rate is a reasonable estimate.

The eight participating sites each submitted between 1.6% and 37.2% of all assessments; therewere four sites from NSW (53.8% of all assessments) and four from SA (46.2%).



Most assessments (90.0%) were completed during August and September. Just over half of allassessments were for clients not receiving any type of service (HACC or other). This indicates thatjust under half of the assessments at intake in the participating agencies were being completed onpeople already in the health or community care systems.

The majority of assessments were completed over the telephone (81.7%) and were entereddirectly into the e-ACCNA. All assessments in SA were conducted over the phone, with 13.2%first using the paper form. In NSW, 71.9% completed the assessment over the phone and just overhalf of all assessments in NSW (55.3%) were completed using the paper form.

Agencies in the trial (and in current practice in community care) vary greatly in how they doassessments at the entry point to service provision. This is in terms of electronic and paper-basedassessment methods and phone and face to face contacts, as well as the number of contactsused to complete an initial assessment. There is no simple or universal ‘access points’ model thatcan be promoted as a gate-keeping role in community care. In the trial about a third of the clientsentered the system from self referral or family, with two-thirds coming from within the system,either from GPs and hospitals, or from within community care.

4.4.1 Profile of clients

The profile of clients assessed in the trial indicates the sample was representative of communitycare clients generally, indicating that the generalisations and conclusions in the reporting of theresults are sound. It also indicates the wealth of detail that is available to agencies and programmanagers for planning purposes when a tool like the ACCNA is used in routine practice.

Age

Half of all clients were aged between 64 and 84 years (55.1%), with about one in four aged 85years or older (See Figure 3). Of those aged 85 or more, 1.7% were over 95, 7.3% were between90 and 95 and 13% were between 85 and 90 years of age.

Figure 3 Age distribution of people assessed using the ACCNA

As expected, most clients aged less than 65 years were not already receiving services (HACC orother) (73.5%), while clients aged 65 years or older were slightly more likely to already bereceiving services (52.6%).

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

0-18 19-40 41-64 65-74 75-79 80-84 85+

Age Range



Gender

Two-thirds of all clients were female (68.5%). Male clients were more likely to be interviewed faceto face (38.2% compared to 30.3%) and slightly more likely to be already receiving HACC or otherservices (51.3% compared to 46.3% not receiving services). Males were more likely to requestassistance to reduce the rate of decline or maintain the current level of function and independencethan they were to try to improve their current level of function.

Cultural mix

Most clients (96.8%) were not of indigenous descent (Aboriginal or Torres Strait Islander origin).Two thirds (64.0%) of Aboriginal or Torres Strait Islander assessments were for people notcurrently receiving any services (HACC or other).

For most clients an interpreter was not required (96.7%), however assessments conducted overthe phone were more likely to need an interpreter than if conducted face to face (4.1% and 1.5%,respectively). Clients already receiving HACC or other services were less likely to need aninterpreter (2.9%) than those not in a service arrangement (4.0%). Need for an interpreterincreased with age, from none needing an interpreter if aged up to 40 years and 5.8% requiring aninterpreter when aged 80-84 years.

Living arrangements

Clients were most likely to live with family (56.2%) or alone (41.2%). Clients living alone were morelikely to be receiving HACC or other services than clients living with family (55.4% and 42.0%,respectively). As age increased, the proportion living with family decreased and the proportionliving alone increased.

Most clients lived in a private residence they owned or were purchasing (71.8%). Clients living inan independent living unit in a retirement village were least likely to be considered able to benefitfrom rehabilitation, 43.1% compared to 66.5% for clients living in an owned private residence.Clients living in an independent living unit in a retirement village were more likely to be receivingHACC or other services than clients living in an owned private residence (58.1% and 47.7%,respectively).

Concerns about living arrangements were reported more frequently when the assessment wasconducted face to face, rather than over the phone (20.3% and 8.0%, respectively). Clientsconsidered likely to benefit from rehabilitation by the assessor were less likely to have concernsabout living arrangements than those considered not to benefit from rehabilitation (8.1% and15.4%, respectively). Concerns about living arrangements were more common among thosealready receiving HACC or other services (12.5% and 8.5%, respectively). Those clients aged upto 40 years or where they were at least 85 years old were most likely to have concerns about livingarrangements.

4.4.2 Referral circumstances

Client goal

As shown in Figure 4, assistance was mostly requested to improve function and independence(54.0%), while one in five (20.4%) assessments was requested to reduce the rate of decline infunction and independence. For one quarter (25.6%) of clients, the goal was to maintain theircurrent level of function and independence. Two in three clients who wished to either maintain(30.1%) or reduce the rate of decline (35.0%) of their function and independence were aged 85years or older.

As shown in Figure 5, just over half of all clients indicated ‘concern about increasing frailty’ or‘hospital discharge’ (27.8% and 26.3%, respectively, where answered) as their key circumstancefor presenting to the service agency.



Figure 4 Client goal

Compared with face to face assessments, those conducted over the phone were more likely to citean acute medical condition (18.1% to 5.9%) or hospital discharge (30.5% to 9.8%) as the keycircumstance for presenting. Assessments completed face to face were more likely to cite carerburden (28.1% to 4.4%). The main shift in key circumstances since that reported in the interimreport is an 18.3% decrease in ‘other’ and 13.1% increase in ‘concern about increasing frailty’.

Figure 5 Circumstances triggering client contact

Source of referral

Referral from a hospital (19.7%) and self-referral (17.0%) were the most frequently selectedreferral sources, followed closely by referral by a GP and referral by a family member (significantother or friend) (Figure 6). However, when all sources of referral from within community care wereconsidered together, they accounted for one in four (24.5%) of all referrals. These sources includegovernment and non-government community services, specialist aged or disability assessmentteam / service such as ACAT, community nursing services and comprehensive HACC assessmentauthorities.

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Concernabout increasing

frailty

Hospital discharge Other Acute medicalcondition

Carer burden Falls

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Improve current level of functionand independence (other)

Maintain current level of functionand independence

Improve current level of functionand independence after a recent

acute illness/event

Reduce rate of decline in level offunction and independence



Figure 6 Source of referral

Only one in three referrals were self-referred or made by family or friends. 67% of referrals camefrom within the health and community care sectors. These findings have important implications forthe proposed reform of access points into community care.

As shown in Table 8, there were differences between the major sources of referral in relation tothe mix of assessments undertaken and these also have implications for access points. Thosewho were self-referred or referred by family and friends were more likely to have a face to faceassessment than those ref`erred by a health agency. One in two face to face assessments wasfor people who were self-referred or referred by a family member (significant other or friend). Incontrast, only 20% of face to face assessments were for people referred from within communitycare. Nearly half of all telephone assessments were for people referred from the health sector.

Table 8 Assessment type by source of referral

Source of referral

Assessment type Community care Health Self/family All

Over the telephone 79.6% 86.0% 75.2% 80.6%

Face to face 19.1% 12.9% 22.4% 17.8%

Both 1.3% 1.1% 2.4% 1.7%

Total – percentage bysource

100.0% 100.0% 100.0% 100.0%

Source of referral

Assessment type Community care Health Self/family Percentage byassessment type

Over the telephone 18.4% 45.1% 36.5% 100.0%

Face to face 20.0% 30.7% 49.3% 100.0%

Both 14.3% 28.6% 57.1% 100.0%

Total 18.6% 42.3% 39.1% 100.0%

Where the reason for assistance was ‘Improve current level of function and independence after arecent acute illness/event’ the referral was most commonly made by a hospital (32.0%). Thosewishing to improve their current level of function and independence for other reasons were mostlikely to have been self-referred (23.9%). Clients identified as wishing to maintain (24.2%), or

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Community servicesagency, incl HACC,community nursing,

ACAT etc

Hospital, incl extendedcare, mental health etc

Self GP, medical practitioner,medical/health service

Family, significant other,friend

All other referralssources incl Carelink

and res care



reduce (26.9%) the rate of decline of their function and independence were most likely referred bya family member.

Evidence of dementia was reported in 185 of 1,041 (17.8%) clients assessed, with the proportionincreasing with age. Where an assessment was conducted face to face (45.8%), assessors werethree and a half times more likely to report evidence of dementia than when assessed by phone(12.6%).

Those clients not currently receiving any services were considered likely to benefit fromrehabilitation by the assessor more often than clients receiving HACC or other services (72.0%compared with 56.2%). As would be expected, most clients requesting services to improve theircurrent level of function and independence were considered likely to benefit from rehabilitation bythe assessor (86.5%). Similarly, most clients aiming to maintain their current level of function andindependence were not considered likely to benefit from rehabilitation by the assessor (66.5%).Relationships in the data around rehabilitation potential are illustrated throughout the analysis andsummarised below in Section 4.4.6.

Eligibility indicators

Eligibility was established for 1,023 (82.0%) clients and was unknown for 202 (16.2%) clients.Almost all of these came from one agency. Only 22 people (1.8%) were recorded as ineligible.

One in four clients was referred from another HACC service (25.2%) or was already receivingHACC services (25.6%). For 95.2% of clients, evidence that current health or disability interferedwith daily living and potential for long-term disability was already documented in the contactreasons. Just under half of all clients (43.3%) indicated they had problems managing activities ofdaily living such as housework, preparing meals or shopping.

Services requested

Most clients requested only one service (70%), with 95% of clients requesting five or less services.The most services requested by any one client was 11 (see Table 9).

Table 9 Services requested by number of clients

Number of services requested

1 2 3 4 5 6 7 8 9 10 11

No. clients 756 173 65 35 24 10 10 12 1 1 1

% of clients 69.5% 15.9% 6.0% 3.2% 2.2% 0.9% 0.9% 1.1% 0.1% 0.1% 0.1%

Table 10 shows that domestic assistance was the service most commonly requested service(40.5%). Allied health care and personal care were also frequently requested (17.3% and 16.9%,respectively).

Table 10 Services requested

Service requested Assessments recommendedby the ACCNA

Proportion (/1,247)

Domestic assistance 505 40.5%

Allied health care 216 17.3%

Personal care 211 16.9%

Respite services 108 8.7%

Social support 95 7.6%

Other services 95 7.6%

Shopping 88 7.1%



Service requested Assessments recommendedby the ACCNA

Proportion (/1,247)

Aids, appliances and/or equipment 82 6.6%

Transport 81 6.5%

Nursing care 58 4.7%

Meals 52 4.2%

Home modification 45 3.6%

Information and/or advice 42 3.4%

Home maintenance 41 3.3%

Provision of goods and equipment 36 2.9%

Case management/care coordination 34 2.7%

Counselling/support, info. and advocacy –care recipient

33 2.6%

Counselling/support, information andadvocacy – carer

28 2.2%

Linen service 22 1.8%

Centre based day care 15 1.2%

Other food services 10 0.8%

Education/training 2 0.2%

Relationships between client characteristics

Three out of four clients (73.3%) requesting domestic assistance were considered likely to benefitfrom rehabilitation by the assessor. Over half (54.9%) of those requesting domestic assistancewere not currently receiving any services (HACC or other). Requests for domestic assistanceincreased with client age. Clients wishing to improve their current level of function andindependence were more likely to request domestic assistance than clients requesting assistanceto maintain current levels or reduce the rate of decline.

Fifty percent of clients requesting allied health care were considered likely to benefit fromrehabilitation by the assessor, while 69.7% were not currently receiving any services (HACC orother). Younger clients (aged less than 65 years) were four times more likely to request alliedhealth care than older clients. Clients wishing to improve their current level of function andindependence for other reasons were twice as likely to request allied health care as clientsrequesting assistance for other reasons.

Two-thirds of clients requesting personal care were considered likely to benefit from rehabilitationby the assessor, while 59.3% were currently receiving services (HACC and/or other). Clients agedat least 80 years and those aged less than 19 years were twice as likely to request personal careas those aged 19 to 79 years. Clients wishing to maintain their current level of function andindependence were least likely to request personal care than clients requesting assistance forother reasons.

Clients considered likely to benefit from rehabilitation by the assessor were less likely to havebeen referred by HACC (15.9% compared with 23.6%). Referral from an HACC agency initiallyincreased with age, from 7.4% for clients aged 0-18 to 20.9% for clients aged 65-74, then declinedto 13.5% for clients aged 85 years or older. Clients referred from an HACC agency were mostlyrequesting help to maintain their current level of function and independence and least likely tryingto reduce their rate of decline.

Among clients already receiving HACC services, assessments were twice as likely to have beencompleted face to face (33.3%) than over the phone (17.4%). The older the client, the more likelythey were to already be receiving HACC services.



Where problems were reported with ADLs, clients were judged as likely to benefit fromrehabilitation (69.9%) twice as often as those thought not to benefit (33.1%). They were also lesslikely to be already receiving any services. Also as expected, as age increases the proportionreporting problems with ADLs also increased. Clients requesting help to maintain their currentlevel of function and independence were less likely to report problems with ADLs compared tothose wishing to increase their current level or reduce the rate of decline (26.6%, 62.9% and66.1%, respectively).

4.4.3 Profiles triggered within the ACCNA

Assessors could over ride the triggers in the ACCNA and either chose to not enter a profile thatwas triggered, or use a profile when it was not triggered. The design did not imply that all triggersand prompts should be automatically followed by the assessor.

While the trigger questions were answered most of the time (range 62.2%–95.5%), the profileswere not triggered as often (see Table 11).

The ‘Health Interference’ profile was triggered for almost all clients for whom the assessor wentinto the ‘Trigger’ screen (81.4%). The financial and legal situation profile was the least triggeredprofile (2.4%). That was consistent with feedback at other levels that suggested more informationon health concerns is useful but that financial issues are either not always relevant or are hard toinvestigate without a measure of rapport being established first.

Table 11 Profiles triggered

Trigger questions Trigger screenquestion(s) answered

Profile triggered %Triggered ofquestions answered

Health Interference 966 95.5% 786 81.4%

Carer 930 91.9% 374 40.2%

Social Support 836 82.6% 362 43.3%

Caring Role 831 82.1% n.a.

Financial and Legal Situation 629 62.2% 15 2.4%

Almost all the profiles triggered were attempted (range 93.3%–99.4%), however not all profilesattempted were the ones that were triggered (see Table 12). This indicates that assessors activelyused their own judgement about the appropriate next steps to take for gathering information for theservice response for the particular client being assessed.

Table 12 Profiles attempted

Profile triggered Profiles attempted

Profiles Total Attempted %Attempted Total Nottriggered

%Nottriggered

Health Interference 786 781 99.4% 1110 329 29.6%

Carer 374 360 96.3% 478 118 24.7%

Social Support 362 344 95.0% 683 339 49.6%

Financial and Legal Situation 15 14 93.3% 788 774 98.2%

Approximately one in four ‘Health Interference’ and ‘Carer’ profiles that were attempted were nottriggered (29.6% and 24.7%, respectively), while half of all ‘Social Support’ profiles completed werenot triggered (49.6%). Most ‘Financial and Legal Situation’ profiles were not triggered (98.2%). Theassessors could use the ‘optional’ status of the profiles with some discrimination. That finding is theweight given to the different domains in the focus group and information sessions (as representedby the profiles used).



Health Interference

Health interference with normal activities (outside and/or inside the home) during the past 4 weekswas reported as ‘quite a bit’ for 57.7% of clients and ‘moderately’ for 23.7%. Clients reportedhigher levels of health interference (quite a bit) if they were considered likely to benefit fromrehabilitation by the assessor, or were already receiving services, or were aged less than 19years, or were aiming to reduce the rate of decline in their level of function and independence

Most clients triggered for this profile had medium function (59.2%), 11.6% had low function. Iftriggered for this profile the key circumstance was more likely to be hospital discharge (29.3%) oracute medical condition (17.8%) than if not triggered.

Social Support

Most clients indicated ‘not at all’ to terms of feeling very nervous, down or lonely or being sick andhaving to stay in bed, or needing someone to talk to (42.1%). Most clients triggered for this profilehad medium function (57.1%) while 13.0% had low function. If triggered for this profile, the keycircumstance was more likely to be concern about increasing frailty (31.2%) and less likely to behospital discharge than if not triggered (23.9%).

Carer

Half of all applicants completing the trigger page did not require a carer. Clients were least likely torequire a carer if they were aged 19-40 years, and most likely to require a carer if aged less than19 years (19.2% and 76.9%, respectively). Those clients seeking assistance to maintain or reducethe rate of decline in their level of function and independence were more likely to have a carer thanthose wishing to improve (57.7%, 62.1% and 44.2%, respectively). Nearly one in ten (9.0%) clientsneeded a carer but did not have one. Most clients triggered for this profile had medium function(67.5%), while 23.7% had low function. If triggered for this profile the key circumstance was muchmore likely to be carer burden (19.5%) and less likely to be concerned about increasing frailty(21.7%) than if not triggered.

Caring Role

One in eight clients (12.9%) indicated they were caring for another person. Clients aged 19-40were most likely to be caring for another person (44.4%) and this declined with age to 6.7% forthose aged 85 years or older. Most clients were caring for their partner (see Table 13).

Table 13 Caring for another person

Who is cared for: Count Percentage

Partner - male 55 6.6%

Partner - female 19 2.3%

Son 17 2.0%

Mother 10 1.2%

Daughter 9 1.1%

Other female relative 6 0.7%

Other male relative 6 0.7%

Female friend 4 0.5%

Father 4 0.5%

Daughter-in-law 1 0.1%

Male friend 1 0.1%

Son-in-law 0 0.0%

Disabled child 19 2.3%



Financial and Legal Situation

Only 2.4% of clients indicated the reason for referral related (at least in part) was due to a financialor legal situation. Most clients triggered for this profile had high function (69.2%); only 7.7% hadlow function. If triggered for this profile the key circumstance was more likely to be concernedabout increasing frailty (37.5%) or citing other reasons (31.3%) than if not triggered. No onetriggered for this profile indicated carer burden or falls as a key circumstance.

4.4.4 Number of profiles triggered

Only one client was triggered for all four profiles. Where an assessment was conducted face toface three or more profiles were triggered more often than assessment conducted over the phone(28.3% and 17.9%, respectively). Clients wishing to reduce the rate of decline in level of functionand independence were twice as likely to trigger at least three profiles as those wishing to improve(29.5% and 16.4%, respectively). As the number of profiles triggered increased from one to threethe proportion with high function decreased (46.9% to 8.7%) while the proportion with medium andlow functions increased (medium: 50.3% to 66.4%; low: 2.8% to 24.8%). As the number of profilestriggered increased, the key circumstance were more likely to be carer burden (3.4% to 17.4%) oran acute medical condition (13.6% to 18.0%) and less likely to be due to concern about increasingfrailty (34.7% to 24.2%).

4.4.5 Performance of the HACC Functional Screen

The functional screen is now in the HACC MDS and is composed of nine items. Other items onfunction in the HACC MDS version 2 that are not part of the functional screen were included in thetrial software. These are useful for formulating a service response but are redundant for thepurposes of measuring functional ability and assigning a priority rating and have not been includedin the analysis.

The first seven items are recorded as either ‘completely unable to do’, or, ‘with some help’, or,‘without help’. The last two items are recorded as either ‘yes’ or ‘no’. All nine items need to becompleted to determine the functional screen score, which is the sum of the nine items (range 9 to27). The lower the functional screen score the more dependent a client is, the higher the score themore independent they are. The functional profile is also useful as a proxy to determine need,measured as low, medium and high.

The technical performance of the functional screen was already known to be satisfactory fromearlier research3 and the database results from the trial further confirmed this, but in considerablymore detail.

Table 14 below summarises the distribution of functional profile scores amongst ACCNA clients.They indicate the expected distribution of scores for the HACC target population.

3 Eagar K, Owen A, Marosszeky N and Poulos R (2006) Towards a Measure of Function for Home and Community Care Services in

Australia: Part 1 - Development of a standard national approach. Australian Journal of Primary Health. 12 (1): 73-81.Green J, Eagar K, Owen A, Gordon R and Quinsey K (2006) Towards a Measure of Function for Home and Community CareServices in Australia: Part 2 - Evaluation of the screening tool and evaluation instruments. Australian Journal of Primary Health. 12(1): 82-91.Eagar K, Green J, Gordon R, Owen A, Masso M and Williams K (2006) Functional Assessment to Predict Capacity for Work in aPopulation of School Leavers with Disabilities. International Journal of Disability, Development and Education. 53 (3): 331-349.



Table 14 Distribution of functional profile scores

Items 1-7 1. Completely unable to do 2. With some help 3. Without help

1. Housework 33.8% 58.5% 7.7%

2. Travel 7.8% 63.3% 28.8%

3. Shopping 24.4% 56.0% 19.6%

4. Medicine 5.9% 31.8% 62.4%

5. Money 13.8% 38.7% 47.6%

6. Walking 5.2% 36.3% 58.5%

7. Bathing 4.2% 38.6% 57.2%

Items 8-9 1. Yes, problems 3. No problems

8. Cognition 31.3% 68.7%

9. Behaviour 13.8% 86.2%

Figure 7 presents the same information but this time as a summary.

Figure 7 Functional profile

0%

10%

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30%

40%

50%

60%

70%

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90%

100%

Housework Shopping Travel Money Bathing Walking Medicine Cognition Behaviour

Can do Needs help

Figure 8 compares the functional profile of clients in the ACCNA field trial with the profile of clientsin the 2001 functional dependency study. The functional hierarchy is consistent with that found inthe original study. The main difference is that (as expected) the proportion of people needing helpis now a little higher than it was in 2001. These results confirm the results of the original study andare further evidence that the clients assessed in the ACNA field trial are a representative sampleof the target population.



Figure 8 Functional profile of clients in the ACCNA field trial compared to the 2001functional dependency study

4.4.6 Rehabilitation potential

As an indicator of how the concept of ‘rehabilitation potential’ and the functional profile can becombined and used in routine practice, a set of clear relationships was found in the data that are ofparticular interest to a number of the members of the Eligibility and Assessment Working Group.These were clients who were identified by the assessor as ‘likely to benefit from rehabilitation’.

Those judged to have rehabilitation potential were most likely to score between 19 and 23 on theirtotal score. Those clients identified as not likely to benefit from rehabilitation by the assessortended to have more extreme scores than those identified as likely to benefit from rehabilitation.They either had low (scores 9-14) or high functional scores (scores 25-27), suggesting thatassessors judged them to be doing too poorly or too well to benefit. This common sense resultsuggests that the functional screen can be used to select those people most likely to benefit fromrehabilitation.

The data showed that same relationship at the item level as well as at the total score level. Thoseclients considered likely to benefit from rehabilitation were:

§ less likely to be completely unable to do housework and less likely to complete houseworkwithout help

§ more likely to be completely unable to shop and less likely to shop without help

§ less likely to be completely unable to take their own medicine and slightly more likely to taketheir own medicine without help

§ twice as likely to be completely unable to walk than those not suitable for rehabilitation

§ more likely to be able to bathe

0%

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ork2001

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Money

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Bathing2006

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Medicine2006

Cognition2001

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Behaviour2001

Behaviour2006

Can do Needs help



§ half as likely to have cognition problems than those not suitable for rehabilitation

§ slightly more likely to have behavioural problems.

Those clients not currently receiving any services were considered more likely to benefit fromrehabilitation by the assessor than clients already in receipt of HACC or other services (72.0%compared with 56.2%).

Most clients requesting services to improve their current level of function and independence wereconsidered likely to benefit from rehabilitation by the assessor (86.5%), and those wishing tomaintain their current level of function and independence were not considered likely to benefit fromrehabilitation by the assessor (66.5%). These results suggest that the client’s self-assessed goalis strongly related to assessor judgement about the client’s potential for rehabilitation.

Rehabilitation assessment

Just over four out of ten (42.5%) clients assessed were triggered for a rehabilitation assessment.The assessment trigger corresponded well with those considered by the assessor likely to benefitfrom rehabilitation (99.4% v 0.4%). This assessment was more frequently triggered byassessments conducted over the phone (57.8%) than face to face (30.1%), and seemedindependent of whether the client was receiving any services (51.2%) or not (45.9%).

The proportion triggered for a rehabilitation assessment fluctuated with age. This assessment wasmost commonly triggered for clients wishing to increase their level of function and independence(73.9%) and least triggered for clients wishing to maintain their level of function and independence(20.5%). Clients were most likely to have a medium level of function (59.1%) and least likely tohave a low level of function (8.4%). If triggered for a rehabilitation assessment the keycircumstance was more likely to be an acute medical condition (20.2%) or concern aboutincreasing frailty (31.4%) or hospital discharge (33.5%), and less likely to be carer burden (4.2%)than if not triggered.

As shown in Figure 9, those potential care recipients with rehabilitation potential were triggered forconsiderably more assessments (the left graph) than the overall group (the right graph). Given thatover 60% of those assessed were identified as having the potential to become more independent,these results suggest that there is considerable scope to review current community care policies togive increasing attention to this cohort. Investment in the necessary assessment systems wouldbe a pre-requisite for such an approach.

Figure 9 Numbers of triggered assessments for Care Recipients with rehabilitationpotential

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Assesssments triggered for all potential care recipients



4.5 Assessments triggered

4.5.1 Type of assessments triggered

Among the 15 assessments that could be triggered by the ACCNA, the two functionalassessments (domestic and self-care) and a rehabilitation assessment were the most frequentlytriggered (see Table 15). Less than one in ten clients were triggered for the caring for others,carer, mental health or child disability assessments.

Table 15 Types of assessments triggered

Assessments triggeredAssessment type

Number Percent of those assessed

Domestic function 748 60.0%

Self-care function 568 45.5%

Rehabilitation 530 42.5%

Equipment 506 40.6%

Medical 499 40.0%

Home modifications 379 30.4%

Cognitive 294 23.6%

Vision 263 21.1%

Hearing 153 12.3%

Speech 132 10.6%

Behaviour 126 10.1%

Caring for others 124 9.9%

Carer 81 6.5%

Mental health 30 2.4%

Child disability 19 1.5%

Figure 10 presents the same information, but this time as a percentage of all assessmentstriggered. Domestic and self-care assessments represented close to 30% of all assessmentstriggered.

Assessors could over-rule the ACCNA recommendations when either they disagreed with therecommendation, or the recommendation was correct but other arrangements were already inplace. For example the client might already be receiving personal care or domestic assistance,making the assessment recommendation redundant.

Given the number of assessments triggered, the use of 3 or more recommended assessments asthe main trigger for a comprehensive assessment is not appropriate as it triggers too many clientsfor a comprehensive assessment. These issues are discussed further in Section 5.7.



Figure 10 Assessments triggered by the ACCNA

4.5.1.1 Domestic function

Six out of ten (58.9%) clients assessed were triggered for a domestic functional assessment. Thisassessment was most frequently triggered by assessments conducted face to face (86.9% v64.7%) and for those already receiving HACC or other services (76.0% v 58.2%).

The proportion triggered for a domestic functional assessment increased with age, from 20.8%among clients aged 19-40 years up to 80.0% among clients aged at least 85 years. Clients weremost likely to have a medium level of function (64.3%) and least likely to have a low level offunction (12.8%). If triggered for this assessment, the key circumstance was more likely to be carerburden (10.3%) or hospital discharge (30.5%) than if not triggered.

4.5.1.2 Self care

Two out of three (66.8%) clients assessed were triggered for a self-care functional assessment.This assessment was most frequently triggered by assessments conducted over the phone (63.2%v 54.2%), and among those already receiving HACC or other services (66.1% v 59.8%).

The proportion triggered for a self care functional assessment mostly decreased with age, from100.0% among clients aged less than 19 years down to 52.5% among clients aged 75-79 years,before increasing again among those aged at least 80 (aged 80-84: 65.1%; aged 85+: 70.4%).

This assessment was most commonly triggered for clients wishing to reduce the rate of decline intheir level of function and independence (72.1%) and least triggered for clients wishing to maintaintheir level of function and independence (52.0%). Clients were most likely to have a medium levelof function (82.8%), none had a high level of function. If triggered for this assessment the keycircumstance was more likely to be hospital discharge (33.9%) or carer burden (10.4%) or falls(7.8%), and much less likely to be concern about increasing frailty (22.6%) than if not triggered.

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health

Child dis

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4.5.1.3 Equipment

Four out of ten (40.6%) clients assessed were triggered for an equipment assessment. Thisassessment was most frequently triggered in NSW (49.8% v 29.9%), by assessments conductedface to face (60.1% v 45.6%), and among those already receiving HACC or other services (53.7%v 39.3%). The proportion triggered for an equipment assessment mostly increased with age, from10.4% among clients aged 19-40 years up to 55.2% among clients aged 80-84 years.

This assessment was most commonly triggered for clients wishing to increase their level offunction and independence after an acute illness/event (56.3%) and for those wishing to reducetheir rate of decline (54.1%). It was least triggered for clients wishing to increase their level offunction and independence for other reasons (42.5%). Clients were most likely to have a mediumlevel of function (65.2%) and least likely to have a low level of function (11.8%). If triggered for thisassessment the key circumstance was more likely to be falls (11.2%) than if not triggered.

4.5.1.4 Medical

Four in ten (40%) clients assessed were triggered for a medical assessment. This assessmentwas most frequently triggered in NSW (51.9% v 26.2%), by assessments conducted over thephone (41.8% v 34.0%) and for those considered by the assessor as likely to benefit fromrehabilitation (45.7% V 28.6%). It was also triggered more often for those not currently in receiptof any services (45.3% v 30.1%).

This assessment was most commonly triggered for clients wishing to reduce the rate of decline intheir level of function and independence (53.6%) and least triggered for clients wishing to maintaintheir level of function and independence (24.9%). Clients were most likely to have a medium levelof function (53.4%) and least likely to have a low level of function (36.0%). If triggered for thisassessment the key circumstance was more likely to be concern about increasing frailty (37.4%)and less likely to be hospital discharge (21.7%) than if not triggered.

4.5.2 Numbers of assessments triggered

Figure 11 shows the percentage of those recommended for further assessments. Only 6% werenot triggered for at least one further assessment. 42.6% were triggered for between one and threefurther assessments and a further 36.9% were triggered for between four and six assessments.Fourteen percent were recommended for seven or more assessments.

As shown in Figure 12, the number of assessments recommended was related to the keycircumstances that led to the assessment.



Figure 11 Number of recommended assessments

Figure 12 Relationship between the number of assessments recommended and keycircumstances triggering contact

The most assessments were triggered for those for whom carer burden was the key circumstance,followed by those who were concerned about falls. For these two groups, less than 20% wererecommended for three or less assessments. Those with acute medical conditions and hospitaldischarges were recommended for less assessments overall.

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Carer burden Falls Concern about increasingfrailty

Acute medical condition Hospital discharge

0 1 2 or 3 4 or 5 6 or 7 8 or more



As the level of function decreased, the number of recommended assessments increased. Fewerassessments were triggered when assessed over the phone.

The number of assessments triggered increased with age. Those aged less than 65 years weremost likely to be triggered for only one assessment (33.7%). Those aged 65-74 years were mostlikely to be triggered for four assessments (18.7%). Those aged 75-84 were most likely to betriggered for five assessments (19.1%) while those aged at least 85 years were most likely to betriggered for six assessments (18.4%).

Those wishing to maintain their current level of function were more likely to be triggered for up tothree assessments than those wishing to improve their current level or reduce the rate of decline(39.8%, 21.8% and 17.4%, respectively). Clients wishing to reduce the rate of decline in their levelof function were more likely to be triggered for eight or more assessments than those wishing toimprove or maintain their current level (23.0%, 11.5% and 7.1%, respectively).

4.5.3 Triggers for comprehensive assessment

The rule for triggering a comprehensive assessment was, for the purpose of the trial, that the carerecipient was recommended for referral if triggered for 3 or more assessments of any type. Asshown in Table 16, this rule resulted in 62.6% of care recipients being recommended forcomprehensive assessment.

Table 16 Number of assessments recommended based on the triggers used in the fieldtrial

No of assessments recommended Number Percentage Cumulative percentage

0 78 6.3% 100.0%

1 222 17.8% 93.7%

2 167 13.4% 75.9%

3 145 11.6% 62.6%

4 172 13.8% 50.9%

5 131 10.5% 37.1%

6 157 12.6% 26.6%

7 94 7.5% 14.0%

8 58 4.7% 6.5%

9 16 1.3% 1.8%

10 6 0.5% 0.6%

11 1 0.1% 0.1%

Total 1247 100.0%

The data suggest some patterns in relation to who was triggered for a comprehensiveassessment. For example, a comprehensive assessment was more often triggered as the age ofthe client increased. The rate ranged from 27.1% among those aged 19-40 years to 83.8% amongthose aged at least 85 years. Likewise, a comprehensive assessment was more likely to betriggered for those assessed as having rehabilitation potential and least likely to be triggered forthose whose goal was to maintain their current level of function.

These patterns make sense. However, the use of 3 or more recommended assessments as themain trigger for a comprehensive assessment is not appropriate as it is too broad and needs to berefined as discussed in Section 5.7.

4.6 Feedback on assessment triggers

One in four assessors gave feedback on the appropriateness of the triggers for assessment andtheir views are summarised in Table 17. Most assessors agreed with the trigger (range 67.6% to



95.4%), with typically 65-75% agreeing when triggered and 85-95% agreeing when not triggered.The exceptions were disagreement with the triggering of vision (49.6%), home modifications(56.1%), speech (23.5%) and carer (33.3%), and disagreement with the small proportion nottriggered for domestic function (45.3%).

Table 17 Recommended triggers and assessor feedback

Assessor feedback - triggered Assessor feedback - nottriggered -

Assessor feedback - total -Assessment type

Received Agreed %Agreed Received Agreed %Agreed Received Agreed %Agreed

Self care function 202 154 76.2% 78 74 94.9% 280 228 81.4%

Domestic function 252 189 75.0% 53 24 45.3% 305 213 69.8%

Medical 69 53 76.8% 164 143 87.2% 233 196 84.1%

Rehabilitation 103 67 65.0% 156 145 92.9% 259 212 81.9%

Equipment 187 125 66.8% 78 72 92.3% 265 197 74.3%

Vision 141 70 49.6% 118 105 89.0% 259 175 67.6%

Home modifications 148 83 56.1% 113 94 83.2% 261 177 67.8%

Cognitive 129 91 70.5% 108 106 98.1% 237 197 83.1%

Hearing 74 51 68.9% 162 143 88.3% 236 194 82.2%

Speech 51 12 23.5% 170 169 99.4% 221 181 81.9%

Behaviour 26 17 65.4% 193 185 95.9% 219 202 92.2%

Caring for 31 24 77.4% 193 186 96.4% 224 210 93.8%

Carer 12 4 33.3% 210 171 81.4% 222 175 78.8%

Mental health 8 7 87.5% 211 194 91.9% 219 201 91.8%

Child disability 4 2 50.0% 215 207 96.3% 219 209 95.4%

A description of the first four assessments in this figure was given in Section 4.5.1 and additionalcomments on the other assessments are contained in Attachment 1.

4.7 Priority rating

A priority rating score was calculated for 57% of all assessments. These were assessments inwhich sufficient data were captured to determine a priority rating. As all items were optional, it hadbeen anticipated that it would not be possible to assign a priority rating to each assessment.However, this raises the issue of how to deal with missing data if a priority rating system is to beused in routine practice. This issue is discussed further in Section 5.3.

As shown in the priority rating model (Figure 13 on page 54), the lower the priority scores, thegreater the need and risk. As anticipated, the distribution of priority scores was not evenly spread.28.7% of clients had a priority score of six and one third (31.3%) had a score less than six.



Table 18 Priority rating scores

Priorityrating

Description Number Percentage Cumulative %

1 Low function or Medium function with significant psychosocial orother problems. No carer able to provide necessary care

62 8.8 8.8

2 Medium function without significant psychosocial or otherproblems. No carer able to provide necessary care

25 3.5 12.3

3 Low function. Carer arrangements exist but are unsustainablewithout additional resources

99 14.0 26.3

4 Medium function without significant psychosocial or otherproblems. Carer arrangements exist but are unsustainable withoutadditional resources

31 4.4 30.6

5 Good function but health, psychosocial or other problems. Nocarer able to provide necessary care

4 0.6 31.2

6 Low function or Medium function with significant psychosocial orother problems. Carer arrangements suitable and sustainable orCarer not required

203 28.7 59.9

7 Good function but health, psychosocial or other problems. Carerarrangements exist but are unsustainable without additionalresources

2 0.3 60.2

8 Medium function without significant psychosocial or otherproblems. Carer arrangements suitable and sustainable or Carernot required

166 23.4 83.6

9 Good function but health, psychosocial or other problems. Carerarrangements suitable and sustainable or Carer not required

116 16.4 100.0

All 708 100.0

Clients assessed face to face were more likely to have a high priority rating (a rating of 1-3) thanthose assessed over the phone and less likely to have a priority of eight or nine. This suggeststhat people with more problems receive more face to face assessments.

Clients wishing to reduce the rate of decline in their level of function and independence were morelikely to have a priority of 1-3 than those wishing to improve or maintain their current levels. Clientswishing to maintain their current level of function and independence were more likely to have apriority of eight or nine than those wishing to improve their current levels or reduce the rate of theirdecline.

Table 19 shows the level of agreement between the priority rating and the assessor. The topsection presents the data as percentages of the total. The bottom section presents the data as apercentage of each mode of administration. In total, assessors agreed with the priority rating intwo thirds of cases but were not sure in another 16%. When they disagreed, they mostly thoughtthat it should have been higher (ie, the person had higher priority for service than they had beenrated).

In considering these data, it should be noted that there was a small programming error in theACCNA software used in the field trial that was identified in the subsequent analysis. This errorled to an incorrect rating being assigned for 7.5% of those cases with all of the informationrequired to assign a priority rating. In these cases, the ratings were typically one or two ratingshigher or lower than they should have been. This error was subsequently corrected during theanalysis but may have had a small impact on the results presented in this table.



Table 19 Assessor judgements about the priority rating

Mode of assessmentAssessor view on priority rating

Over the telephone Face to face Both

As % of total

Agree 33.5% 28.5% 3.7% 65.7%

Disagree - should have been higher 12.8% 2.5% 0.4% 15.7%

Disagree - should have been lower 0.4% 2.1% 0.0% 2.5%

Not sure 14.0% 2.1% 0.0% 16.1%

As % of total 60.7% 35.1% 4.1% 100.0%

Mode of assessmentAssessor view on priority rating

Over the telephone Face to face Both

As % of total

Agree 55.1% 81.2% 90.0% 65.7%

Disagree - should have been higher 21.1% 7.1% 10.0% 15.7%

Disagree - should have been lower 0.7% 5.9% 0.0% 2.5%

Not sure 23.1% 5.9% 0.0% 16.1%

As % of mode of assessment 100.0% 100.0% 100.0% 100.0%

Assessors were more confident about assessments undertaken face to face and were significantlymore likely to agree with the rating assigned. When they disagreed, they were fairly evenly dividedbetween thinking that the rating was too high or too low. Likewise, assessors agreed in mostcases for the small number of assessments that involved both a telephone and a face to faceassessment.

These results, in combination with feedback received, suggest that the priority rating system wasseen as useful and had face validity in the field. On that basis, it should be included in the firstversion of the ACCNA. This issue is discussed further in Section 5.3.

4.8 Feedback from the Level One agencies

4.8.1 Assessor feedback about individual assessments

Assessors were invited to provide feedback after completing each assessment. Assessors took upthis invitation in relation to 942 assessments (75.5%). Table 20 summarises their views. Nofeedback was provided on 305 assessments, with over half of these coming from one agency.Where no feedback was received this was interpreted as assessors skipping the feedback pageeither because they were busy and/or the assessment was routine and there was nothing toreport.

Assessors had three options to summarise their overall view. 84% were satisfied with using theACCNA with the particular client they were commenting on. 5.5% indicated that they were toobusy to provide feedback while 10.5% wanted to provide more comments. These comments wereboth positive and negative and have been incorporated in the feedback summarised elsewhere inthis report.

Table 20 Assessor satisfaction with the ACCNA by mode of administration

Mode of administration

Feedback Phone Face to face Both All

Satisfied, no further comments 633 118 12 791

Too busy to complete evaluation 34 4 1 52

Want to provide more details 67 28 4 99



All 734 150 17 942

Satisfied, no further comments 86.2% 78.7% 70.6% 84.0%

Too busy to complete evaluation 4.6% 2.7% 5.9% 5.5%

Want to provide more details 9.1% 18.7% 23.5% 10.5%

All 100.0% 100.0% 100.0% 100.0%

Table 21 provides results to the same question by agency. It will be seen that the percentagesvary by agency. Overall, the agencies that did more assessments were more satisfied andprovided fewer comments, suggesting that satisfaction increased as assessors became morefamiliar with the tool. This is consistent with the agency-level feedback at the end of the trial.

Table 21 Assessor satisfaction with the ACCNA by agency

Agency No ofresponses

Satisfied, nofurther

comments

Too busy tocomplete

evaluation

Want toprovide more

details

Total

Agency 1 413 90.6% 1.7% 7.7% 100.0%

Agency 2 192 82.8% 17.2% 0.0% 100.0%

Agency 3 120 83.3% 1.7% 15.0% 100.0%

Agency 4 92 57.6% 7.6% 34.8% 100.0%

Agency 5 72 100.0% 0.0% 0.0% 100.0%

Agency 6 46 63.0% 4.3% 32.6% 100.0%

Agency 7 7 57.1% 14.3% 28.6% 100.0%

All 942 84.0% 5.5% 10.5% 100.0%

Note No responses to this question were received from one agency

Assessors were also invited to rate their confidence about the outcomes of the assessment. Onlya quarter did so and so the results shown in Table 22 need to be treated with some caution. Withthis caveat, Table 22 shows that assessors were confident with the assessment outcomes, with52% very confident and a further 42% somewhat confident. Only 6% were not confident.

Table 22 Assessor confidence about the outcomes of the assessment



Very confident 96 57 2 155

Somewhat confident 91 27 8 126

Not confident 16 1 0 17

All 203 85 10 298

Very confident 47.3% 67.1% 20.0% 52.0%

Somewhat confident 44.8% 31.8% 80.0% 42.3%

Not confident 7.9% 1.2% 0.0% 5.7%

All 100.0% 100.0% 100.0% 100.0%

One third of assessors took the opportunity to comment on whether or not important informationwas missing and, if so, to identify what else they needed to know (see Table 23). 87% thoughtthat no important information was missed, while 13% did not agree. Those conducting face to faceassessments were more likely to identify missing information than those conducting phoneassessments.



Table 23 Was any important information missing?



No 303 68 2 373

Yes 30 17 8 55

All 333 85 10 428

No 91.0% 80.0% 20.0% 87.1%

Yes 9.0% 20.0% 80.0% 12.9%

All 100.0% 100.0% 100.0% 100.0%

The missing information was highly variable with no additional items being mentioned more than afew times. Some commented on specific issues with the electronic version as illustrated by thefollowing examples:

Client has both cognitive and physical reasons for being unable to do medications orhandle money on the Functional Screen. Unable to tick both at present.

A section where I can express further information which does not relate to any of thequestions asked.

An area to advise assessor to contact carer instead of client due to her not being ableto speak English. I had to find an area where I thought it was most appropriate.

Examples of the other information assessors wanted included:

I felt it needed to show future deterioration in client’s health due to his diagnosis.

Other gov. pension type, no room to mention a UK aged pension.

The service choices on screen 2 are too limiting, no nursing service and no dementiaservices which I think should be included.

There was nowhere to indicate family are providing her care even though they are notofficial carers and are unable to sustain it.

It does not allow for the situation where a person is in assisted living and thereforeeffectively living alone but with staff assisting from the facility who are his carers.

Need more room to discuss social and personal issues, rather than issues relating tohealth.

Other family issues

Client is carer for her intellectually disabled son and I could not find anywhere to putthat information

Client is two year old, seems form is designed significantly for older people.

4.8.2 Agency level feedback

In addition to seeking feedback on each assessment, feedback sessions were also held at the endof the trial with the Level One agencies. As anticipated, the feedback varied considerably betweenagencies, in large part reflecting their local context, whether they used electronic or paper versionsand whether they did phone or field assessments or a mixture of both.



For example, some agencies had been looking to move to an electronic assessment system andsaw participation in the ACCNA trial as an opportunity to pursue their existing agenda. Notsurprisingly, these agencies were extremely positive about the electronic version and want tocontinue to use it after the trial ends.

In contrast, other agencies were less positive. Some experienced local difficulties at the time,including the loss of their manager; some had a delay between receiving training and beginningthe data collection and some undertook only a small number of assessments in the trial period.The mixed experience of the agencies is a good example of the challenges in the implementationof new systems in agencies undergoing continuous change.

The feedback from those agencies with existing electronic systems differed to that of agencieswithout pre-existing systems. For those with existing systems, the feedback was much moreabout comparing the ACCNA to their current systems and focused more on issues such as theinteroperability between the ACCNA and existing assessment and reporting systems.

The other issue that influenced agency experiences with the ACCNA is whether the agency testedthe electronic or the paper version. As anticipated, the feedback on the electronic version wassignificantly more positive than the feedback on the paper version. While this had been expected,it suggests the need in the longer term for hand held electronic solutions such as PDAs, smartphones, laptops, or tablets

4.9 Feedback from the Level Two agencies

There were 67 applicants for CDs containing the data base version, and the interest was in howthe ACCNA and CENA tools could work together. There were 5 requests for ACCNA only, 60 bothACCNA and CENA and 2 for only the CENA. Most of those registered did not provide feedback,indicating the commitment of time need for using and understanding the tools and the need forsupport in training and backup testing the tools. Those registered were given e-mail prompts andoffered further assistance to send in their feedback with few additional responses.

A common response to the prompts at Level Two was ‘we looked at it and realised we don’t dothis level of assessment’ and ‘I haven’t even had a chance to load it on and open it yet.’

In spite of low numbers, the quality of the feedback in written responses and submissions fromthose who had looked at the tools in detail was good. The comments are summarised in Section4.11 below.

4.10 Feedback from the Level Three agencies

There were about 7,000 hits on the CHSD project website in the period from August 2005 toOctober 2006, half of which were in the field testing period (August-October 2006). There was alot more looking than responding, indicating a useful communication strategy with relatively lessimpact on the evaluation itself.

At Level 3 of the trial, 184 people registered to use the site and look at the web versions of theACCNA application. 38 gave feedback. 22 (58%) were satisfied, 12 (32%) provided morecomments and 4 did not respond.

The trial also received written feedback from the Level Two and Three sites as illustrated in thenext section. Points that were reinforced were the value of the extra breadth of investigation butworries about how the extra dimensions would be used. The Action Plan and the scope of thedomains were viewed positively, and some of the items were said to be better included in a deepand broad assessment.

In the design of the priority rating the feedback urged the CHSD team to think more about how touse the rehabilitation concepts and the use of ‘capacity to improve’ as a factor. ‘We recognisedthere would need to be training in how to ask the questions from a cultural perspective, a wellnessperspective, rather than a maintenance perspective.’



4.11 Combined Levels Two and Three feedback including written submissions

Agencies and individuals inspected the tools on the web site and gave their comments. Therewere 184 Individual registrations, and 38 people gave comments

Some participants also put their views in a submission format in relation to both of the ACCNA andCENA, and many of these went beyond commenting on the data elements and the layout andalso provided feedback from a broad “policy” perspective.

4.11.1 Generally Positive

“We commend your team on the excellent achievements to date and offer our supportfor the direction outlined.”

“(Our agency) supports and commends assumptions outlined in the ACCNA ProjectConsultation Paper. The assumptions underpinning the project cover importantdimensions in assessment and it provides a strong platform for the development of arobust assessment tool to support community care delivery.”

Features of the data elements and the derived items were given positive remarks.

“The action plan was a feature that the representatives from the assessment teamviewed very positively and would value a good deal.”

“Screen 8 - Pre-Profiles Summary - Comments Summary is excellent.”

Software was not the primary focus of the pilots, and was developed as a mechanism to achievethe testing of the assessment data elements. However users acknowledged the value of some ofauto-populating features.

“Despite some minor glitches, it is apparent that the intent is that information collectedearlier in the assessment will “pull through” and automatically populate later fields.This is an excellent feature and we hope that this will also be possible between theACCNA and the CENA”.

The highest support was for the Action Plan and Referral Reasons, and the feedback fromexperienced users and discussion in the Focus Groups indicated that practical issues like why theconsumer made contact and what to do next were most valuable.

The lowest support in the feedback from Levels 2 and 3 and in the Focus Groups was for theFinancial and Legal profile and Client Goal. Financial matters were thought to be too intrusive foran initial contact or over the phone.

4.11.2 But the inter-relationships are too limited

“Could there be a link from the ACCNA to the CENA and vice versa?”

The obvious next step was two-way compatibility so that:

“there should be a link between the two assessments so that information could be“pulled through” rather than re-asked and re-entered.”

“Of concern however, was that there does not seem to be any ‘system logic’ in thissoftware, ie the information gathered during the assessment does not drive anyrecommendations in relation to the services recommended in the action plan.”

Ensuring consistent and mappable data elements between the ACCNA and the CENA was themost immediate of the wider system level integration issues that were raised consistently in the



field. The prerequisites to wider system reform were recognised as a common language and thedevelopment of inter-agency protocols and business rules.

4.11.3 And the domains are not positive enough

The maintenance focus of the ACCNA was seen to not positive enough and this was reflected incomments such as:

“there did not appear to be recognition of any pro-active or preventative approach tothe circumstances.”

The tone of much of the feedback showed an appreciation of the need for a more positive view.

“Currently, the majority of tools developed to assist in planning are heavily geared tothe identification of need. This practical focus on identifying one’s need isunderstandable as this is a prerequisite in the design of a service support plan.However, over-emphasis on need skews our view of an individual and it alienates aperson in contributing to his/her recovery process. The uniqueness and value of everyindividual with his/her strengths, abilities and desire to live a normal life should not belost in the course of an assessment.”

The priority rating was strongly encouraged to be changed:

“to consider the capacity to improve as one of the criteria for this process.”

The service response should be linked on the Contract Reasons page under “assistance requiredto” … and connect with “Improve current level of function and independence”.

“This should be included in the calculation of priority.”

“Conceptually this approach is not restricted to clients with low levels of need but couldbe applied across the board. An investment of this type for all interested clients,irrespective of their level of dependency may provide them with new approachesand/or aids and equipment that will mean that they are more independent, thusreducing the need (and consequently volume) for ongoing services. This would thenincrease the amount of service available to other clients, reducing the amount of unmetneeds in the community, whilst promoting a person-centred independence philosophy.Thus “early intervention” does not only relate to the point in the client’s journey whenthey first access services, but also “early” in the various stages of care as their needschange – for whatever reason.”

4.11.4 Scope of the ACCNA remains a big issue

Concerns were raised about the appropriateness of some of the domains for inclusion in apreliminary “broad and shallow” instrument, “with many of them believed to be more appropriatefor inclusion in a comprehensive, ‘broad and deep’ assessment.”

“Overall the assessment appears to go into the area of comprehensive assessmentversus basic assessment with a trigger or outcome of comprehensive assessment.”

“Screen 9 - Financial and Legal- Decision making responsibilities is subjective andthere may be multiple answers re ability to make some decisions but not others.Believe overall the questions are too deep for basic HACC services, realising that allquestions are not required to be answered at first contact or if not appropriate."

Scope can be a design feature if seen as a set of levels each containing modules that theassessor then navigates along with the consumer.



“Whilst the assessment is designed to provide a holistic overview of needs, clients whoare requesting a specific service may have different expectations and expect only to beasked questions that pertain specifically to that service. This can be managed bycareful filtering of questions to limit assessment to what is required and appropriate.”

4.11.5 Training was an issue everywhere and for everyone.

The scope of interventions in community care is wide and it was felt by some agencies that theACCNA could be used to flag interventions “prior to the establishment of ongoing “maintenance”type services to support the client to achieve their optimal level of functioning.”

The rehabilitation potential of community care was one of many cultural, organisational andcompetency issues that were raised in the ACCNA field-testing.

“Conceptually this approach is not restricted to clients with low levels of need but couldbe applied across the board. An investment of this type for all interested clients,irrespective of their level of dependency may provide them with new approachesand/or aids and equipment that will mean that they are more independent, thusreducing the need (and consequently volume) for ongoing services. This would thenincrease the amount of service available to other clients, reducing the amount of unmetneeds in the community, whilst promoting a person-centred independence philosophy.”

Training in identifying consumer issues for rehabilitation, health promotion, mental well-being andhealthy behaviours were flagged as areas outside the scope of some agencies’ currentapproaches to service provision.

“We recognised there would need to be training in how to ask the questions from acultural perspective, wellness perspective rather than a maintenance perspective.”

“Re K10 - Concerns are that staff not adequately trained to ask questions in the mentalhealth and well-being scale.”

“The question re the Mental Health Act, what are we doing with this information? Howuseful is it in service provision?”

“Financial Decisions, we did not understand these questions. Are these asked on thetelephone? With the outcome from this we question how helpful a GP would be inmanaging this issue.”

“Financial Decisions – Do you have enough financial resources to meet emergencies -doesn’t this depend on the emergency?”

“Screen 12 - Carer - Other than basic contact details, we do not believe that thesequestions are appropriate to ask on the first interview or contact.”

4.11.6 Most responded wanted the CENA and ACCNA combined, with a specific purposeidentified and both with multiple levels

Feedback was quite specific about how the purpose of the tools needs to be made more explicitand how that relates to the depth of inquiries to be made.

“Form layout modifications. It is suggested that in addition to the word OPTIONALincluded under the headings (e.g. Optional Health Conditions Profile; Optional CarerProfile and etc.) segments be preceded by an indication of the specific function itintends to support e.g. indicating whether the information gathered in that sectionsupports intake/intervention or care planning and so on.

It is also suggested that a clear statement outlining the purpose of the tool be includedin the form emphasising that the assessment instrument is designed to bring



consistency to the assessment system at a national level and, that the tools areadaptable and designed to serve as a baseline guide to agencies.”

“However our primary concern surrounds the conduct of the assessment, primarily thatmuch of it is inappropriate to be undertaken on anything but a face-to-face basis, andpreferably after some rapport has been developed between the assessor and thecarer.

As with the ACCNA, this issue would be addressed if the key initial screening andeligibility items are identified and undertaken at first contact, with others identified asonly appropriate at subsequent stages.”

“Good. For our service type we would need to do a little more work around when andunder what circumstances we used which parts of the tools. This is consistent with ourexpectations though.”

4.12 Level Four - Focus Group Feedback

The Focus Groups included presentations to experienced assessors who had no direct priorexperience. Feedback was obtained in written form and in a limited number of groups anautomated method using electronic keyboards was used as well. In total 33 assessors providedwritten feedback. Their average experience was 11 years.

The combined findings from the Aboriginal and Torres Strait Islander evaluation session, focusgroups and information sessions that were not all conducted under Level Four of the trial but arediscussed in a consolidated form in Section 4.13 below.

The general results from the focus groups are aggregated below across all groups. The placesand purposes of the groups were included in the trial evaluation plan4.

Participants were asked to record their ratings of the relevance, appropriateness and importanceof the domains covered in the ACCNA on a five-point scale from low to high (i.e. the higher thescore, the more relevant, appropriate and important).

The results indicate a satisfactory level of support for the domains included in the ACCNA. Theaverage across the three dimensions of relevance, appropriateness and importance are shownbelow.

Table 24 Rating of the ACCNA domains by the focus groups

Domain Average score out of 5

Action plan 3.95

Reason for referral 3.89

Functional profile 3.74

Carer profile 3.73

Eligibility 3.65

Priority rating 3.56

Social and emotional 3.50

Living arrangements 3.50

Health conditions 3.27

Client goal 2.86

Financial and legal 2.82

4 Samsa, P. et al (2006) Australian Community Care Needs Assessment (ACCNA) Progress Report No. 2: the tools, the field test and

the evaluation. Centre for Health Service Development, University of Wollongong.



The highest support was for the Action Plan and Referral Reasons. The lowest was for theFinancial and Legal profile and Client Goal. The discussion in the Focus Groups indicated thatpractical issues such as why the client made contact and what to do next were most valuable.Financial matters were thought to be too intrusive for an initial contact but would be collected at asubsequent date.

Client acceptability is included in the above ratings indirectly via the assessor. Client views viafocus groups of direct clients who were assessed using the ACCNA will be included in the FinalReport.

4.13 National Aboriginal and Torres Strait Islander consultations

4.13.1 The processes used in the project and the field trial

The National Aboriginal and Torres Strait Islander HACC Reference Group was given initialinformation regarding the ACCNA project and additional information on the strategies used toencourage responses in the consultation phase in 2005 and the views of those participants weresummarised. The 2006 field trial was described including the opportunities for input at the fourlevels, plus an invitation was made to provide direct input via submissions. Keeping up with theprogress of the trial via the website was promoted as an informative strategy.

The briefings also referred to the Carers Eligibility and Needs Assessment (CENA) tool and theway it was being field tested in parallel with the ACCNA and steered by a reference groupconvened under the National Respite for Carers Program. Most of those consulted were interestedin understanding the needs of both the care recipients and the carers.

Advice during the project was focussed on the strategies being used within the ACCNA andCarers field trials to address Aboriginal and Torres Strait Islander assessment issues and toensure their adequate representation in the findings. The briefings included a request to makerecommendations to service providers or other groups with particular expertise that couldparticipate in particular in Levels 2 and/or 3 of the field-testing. This was a strategy to ensure arepresentative sample was achieved.

An Aboriginal-specific assessment component was included within one agency in Level One,which was also related to a separate project to develop an indigenous assessment strategy. Thatmeant participation in training, advice and support via the hotline and assistance in preparingpresentations and strategic advice was included. A Level One evaluation session was specific toAboriginal assessments and included an assessor with experience in using the tools in the trial, aswell as experienced assessors who had not used the tools in practice. Longer meetings with adetailed description and demonstration of the ACCNA and CENA tools took place at the Level 4focus groups and at the information sessions.

Level 4 of the trial targeted providers for groups with special needs. It covered the acceptability toagencies that provide services to indigenous communities and in regional and remote areas whereit may not be realistic for them to try a data base or website version. Focus groups were held inAlice Springs, Darwin, Townsville and Thursday Island and information sessions were held inmetropolitan Sydney with the HACC Gathering executive group and a carer network, both of whichincluded rural and regional agency representatives and some experienced assessors.

The key points for Aboriginal and Torres Strait Islander assessments from the responses to theACCNA and the CENA in the field trial can be summarised under the headings of responses to thetools being trialed and comments on current systems being routinely used.

4.13.2 Responses to the ACCNA and CENA

The consensus view in Level One (where the experience was in using a phone-based model) wasthat a modular approach would help, that modifying the layout into more explicit levels made senseand that some domains and items hardly got used at all.



The background of the Level One advice was that apart from a small number of agencies thecurrent assessment practices are not standardised and the tools and processes being used varywidely. In that context the ACCNA (and CENA) could be used with indigenous clients but not inthe same way as in the mainstream. Where they had been used they were perceived to takecurrent practices well beyond the CIARR-type level.

Points to consider for changes or more clarification were identified at the Level One evaluationsession as:

§ priority rating is not useful unless the assessor captures sufficient context information

§ the basic functional screen is more practical than the expanded version

§ availability of open fields and comment boxes made it more useful

§ social and emotional domains were less useful than the health items and the financial andlegal items were not used at all

§ health conditions and current treatments were a good focus for steering a conversation

The key issues (that mirrored the concerns in the ‘mainstream’) were the current skill andconfidence levels and the provision of adequate training and support for assessors, especially inusing standardised components such as the functional screen and the K10. Regardless ofethnicity or indigenous status the ability to get and retain the right skill sets in remote areas andeven in larger regional centres, was a problem.

The important qualification was that there were no real problems in current practice as long asassessors knew whom to refer to for covering assessment areas where they felt their skills wereinsufficient.

‘I believe we have been able to use both our formal assessment / referral tools &conversations with referrers to get plenty of information on both the carers and thecare recipient with whom we really have the most contact.’

But any ‘new’ national approach should be seen as an opportunity to raise the levels ofcompetencies and confidence in the sector and be backed up by resources for training andsupport. This implied a training strategy where agencies within a region agreed on the assessmentcompetencies required for different types of services and at different levels of depth. A roll-outstrategy that had these ideas built in would be welcomed.

The major differences between the ‘mainstream’ assessment tools and those used for Aboriginaland Torres Strait Islander assessments that were noted in the consultations and the field testingwere that additional items should cover:

§ added questions on literacy and numeracy

§ include in the ACCNA some scope for specific attention to local or familial considerations -about ‘the way of talking to certain people about certain things’

§ a simple version of the carer items that allows for a network of care-giving, not just a primarycarer, or have good links to the more detailed carer tool

§ stolen generation – as an optional part of a psychosocial domain

§ a set of teeth in the health profile - oral health is a major issue

§ consider an additional profile on home safety and the environment - public health is a majorissue.

Most responses were not about the ACCNA per se, as exposure to the tool and its use with acritical volume of clients was limited to the Aboriginal and Torres Strait Islander assessments



under Level One. Most of the focus group discussions and comments were based on experiencesshaped more by the assessment tools and systems currently in use.

4.13.3 Comments on current assessment systems

1. They needed the ONI (for example) to be adapted to meet the needs of Aboriginal and TorresStrait Islander and CALD. Indigenous clients require a modified, more appropriate tool.

‘Modified ONI for ATSI and CALD, financial assessment tool that is carried through byall providers, risk identification eg elder abuse.’

2. The CIARR questions were reported as not being sensitive to Aboriginal and Torres StraitIslander clients but coordinators would use discretion to ensure that the client is assessed.Some assessors said they needed a combination of qualitative and quantitative data, ie.objective indicators combined with client’s self reported needs of carer and recipients, and theexperience and opinions of professionals, including our Coordinators and others advising them,eg ACAT, nurses.

3. Aboriginal clients and clients in rented accommodation were said to be under-represented inservice provision, so providing a culturally appropriate service to Aboriginal people who areaged, have a disability or carers of those people requires a better assessment approach. Insome current examples the assessment method is clear and is based on a point scoring modelthat takes into consideration the care recipient/carers situation.

‘The approach also takes into account our organisation’s available resources at aparticular time.’

4. A list of common assessment tool requirements:§ It can be simple, but lends itself to expanding where necessary

§ Is done in a way that checks back with the client to ensure that the client activelyparticipates as an equal partner in the assessment process and that information recorded isaccurate and recorded with the carer’s/recipient’s consent.

§ Is formatted to ensure data feeds into formal departmental reporting systems

§ Is ongoing throughout the client’s stay on the program

§ Balanced - does not entirely rely on scores and reports but gives equal weight to thecarers/recipients, coordinators and other professionals considered opinions.

§ Flexible - not all sections need to be completed for all carers/recipients.

5. The most important message about the current system (and this message was consistent from‘mainstream’ service providers as well as), was that the various Departments (state andnational) were insensitive and patronising when they introduced new requirements for reportingsuch as in the new versions of the Minimum Data Sets. The field trial was given consistentfeedback that culture change in the bureaucracy would help a lot. In particular a ‘compliancementality’ gets in the way of the wider purpose, which should be to assist and improve practicein the field.

‘Perhaps one of the major problems that we find when conducting care recipients andcarer assessments are the various forms that we are required to use from the variousfunding bodies. Each funding body has its own emphasis as to who is the main servicerecipient. For the HACC program the client is the main service recipient, howeverHACC also acknowledges the carer as a client (but this is only secondary). The NRCPprogram acknowledges the Carer as its main service recipient.’

6. The message for assessment reform from the Aboriginal and Torres Strait Islanderconsultations was that taking a fragmented approach and getting too bogged down in tediousprogram-specific detail was a problem created by the bureaucracies. That was compounded



when not enough effort and resources were put into training and support, so overall, new toolsare likely to just add to the overall level of frustration with bureaucracy that is widely felt in thecommunity sector.

7. An issue that arose for rural and remote services concerned the turnover of coordinators whoseresponsibilities included assessment and service delivery. The ACCNA (and CENA) were seenas valuable tools to create a continuous record of client needs and service provision that couldoff-set the consequences of high staff turnover.

4.14 Culturally and Linguistically Diverse (CALD) Focus Group

This group was held in Melbourne and 25 people attended from a range of organisations andagencies selected by the jurisdiction. They were from Local Government, ethno-specific provideragencies and peak groups. Some were assessors and service providers for single service types,others had experience in multiple programs and with packaged care and others were managersand policy workers.

Key points made about the data elements were:

§ More detailed items are needed that go beyond the ABS categories of country of birth andmain language spoken at home.

“Client’s country of birth does not indicate their culture i.e. someone born in China maybe Russian.”

§ Extra CALD items for perceived ethnicity and religion and any special cultural requirementsshould be added.

§ Include questions about migration experience and settlement.

§ Change the term “residency’ as it triggers visa status concerns.

§ The term ‘threat to carer arrangements” is too negative.

§ Question on the disability of the person being cared for.

§ Will need some cultural validation of the tool – and then translation so that interpreters don’tuse their own interpretations.

§ Reluctance to use the K10 and the “much more intrusive information”. More space forcomments in the social and emotional side and the mental health questions will have to beasked in a different way.

§ The main challenges were “learning to use it and incorporating it into conversation techniques.After this though it should become normal practice.”

“Will be useful in new clients currently from Intake currently requiring reassessment infull.

“Missing the Health Behaviours Profile in the SCTT V2.”

“This tool appears to have lots of prompts which the SCTT doesn’t – may decrease thechance of the assessor missing valid information.”

4.14.1 System-level comments

National consistency was one key factor as was standardising data and the electronic interchangeof information.

“Having a more consistent assessment framework across services and states wouldbe an advantage.”



“I think it is important to have only one tool for all programs and one which is used bythe whole Community Care industry.”

And the advantage that much of the tool was contained in the SCTT form was noted.

“It appears to be little different to the existing SCTT2 assessment so I think it would bereadily adapted. Some customising may be needed, but this seems to be easy.”

Many comments were related to system-level issues in the Victorian context where “there could bemuch confusion both with understanding this ACCNA tool and in conjunction with the developmentof the Assessment Framework.”

“How to integrate this tool into our current client management system for the purposeof reports (MDS) and referral (SCTT V2)”

“How to incorporate into current tools and processes … protocols about sharingassessments and which parts. Further definition of the new assessment model”

“Needs to be a fair degree of education delivery to the sector to avoid confusion.”

“Funding for training and for IT upgrades.”

“Also, ethno-specific agencies do not receive funds for assessment, which is a pity asthey are obviously in a position to be more culturally competent in assessment …mainly generalist organisations conduct basic assessment. It may be useful for theseagencies to broker with ethno-specific agencies to get accurate assessment of CALDclients.”

There was a clear consensus that the ACCNA did not pose any major challenges in being usedand was a “good broad based assessment that alerts to the need for more complex needsassessment” but that it required more specificity on CALD issues. The group appreciated theadded focus on the client goal and self perceptions and the way it allowed more investigation ofthe reasons for the referral.

4.15 Consumer Focus Group

Participants were selected from agency recommendations and approached through the agency toinvite their participation. The focus group session was jointly run with the Community Advisor whois an experienced assessor who also operates in the role of the agency’s intake officer. The areasof interest to consumers were grouped around the assessment and the idea of a consumer self-report version of the ACCNA.

The participants (names changed) were:

§ Charles is 43 yrs old; he has case management in a rural town and has home care 1.5 hours aweek for domestic assistance. He intermittently needs nursing care and extra services whenhe has a health crisis and has been having episodic case management for many years.

§ Jane is 81 yrs old. She is on a CACP and has 2 hours per week of domestic assistance andwashing each week and 2 hours for shopping fortnightly with social support the oppositefortnight.

§ Mary is 84 yrs old. She is on a CACP, has 1 hour of domestic assistance weekly, plus 2 hoursof social support and 3 hours of shopping social support each week.

§ Doris is 80 yrs old. She is not on any ongoing program with the agency but had a CommunityAdvisor assessment, plus referral and linkage to current services which consists of 2 hoursdomestic assistance and washing fortnightly and linkage for social support, transport andluncheon club through other HACC providers.



§ Kathleen is 76 yrs old. She has had a Community Advisor phone assessment and linkage butrequired a face to face visit as her doctor was overseas she was very anxious and herdaughter wanted her linked to more supports. Service links are to HACC domestic assistanceand washing, the Community Occupational Therapist and HACC transport.

§ George is 88 yrs old. He is on a CACP now but started out on Dementia Monitoring. He nowhas 1 hour of meal preparation, social support 5 days per week, 2 hours of financialcounselling, 2 hours shopping assistance and 2.5 hours of social support each week.

Key Points

Participants tended to focus on the process of assessment rather than the content. It was clearthat the process of assessment was more important. They commented it must be “empathic” andpreferred assessors to focus on the things they could do rather than what they can’t do.Establishing some rapport is an important part of the assessment process and repetitivequestioning is not helpful, as they do not want to have to tell their stories each time. It is better tocapture information over time rather than all information at first contact.

§ One consumer stated it was “very enlightening” and said the “questions made sense”. Shealso said that she did not feel like it was a test and she recognised that a service providerwould need that type of information.

§ It is always better to suggest types of service rather than be prescriptive about what the clientneeds. Assessment needs to be an empowering process where the final choice about whetherto accept services is the client’s.

§ One consumer said it was important to investigate ‘strengths’ and acknowledge theconsumer’s perspective in the assessment process.

§ The process is ‘empowering’ when services are targeted where they are most needed.

§ Like the question “what do you need?”

§ It might be useful to ask the client about their satisfaction with the service – some consumersindicated they would feel comfortable complaining because “it is not personal” and anotherconsumer said they would feel “anxious” because they received a high level of care (despitehaving a legitimate reason to complain). This would be more suitable to reassessment.

§ They commented assessment and the provision of service is important for independence in thecontext of remaining at home.

§ Must include emergency contact details – need to differentiate between next of kin andemergency contact.

§ All consumers said social support is “very important”.

§ None of the consumers felt the health questions were intrusive and acknowledged it isnecessary information that service providers need to know.

Comments on the idea of a consumer self report version

In the course of the ACCNA-CENA field testing the idea of consumer self-report versions wasraised in a number of settings as a way of ‘forward organising’ an assessment. It was proposed asa way of taking away some of the burden of time and energy being expended on very routineinformation collection that could be initially completed more conveniently by the client. Theconsumer focus group presented the opportunity to explore directly the concept of a self reportversion of the ACCNA.

The idea was favourably received. One consumer commented that they “open up” with the writtenword and are not as open verbally. The self report version could be mailed out initially and thenfollowed up with a phone call or home visit depending on the depth of assessment required.



§ The reaction to the self-report version was that it needs a big comments section, and allconsumers felt it needed narrative to capture their story.

§ Two consumers commented that assessment questions should be open and not “black andwhite” so that they can add contextual information (i.e. in comments boxes)

§ One consumer had eyesight problems and commented she would be willing to complete theform with some assistance. When asked if she would feel insulted if someone asked her thefunctional profile questions she stated “no, not at all”. She indicated a high level of willingnessto complete the form.

§ One consumer stated “knowing what I’ll be asked is good” and indicated she would be willingto complete it and post it back to the agency.

§ One consumer said completing it as a self report version would “give me more time to answer”.However she also said that she could not read the form and would need her carer present inorder to complete it.

§ One consumer said they would prefer some personal contact in the assessment process andhighlighted that an effective assessment requires additional prompting to identify issuesbeyond the questions on the form. This supports the idea that a self report version is a basicstarting point and inadequate in itself to capture all the necessary information.

§ One consumer said the paper form could be used as a “core record”.

§ This consumer stated “the grey bits are more important”, however they commented that theself report version could be used to better target face to face assessments. This indicates itcould be used to initially differentiate between those that need a face to face assessment andthose that don’t.

§ One consumer commented they might “worry about not doing it right” and suggested it wouldneed to come with a set of brief and clear instructions to guide the process.

§ One consumer suggested that certain questions could be sent to consumers for periodicreview of their circumstances.

4.16 Summary of evaluation results

The quantity and quality of the data collected in the field testing of the ACCNA has given acomprehensive picture of the client group that is arguably the most detailed profile produced todate. It is more comprehensive in the range and relevance of information than that contained inreports based on the HACC MDS. It contains more client episodes than has been previouslyreported in any Australian survey conducted across a range of community care agencies.

The feedback from assessors in the field trial was consistent. Where feedback was more negativeit was from agencies where the assessors had less experience in using the tools due to lowvolumes in the agency and where there were delays between training and using the tools. A lot ofthe problems raised were process concerns rather than content, where the assessors hadtechnical problems in printing paper forms, using Internet access, and where there was a lack oftraining support at the agency-level.

None of the substantive issues arising in the field trial were unexpected. Planning for anysubsequent implementation stages must give detailed attention to the level, the strategies and thecontent of the necessary training and support, as well as the ‘technical’ preparation time neededfor agencies to adapt new, national and standard data elements into their existing systems. Thefeedback about the electronic version at all levels of the trial has, overall, been very positive

In summary, the results at this point suggest that it is safe to proceed with further development andrefinement of the ACCNA in the context of system level trials and developments. A more layeredstructure for the data elements can accommodate most of the issues raised in the field-testing.The refinement of ‘modules’ for specific service types can accommodate the changes that areneeded.



Section 5 includes a discussion of the findings from the different levels of field testing and adiscussion of the key issues raised by the results. The focus is on the implications for the use ofthe functional screening items and priority rating, the design of the triggers for assessorjudgements built into the tool. There are suggestions about the interaction between the ACCNAand the next version of the CENA. It also briefly covers how the examination of rehabilitationpotential in the community carer client groups might be further developed.



5 Discussion

5.1 The need for the ACCNA

The ACCNA has ambitious goals and the feedback from all levels of testing indicated that itswidespread introduction into the community care system will require a coherent and well supportedimplementation strategy. This poses a potential dilemma for the national approach.

For some, the ACCNA was seen as too ambitious, too ‘big’ and too expensive. However, thealternative of producing a lowest common denominator was seen as unattractive and containingtoo few incentives to create a national approach to improve current assessment practices. Aminimalist approach would result in the ‘status quo’ for some but would be a regressive step forothers. Few in the field saw that a minimalist model could be seriously promoted as any sort ofprogress on a national ‘way forward’.

On balance, the more sophisticated approach that the ACCNA represents is to be preferred.However, this is on the basis that it is clearly understood that it is not a big ‘minimum data set’.The ACCNA is a set of data items and not all items are relevant to all consumers. The strength ofthe ACCNA model is that it allows for the use of different items at different times.

Based on the ongoing review of the Australian and international literature, the ACCNA is movinginto new ground. It introduces a number of new concepts and processes that are all present invarying forms in current practice but have not been part of a national approach, including:

§ Priority rating

§ Action plan

§ Planning information on unmet need

§ Use of software as an electronic information exchange mechanism

§ Development of simple action plans for communicating between programs and agenciessharing community health and care clients.

Only some of these concepts and processes have been tested individually, let alone collectively.In this context, it is not surprising that the results suggest the need for ongoing technicalrefinements and a coherent and well-resourced implementation and training strategy. The resultsalso point to areas for policy clarification and refinement in the next stage of the ACCNA’simplementation.

In particular, the evidence to date suggests the potential now exists to move towards a nationalsystem and to move from a theoretical to an empirical approach to community care reform. Thatpotential will not be realised from an assessment approach that is minimalist and not in step withthe more progressive examples of current practice in the field.

The following discussion illustrates how that potential might be realised. This includes the specificuse of the ACCNA in selecting clients who might benefit from rehabilitation in community caresettings and in demand management.

5.2 Relationships between rehabilitation potential, function and other factors

The functional profile can be used in routine practice to understand a number of related clientattributes. A set of clear relationships were found in the data that are of particular interest to somemembers of the Eligibility and Assessment Working Group. In particular, where clients areidentified by the assessor as likely to benefit from rehabilitation, then a referral for a rehabilitationassessment can be confidently recommended.



The data in Section 4 showing the relationships at the item level for the functional scores could beused for developing indicators of where a client might benefit from a program of rehabilitation.They would be:

§ More likely to need help with housework. Those at the extremes (completely unable or able todo housework) were less likely to be assessed as having rehabilitation potential.

§ More likely to be completely unable to shop and less likely to shop without help

§ Less likely to be completely unable to take their own medicine and slightly more likely to taketheir own medicine without help

§ Twice as likely to be completely unable to walk than those not suitable for rehabilitation

§ More likely to be able to bathe

§ Less likely to have cognition problems than those not suitable for rehabilitation

§ Slightly more likely to have behavioural problems than those not suitable for rehabilitation.

The development of such an ‘index of rehabilitation potential’ was beyond the scope of the presentproject, as was the suggestion from the field that this factor might be incorporated into the systemof priority rating. The data collected in the field trial suggest that such further refinement would befeasible and could be part of a longer term research and development agenda.

5.3 Priority Rating

The logic of the Priority Rating approach used in the trial ACCNA was already well established andindependently evaluated and based on the model developed for the Queensland ONI5 and thePriority Rating System developed for NSW Home Care6.

The Priority Rating Tool provides a way of determining an individual consumer’s priority forcommunity care, based on their needs, burdens and risks, and is an optional tool for serviceproviders to use if sufficient information is collected. The purpose of priority rating is to allowconsumers to be consistently screened for their needs and their risks, with the intention that thosewith greater needs and risks will get access to services first.

While both need and risk can be objectively measured, it is inevitable that the decision about anindividual consumer’s priority for services (ie. combining need and risk) will involve some level ofvalue judgement. The judgement (usually by an assessor) takes the form of the agency orprogram-level policies that set the ranking of the priority categories, and within that ranking, thethresholds for the points at which different services are then offered.

The priority rating tool used in the ACCNA arrives at a rating category that is based on combiningthe scores from selected items, with item selection based on evidence from previous studies andexamining the data from a number of relevant ACCNA items collected on a routine basis. Thecombination of scores gives a ranking system that can be used to determine priority for care andthereby help to manage demand by recommending a rank order for access to services. Thisranking can of course change, depending on the consumer’s needs at a certain time, for exampleif the consumer has an episodic illness or a degenerative disorder. On reassessment, either theconsumer’s priority rating may be higher or lower, or the level or distribution of resources within anagency may change, allowing for lower or higher priority consumers to be offered a service.

The ACCNA tool was designed to be a practical and reliable way to determine a consumer’spriority, relative to that of other consumers, usually those who are on a waiting list. Logically, thosewith the highest need and urgency should be seen first. Priority scales add fairness to the system,with access to services being determined by a consumer’s needs. When used in a sophisticated

5 Owen, A, Ramsay, L., Holt, N, Eagar, K (2004) Ongoing Needs Assessment in Queensland Community Care: Why Use the Tier 1

Screening and Referral Tools -Evidence and Explanations . Centre for Health Service Development, University of Wollongong6 Stevermuer, T, Owen, A and Eagar, K (2003) A Priority Rating System for the NSW Home Care Service: Data Driven Solutions.

Centre for Health Service Development, University of Wollongong



(rather than rote) way by experienced assessors, it is possible to include the recommended ratingwithin broader judgements about the relevance of other factors such as the potential to benefitfrom particular interventions or the components of a care plan.

The ACCNA tool can be represented as a matrix with two axes (see Figure 13). On the far leftcolumn, the care recipient’s category is identified in relation to their carer arrangements and livingsituation, based on information collected earlier in the ACCNA. In the top row, the care recipient’scategory of need is identified including the level of function and the presence of related factorssuch as significant health or psychosocial problems. The priority rating is the score in the boxwhere these axes cross. The algorithm for allocating a priority is shown in Figure 2191.

Figure 13 Priority rating model

Need

Medium Function

Risk

Low Function

With significantpsychosocial or other

problems

With no significantpsychosocial or other

problems

Good function buthealth, psychosocial

or other problems

No carer able toprovide necessarycare

1 1 2 5

Carer arrangementsexist but areunsustainable withoutadditional resources

3 3 4 7

Carer arrangementssuitable andsustainable OR

Carer not required

6 6 8 9

The results of the field trial suggest that the priority rating system was seen as useful and had facevalidity in the field. On that basis, it should be included in the first version of the ACCNA. In doingso, one technical issue to resolve is how to deal with missing data items. With the exception of thefunctional profile, the items used to assign a priority rating are optional. In the ACCNA softwareused in the trial it was assumed that a missing value indicated that a client did not have a problem.For example, if the psychosocial items were not completed it was assumed that the client had nopsychosocial problems. Whether this approach is taken in version 1 of the ACCNA will need to bedetermined. Likewise, rules will be required for how to deal with missing scores within thefunctional profile.

How the priority rating system is subsequently used then needs to be determined as a policyissue. In this regard, the way that the priority rating system in the Queensland ONI tool has beenimplemented is helpful. In that context, assessors can, with the agreement of their supervisor,override the priority rating if they have other information available to them that justifies overriding it.The priority rating is thus used to assist assessors to make decisions. It does not make thedecision for them.

However, one of the issues raised about the priority rating is that it does not take account of aperson’s rehabilitation potential, with some suggestion that priority should be given to those withthe capacity to become more independent. Similarly, there was also feedback that priority shouldbe given to early intervention rather than to those people who are already high need.

These are important issues that need to be determined by policy rather than a technical analysis ofthe results of the ACCNA field trial. One option is to include each of these dimensions in thesummary and action plan. As one example, one care recipient may be flagged as, say, a priority6, with rehabilitation potential (6R) while another may be priority 6 without the potential to becomemore independent (6). Whether 6R should be given priority over 6 would then be a matter for a



policy decision. Irrespective, it is likely that the services required by someone classified as 6R willbe different to those classified as 6.

5.4 Interoperability

A key issue raised at all levels of the field trial is the need for interoperability. Given this, thissection defines the various levels at which interoperability can operate. The level ofinteroperability depends on the amount of human involvement required, the sophistication of the ITand the level of standardisation in how agencies share information:

Level 1 Non-electronic data - no use of IT to share information (examples: mail, telephone).

Level 2 Machine transportable data - transmission of non-standardised information via basicIT; information within the document cannot be electronically manipulated (e.g. fax orPC–based exchange of scanned documents, pictures, or PDF files).

Level 3 Machine-organisable data - messages contain non-standardised data; imperfecttranslations because of vocabularies’ incompatible levels of detail e.g. e-mail of freetext, or PC-based exchange of files in incompatible/ proprietary file formats, HL-7messages.

Level 4 Machine-interpretable data - transmission of structured messages containingstandardised and coded data; all systems exchange information using the sameformats and vocabularies.7

There was a clear recognition in the field trial evaluation sessions of the need for Level 4 machine-interpretable interoperability. This applies to interoperability between agencies sharing ACCNAassessment information (ie, those agencies undertaking ACCNA assessments as well as thoseagencies receiving service referrals after an ACCNA has been completed). It also applies tointeroperability with the CENA and with ACAT assessments. It is only by achieving this level ofinteroperability that information can be efficiently shared and information duplication reduced.

5.5 Inter-relationship between the ACCNA and next version of the CENA

It is clear that the ACCNA and CENA should be designed so that they can ‘inter-relate’. Carerecipients and their carers are a duad and their needs to be considered together.

A large proportion of field trial agencies indicated interest in using both the CENA and the ACCNAin the future. The two assessments need to be linked in a way that enables information to be‘pulled through’ rather than be re-asked or re-entered. That is, the two systems need to beinteroperable. This requires the information about the carer and care recipient to be consistent inboth the ACCNA and the CENA. The diagram below emphasises the primary purpose for bothassessment systems.

The ACCNA primarily includes data items for the care recipient with a subset of carer items. Thissubset of carer items should be able to be pulled through to form the basis of a CENAassessment. Conversely the CENA primarily includes data items for the carer with a subset of dataitems for the care recipient. This care recipient information needs to be consistent with the ACCNAdata set so that information can be shared and auto-populated if necessary.

It cannot be assumed at this point that an ACCNA will be completed as part of a referral processfrom a HACC agency to an NRCP agency. It has thus been necessary to include a subset ofACCNA care recipient items in the CENA care recipient module to meet the needs of NRCPagencies. The relationships are shown schematically in Figure 14.

Figure 14 Relationship between the ACCNA and the CENA

7 Walker J et al The Value Of Health Care Information Exchange and Interoperability Health Affairs 19 January 2005



If the data items are consistent between the ACCNA and the CENA:

§ It is likely to reduce the likelihood that assessments will be duplicated

§ subset of carer items in the ACCNA should form the basis for a reliable trigger to identify theneed for an agency to conduct a more in-depth carer assessment using the CENA.

§ It will reinforce the idea that assessment is not a one-off event but rather a process whereinformation is collected at different points in time and should be based on a combination of theneeds of the carer and/or care recipient and agency requirements.

If the information is to be consistent across both tools, then key data items in the CENA should beincluded in the ACCNA data set. The following CENA data items about the Care Recipient havethus been built into the ACCNA:

§ Primary Disability (in Health Conditions Profile)

§ Information about medication routine (in Health Conditions Profile)

§ Medical diagnosis of dementia (in Health Conditions Profile)

§ What are the care recipient’s primary care needs? (Action Plan)

§ Does the care recipient have challenging behaviours? (FP item as a trigger)

§ And if yes, what is the level of support needed? (Action Plan)

§ What is the care recipient’s level of need? This can be generated by using a combination ofthe following ACCNA data items:

§ FP score to give level of need/function, with FP questions 8 and 9 indicating level of need

§ Diagnosis of dementia

§ K10 score.

5.6 The interface with the Aged Care Assessment Program

Field testing at Level One included some agencies with strong working relationships with ACATand their services. Some had aged care assessment teams inside their organisational structure,some were co-located but, because of the different functions and reporting requirements for theACAT, most did not formally include them in the trial.

ACCNA Care Recipient Items Carer Items

CENA Carer Items Care Recipient Items

ACCNA

CENA



In one agency the ACAT was a formal participant and organisationally linked and co-located withthe Carer Respite and Care Link service. The intention of including an ACAT in Level One of thetrial was to see whether the ACAT could use the ACCNA in managing demand for ACATassessments and in ordering the waiting lists.

There were considerable delays in installing the trial software at the site so there was a gapbetween the training and the use of the ACCNA. The delay led to all the assessments being doneon paper and these were then entered separately into the database. This meant that thefunctionality of the database version was not tested in the expected way at this site.

The trial was not aiming to test whether the ACCNA could act as a substitute for an ACATassessment. It was to see if the information collected in an ACCNA at the screening level couldbe used by the ACAT to inform its decision-making and as a starting point for more specialisedand comprehensive assessments.

5.6.1 Use of the ACCNA by the ACAT

There are many reasons why someone might be referred for an ACAT assessment. And an ACATassessment is often, but not always, the same as a comprehensive assessment. This is becausenot all of the people referred to ACAT need a comprehensive assessment. Some may want helpwith a respite or permanent placement decision; some referrals may be from a service providerrequesting a package of care. Some requests are mainly about assessing the care recipient in thehome environment or reviewing carer arrangements.

Comments from the evaluation sessions suggested that the ACCNA is potentially useful as a toolto help the ACAT to better manage demand. An initial ACCNA assessment can potentially beused to identify whether or not a full ACAT assessment is required and, if so, to assign a priorityrating to each applicant. The flexibility of the ACCNA and its use as a “layered” tool of variabledepth was seen as a potentially valuable way to reduce waiting times for a full ACAT assessment.

However, the ACAT could not use the ACCNA to cover all of its formal reporting requirements andnor could it be used to replace the existing ACAT forms.

Where there were difficulties or inconsistencies in the use of the ACCNA by the ACAT, it was forunderstandable reasons. While assessors were initially positive about use of the ACCNA, the factit had to be used in parallel made it problematic because of the extra work involved in a pressuredassessment environment.

There are organisational ways around this problem if the work flow could be redesigned. By usingthe ACCNA at the intake point to deeper assessments, it should be possible to reliably select thepeople most in need of the more specialised or more full scale assessments and pre-populatelarge areas of the ACAT assessment domains before doing further assessments.

Most difficulties could be overcome by increasing the “interoperability” of data items between theACCNA and ACAT and other assessment systems. The more immediate potential to link theACCNA electronically with the CENA was seen as an achievable bonus. The carer issues wereacknowledged as an important part of the context to be assessed by the ACAT and the workingrelationships with the CCRC were important and although already well established, could beenhanced by a greater inter-relationship of the two systems.

Other difficulties are less easy to resolve. For example, there is (by design) a lack of directcorrespondence between the criteria for assigning priority in the ACCNA and in the ACATassessment. The concepts are different. The ACAT priority rating is concerned with the urgencyfor the assessment to be undertaken. The ACCNA assigns priority based on client needs andrisks and these are related to the priority of access to community care service provision.

The net responses from the ACAT on the usefulness of the ACCNA were positive after theproblem of the burden of double assessments was taken out of the feedback. The domainscovered in the ACCNA and the potential to be prompted to go into greater depth of assessment



were seen as comparable to the requirements in the ACAT context, but the assessmentapproaches are, by design, not directly substitutable.

5.6.2 Receiving ACCNA information by the ACAT

As expected, duplication was an issue in the field trial. In the absence of electronic interoperabilitybetween the ACCNA and the ACAT assessment, information collected in the ACCNA could not beelectronically fed into the ACAT assessment. Further, while there is a similar breadth of coverageof the domains, the depth of an ACAT assessment is (by deliberate design) lacking in the ACCNA.The implication of this is that the same issues need to be canvassed in the ACAT assessment butat a greater level of depth.

When taking account of the different purposes of the ACAT and ACCNA assessments, theevaluation session feedback overall was that the ACCNA has the potential to improve the qualityof information that could be formally shared with an ACAT and that it could potentially increase thecredibility of community care assessment information. While there is the potential to reduce theduplication of information, that potential cannot be realised until such time as there is electronicinteroperability between the two systems.

5.7 Triggers for comprehensive assessment

Given the number of assessments triggered in the field trial (see Section 4.4.4, page 25), the useof 3 or more of any recommended assessments as the main trigger for a comprehensiveassessment is not appropriate. This rule triggers too many comprehensive assessments.

It is possible to change this rule but, based on the available data, the only criterion that can beused is the number of assessments triggered. Figure 15 and Figure 16 outline one suchalternative approach. The ACCNA currently includes automatic prompts to 15 different types ofspecialist assessment and the design rule used in the field trial is that referral to 3 or more of thesewould automatically trigger referral for a comprehensive assessment. Figure 15 contains a list ofthe specialist assessments that are considered to be particularly relevant as indicators of the needfor a comprehensive assessment. These six assessments are a subset of the 15 built into theACCNA.

Figure 15 Specialist assessments that are relevant to comprehensive assessment

Assessment type

Self-care function

Aids, appliances and equipment

Medical

Cognitive

Behaviour

Mental health

Figure 16 shows the percentage of comprehensive assessments that would be triggered by thissub-group. As an illustration, 30% would be triggered for comprehensive assessment if the newrule is that referral to any one of these assessments would trigger a comprehensive assessment.In contrast, if the rule adopted is that three or more of these assessments would trigger acomprehensive assessment, 16.4% would be triggered. Only 1.6% would be triggered if thethreshold is set at five assessments. No one was triggered to all six of these assessments.

Figure 16 Comprehensive assessments triggered by the assessments listed in Figure 15

Number of assessments Percentage triggered for comprehensive assessment

1 30.0%

2 25.4%

3 16.4%



Number of assessments Percentage triggered for comprehensive assessment

4 6.0%

5 1.6%

6 0%

Whether the triggers for comprehensive assessment should be determined solely on the basis ofthe number of assessments triggered is fundamentally a policy decision, as is the threshold.Irrespective, these results have implications for the design of the next version of the ACCNA andhow it can be used to trigger further specialist or comprehensive assessment.

It would also be possible to include other factors to determine acceptability for referral tocomprehensive assessment. Experienced assessors in the Level One evaluation sessionssuggested the following indicators:

§ Age (85 years and over) – 23.5% of the sample in the field trial

§ Lives alone – 41.2% of the sample

§ Carer stress – 24.9% of the sample

§ Diagnosis of dementia – 17.8% of the sample and/or

§ Major mobility problems - 5.2% of the sample were completely unable to walk and a further 36.3% needed assistance to walk.

These factors overlap with the recommended subset of assessments above.

The only way to know whether or not triggered assessments are actually required will be to ‘lookback’ to the screening level assessment after having further assessments completed. This shouldbe possible in the proposed system level trials. The results can then be used to refine the waythat the ACCNA triggers both specialist and comprehensive assessments.

In the interim, the best approach at this stage is to modify the original criterion by restricting theassessments being used to the sub-set listed above in Figure 16. A care recipient would thereforebe referred to a comprehensive assessment if they were recommended for referral to 3 or more ofthe 6 assessments listed in Figure 16, with assessors maintaining their discretion to overrule it.

5.8 Key implementation issues

To summarise the lessons from the field trial that are useful for implementation, the following keypoints are emphasised:

§ The ACCNA contains a number of relatively sophisticated triggers and prompts and the priorityrating score, all of which need practical training to work effectively for the purpose for whichthey were designed.

§ The ACCNA makes use of the routinely collected HACC functional screen and other key dataitems such as rehabilitation potential that can be used at reassessment as a form of outcomemeasurement. This is a relatively new concept in some parts of the service sector.

§ The data analysis indicated a number of refinements and clarifications of scoring rules wereneeded to improve the way the electronic version was programmed.

§ This comes down to practical explanations of rules on how to avoid missing values in thefunctional screen and priority rating and in scales such as the K10. These explanations werenot explicit enough and became a problem for some agencies and affected the useability ofthose components in the field trial.

§ There is potential for further refinement of the tool that can occur as part of further trials or aspart of a progressive implementation. This is particularly the case with respect to assessing forrehabilitation potential and taking account of this in the priority rating system.



§ There are training issues in IT/IM systems for agencies implementing the ACCNA at differentlevels.

§ Because of the variability of service types, agency settings and assessor roles, there areassessor skill and competencies issues that will have to be explicitly addressed in the nextstages.

§ There are agency process and culture issues around sharing assessment information that varyaccording to the regional context and will need to be a major focus of any further system trials.

Principles in implementation

The following is a list of higher-order principles for assessment agencies. They are based on theexperience of the field trial and form a useful starting point to guide subsequent implementation.

§ The first step in understanding how best to use the ACCNA is to understand that, in order toavoid pointless duplication, assessment information should be collected for more than thepurpose of your own service delivery and should be collected so it is able to be shared.

§ Not all items or components will be relevant for every consumer. Accordingly, the ACCNAshould not be seen as a type of minimum data set that is, by definition, collected on all clientsfor a particular program.

§ The ACCNA should be used flexibly to aid decision-making and to standardise how theinformation is collected and shared. The ACCNA is designed to guide assessor decisions. Itis not designed to make assessor decisions.

§ The data elements are for the purpose of screening and are not diagnostic.

§ The ACCNA can be used to organise a simple or a more complex service response. It looksbig but does not have to be used in a complete form or a rote format.

§ The data elements are designed for use over the phone or face to face

§ The data elements are designed for completion based on all sources of information availableto the assessor

§ Do not ask consumers about issues in the order that they are listed if they are inappropriate inthe context

§ The functional profile may not be relevant for children and adolescents

§ Screening is intended to focus on all the client’s needs, not just those that any one agency canmeet

§ There may be additional information that service providers need to collect over and above thatgathered in the ACCNA

§ Assessment needs to be based on the client and carer’s social and/or cultural context

§ As assessors complete the assessment, they should consider whether the person requiresparticular types of assessments and/or urgent services that cannot wait for a formalassessment process to be completed

§ To obtain a Priority Rating for a consumer, a minimalist approach to assessment is notadequate or safe and more profiles than just the functional profile will need to be completed.

5.9 Other issues raised in the field-testing

The additional levels to the functional profile (who helps and whether the needs were met orunmet) were reasonably (but not universally) well accepted. The results suggest that, while thecollection of this information represents additional work for many agencies, the resultinginformation is useful in organising a service response. Feeding this information into the service-level priority rating process would further enhance its value. This would indicate where additionalsupports for a client are needed, adding useful information about the urgency and complexity of aservice response.



The Action Plan component of the ACCNA provided good summary feedback to the assessors.The automatic triggers used in the Action Plan prompted assessors about the wider needs ofclients. The Action Plan developed at the initial assessment point provided the basis to meet thecurrent needs of clients that can then be used efficiently by service providers, plus a means toshare information to prompt any additional services in a practical way.

Assessment of clients should not be seen as a one-off event but rather as part of the process ofthe provision of services to clients to ensure that these services are relevant, and useful. Regularassessment reviews will identify whether the services that a client receives are still relevant, andhow they should be modified and these changes then form part of a continuous record.

Finally, it is clear that the states and territories are thinking differently about how the ACCNA willbe implemented within their jurisdiction. Implementation will inevitably differ in each jurisdictionand the next steps need to be considered in that context.

5.10 Towards a national assessment system

Given the generally positive outcome from the field testing, this Final Report recommendsrelatively minor changes to the design of the ACCNA instrument. Each of the domains is useableand acceptable but some items need to be removed while others are added or refined. The finallist of ACCNA data elements is included in Attachment while Attachment 3 lists the changes madeas a result of the field trial.

The preferred number of steps for moving to full implementation, after modifying the trial version,will need to be agreed by the Working Group. Irrespective, a pre-condition for successfulimplementation will be detailed attention and dedicated resources devoted to the training needs ofassessors. These needs differ by service type, agency size, and the mode of administration. Astrategy will be required to build competencies in the sector through training and communication,both as an assessor and in the use of the ACCNA.

A number of parallel initiatives are underway as part of The Way Forward agenda, includingaccess points/systems trials and an electronic Continuous Client Record. Inevitably, the ACCNAneeds to be incorporated into these initiatives.

But these initiatives, alone, will not achieve national implementation of the ACCNA. This isparticularly the case because the ACCNA is not designed solely for use at the first point of entry.The ACCNA is designed for both initial assessment and for periodic reassessment.

The options for introducing the ACCNA into routine practice are:

1. Progressive implementation, one or two jurisdictions at a time

Under this option, implementation would commence in each jurisdiction as they are ready, with thefirst one or two jurisdictions acting as national demonstration sites for the rest of the country. In thecase of larger jurisdictions, this may include progressive implementation on a region by regionbasis. Training would be organised on a regional basis and implementation would include theestablishment of systems to allow interoperability (electronic information sharing) betweenagencies.

2. Progressive implementation, with agencies commencing as they are ready

Under this option, community care agencies across the country would volunteer to commenceimplementation at different times. The first wave of agencies within each jurisdiction would act asdemonstration sites. This would include the agencies in the field trial that wish to continue to usethe ACCNA and participate in its ongoing development. After implementation in a critical mass ofagencies, the focus would shift to achieving interoperability between agencies.

3. National implementation on a designated ‘go live’ date



Under this option, a designated ‘go live’ date would be agreed. Planning in the preceding periodwould focus on producing the necessary versions of the ACCNA (see Section 6.3), trainingassessors and establishing systems for interoperability.

+++

Our assessment is that implementation would be best achieved on a progressive basis (options 1or 2), with either commencing no later than November 2007.

Option 1 has the advantage that training resources can be concentrated and interoperability issuescan be addressed as part of the initial implementation. Further, jurisdictions could add to (but notchange) the core ACCNA data elements to meet their own needs.

The downside is that not all agencies that undertake the assessment function in any jurisdictionwill be ready at any one time. A further risk is that, while implementation is proceeding in a smallnumber of jurisdictions, inertia may develop in those not involved in the initial implementation.

Option 2 has the advantage that community care agencies would self-select to implement theACCNA as they are ready. The initial group is likely to be those that are the most progressive andmost ready for practice and cultural change. They will thus act as practice and culture changeleaders for the sector. The downside is that training resources are likely to be dissipated and, atleast initially, interoperability will not be achieved. This option also runs the risk of cutting acrossthe plans of those jurisdictions that intend to streamline their entry points.



6 Recommendations

6.1 The ACCNA Version 1 national assessment system

It is recommended that the Australian Community Care Needs Assessment (ACCNA)Version 1 instrument, including the layered structure summarised in diagrammatic belowand the ACCNA data elements included in Attachment, be adopted as a generic and multi-layered collection of standard national data items.

The major structural change coming out of the field trial is that the ACCNA is restructured withmore explicit layering of the data items. Different layers provide the ability to collect the right levelof information about care recipients that is relevant to the agency and the care recipient at thatpoint in time. They provide the opportunity to determine what more detailed information needs tobe collected, either at that point, or at a subsequent point in time.

The information that needs to be captured generally consists of:

§ Information relating to assessment

§ Information required to formulate an appropriate service response

Other information may be required for reporting purposes but that is outside the scope of thisreport. Ideally, this other information should be reviewed and revised and reduced in volume,have the redundancy removed and should be a by-product of the above types of information,rather than as an extra burden for community care agencies, their staff and care recipients.

The breadth of the information that needs to be captured will depend on the purpose of theassessment. The assessment purpose will specify which types of information are collected and atwhat depths. It is almost impossible for all the relevant information about a person to be collectedat one assessment. It is almost certain that the information will be gathered by a range of differentagencies and services over time, each collecting the information that is relevant at that time.

Because these agencies and services have complementary roles, they do not need to collect thesame information, but similar agencies and services will collect similar information. This collectionof similar information can be formalised by calling it a “module”. A module is a standardisedcollection of data-items for a specific purpose. Examples include:

§ A first contact module (see Figure 18)

§ Reassessment module (see Figure 19)

It will be seen that different data items are included in each of these two modules, withconsiderably more items included in the reassessment module. Other modules could bedeveloped over time. For example, it would be possible to design one module for ‘first contact byphone’ and another for ‘first face to face assessment’ or ‘first home-based assessment’.

In an electronic environment, the first screen would allow the assessor to click on the module theywished to complete, with one of the options being the ‘full ACCNA’. In a paper environment, therewould be different paper forms for each module.

The proposed layers are shown in Table 25. An ACCNA module consists of a different mix of dataitems and different levels of information.



Table 25 Proposed ACCNA layers

Level and type Description

Layer 1

Initial Client Contact Information to identify the type of assessment, the potential care recipient,and how they arrived there

Reasons/Client Goal What the potential care recipient wants from the assessment

Functional Profile To determine the functional ability of the potential care recipient

Provisional Eligibility To determine whether the potential care recipient is eligible for further action.This needs to be based on the policy of the relevant agency and may varyover time

Layer 2

Registration Collection of detailed contact information about the care recipient

Trigger Information for ServiceResponse – Fixed

Basic information about the care recipient that will not change over time (eg,cultural identity). This information needs to be collected only once

Trigger information for ServiceResponse – Changeable

Basic information about the care recipient that may change over time (eg,GP). This information needs to checked at each subsequent assessment

Trigger Questions To determine which detailed assessment information needs to be collectedfrom the care recipient.

Layer 3

Health Conditions Profile Health information

Social and Emotional Profile Social and emotional information

Financial and Legal Profile Financial and legal information

Carer Profile Information about the sustainability of the care relationship

Care Recipient as Carer The care responsibilities of a care recipient

Detailed Information for ServiceResponse – Fixed

Detailed Information for ServiceResponse – Changeable

Detailed information about the care recipient

The end result of any assessment, which outlines the immediate next stepsfor the care recipient.

It summarises the service response and comprises a list of possible triggeredreferrals to assessments, or assessor judged referrals to other assessmentsor services

Action Plan

Assessors can get to the Action Plan from any level

As a guide to the re-design decisions, the areas for improvement were noted in the feedback foreach assessment and the evaluation sessions with Level One agencies. Those suggestions areaccommodated in the Table above, including:

§ More ‘layering’ of the information to achieve a better ‘flow’ of the conversation

§ Improve the triggers for referral and further assessment

§ Extra information for CALD clients, adding ethnicity and religion

§ Aboriginal communities (and others) need better links between carer and care recipientinformation, and links to greater depth on medical and health issues

§ Better consistency between the electronic and mobile versions, by using mobile applications toavoid the double data entry inherent in paper forms

§ Resolve inconsistencies and reduce the reporting burdens in the HACC MDS items



§ Resolve inconsistencies with similar items in existing tools in common use in jurisdictions i.e.SCTT (Vic), ONI (Qld) and HNI (WA).

Figure 17 Proposed ACCNA Re-design



Figure 18 Proposed module for first contact by phone



Figure 19 Proposed module for reassessment and face to face assessment



6.2 National protocol

It is recommended that jurisdictions and agencies be given flexibility in adopting variousmodules (combinations of data elements) for use in different circumstances:§ in the initial assessment of those seeking community care services.

§ in the periodic reassessment of those in receipt of community care services.

It is recommended that jurisdictions and agencies be given flexibility in adding any dataelements they require for their own purposes and in building in the ACCNA as the front endof their existing assessment tools (eg, the ONI and the SCTT).

The concept of modules was described above. These standard ACCNA modules may besupplemented with additional data items (or with additional modules) as required by eachjurisdiction. For example, jurisdictions may wish to add standard modules such as a home-basedoccupational health and safety assessment module or a health behaviours module. Theincorporation of additional data items and modules will thus allow the ACCNA to act as the frontend of existing assessment systems such as the Queensland ONI and the Victorian SCTT.

It is recommended that all consumers in the community care system undergo an ACCNAwithin 6 weeks of the receipt of first services if such an assessment was not undertaken atthe initial point of entry.

It is recommended that protocols for routine reassessment be developed and implementedby each jurisdiction.

There are five possible outcomes arising from an ACCNA. Either the person may be:

§ Referred on for a more thorough (deep and broad) assessment of need – a Type 4assessment. The outcome from that assessment could include the person being referred forbasic services or for packaged care.

§ Referred on for a more specialised (deep and narrow) assessment of need – a Type 5assessment.

§ Directed straight to a specific (basic) service, at which point they will receive a service-specificassessment – a Type 6 assessment.

§ Be referred elsewhere for other (more appropriate) services beyond those provided by thecommunity care sector.

§ Found to have no/low needs and not need services and thus exit the system.

There are many pathways into the community care system and, on all accounts, these willcontinue to exist. While some people will be referred directly to, and will be assessed by, anindependent assessor, others will continue to be referred directly to a specific service. Forexample, hospitals and GPs will continue to refer directly for services such as community nursingor an ACAT assessment.

Accordingly, there is no expectation that the only pathway into community care will be through anACCNA. Nevertheless, it is recommended that, as a matter of good practice, the followingnational protocol be adopted:

§ All consumers in the community care system would undergo an ACCNA within 6 weeks of thereceipt of first services if such an assessment was not undertaken at the initial point of entry.

§ Community care recipients would be reassessed using the ACCNA at regular intervals.



The overall model and protocol proposed for national adoption is shown as a flow chart in Figure20.

Figure 20 The overall assessment system

6.3 Products

It is recommended that different versions of the ACCNA be developed with jurisdictionsand agencies being given the choice of which version to adopt:§ A public domain stand alone ACCNA software program

§ A set of data specifications to allow agencies to include the ACCNA data elements intheir information systems

§ Paper form versions

§ Hand held application version. Such mobile (PDA/phone/lap-top) versions could eventuallyreplace or supplement the more ‘layered’ paper versions used for home visits

§ Web based version

A range of versions of the ACCNA will be required to accommodate the diversity of starting pointsin the sector and the diversity of roles and approaches within different agencies. Several of theseproducts will be required as a prerequisite to the proposed access points trials. All will eventuallybe required for a broader national rollout.

These products will need to be accompanied by documentation, including specifications and avariety of manuals (technical, site, training and assessor).

There is also some interest in a client self-rated version of the tool, or at least parts of it. Thiscould be developed as one or more paper forms. There is also the potential to develop a webversion for self-reporting particular domains of client need.

6.4 Inter-relationship issues

It is recommended that the ACCNA and CENA data elements be combined to form an initialversion of a Community Care Data Pool to be shared across a range of programs, servicetypes and agencies.

Structured linking between the ACCNA and the CENA was identified at all levels of the trial as themost immediate and important integration issue for the sector. As such, the ongoing development

Other entry pathways (with Type 1completed at referral). ACCNA (at aminimum) to be undertaken no more

than 6 weeks after receipt of 1stservices

Australian Community CareNeeds Assessment

(ACCNA)

Type 4- deep and broad

basic service/s packaged care

Type 5- deep and narrow

Type 6- basic service/s, including

service-specific assessment

Exit / Refer elsewhere forother (more appropiate)

services

Undertaken either by a serviceagency or an independent assessorIf service agency, may undertakeTypes 4-6 as appropriate at same

time



of both tools needs to be considered together. Agencies in the field test recognised the need forefficiencies in reporting on programs and had strong views that reporting should be automated asan offshoot from assessment.

Wider system level integration issues were raised consistently in the field and it was clear that theprerequisites to wider system reform were the development of a set of mappable data items, and amajor re-think of the burdens and inconsistencies in the range of reporting requirements imposedon service agencies.

The AIHW reports on the ‘Comparability of dependency data items’ and the National CommunityServices Data Committee report on ‘Cutting the red tape’8 both make the same points aboutreporting burdens, redundancy and problems of multiple data entry.

In the immediate context of the next stages of work under The Way Forward, there is a need tostandardise those MDS items that are common between the ACCNA and the CENA. An exampleof an inconsistency that could be easily resolved is illustrated in Table 29 on page 95. This tableshows the inconsistencies in the HACC and NRCP code sets with respect to the coding of referralsource. This should be a straightforward item and is just one illustration of the problem.

Reconciling the different items collected on the same clients is a task for program managers. TheAIHW has gone a considerable distance in the direction of identifying the various inconsistenciesin dependency information and the responsibility for resolving the many other inconsistencies andremoving the redundancies lies with the National Health and Community Services DataCommittees.

6.5 Implications for ‘The Way Forward’ agenda

It is recommended that a training strategy be developed that builds on existing modelssuch as the Queensland Ongoing Needs Identification Tool training model. This model hasbeen reported as being effective and has the potential to provide generalisable lessons.

Agencies in the field trial made recommendations about the type of training and support that willbe most useful:

§ Training requirements will vary within and between agencies according to the type of service,years of experience and/ or the existing skill level of assessors

§ Training and support should be ongoing and developmental, rather than being seen as a one-off training session - training sessions are necessary but not sufficient in themselves

§ Other resources should be provided for enhancing the quality of ongoing support, i.e. researchto find out what works best and for whom (via a training needs analysis), and this wouldprovide direction to build the content and style of self-directed learning packages

§ Given the nature of the community care sector, a training strategy needs to accommodateexperienced assessors and ‘entry-level’ workers as a recognition of the rate of staff turnover

§ It is important for the training strategy to acknowledge the importance of within-agency supportto back up training sessions and other self-directed learning by models such as debriefing andmentoring.

As well as using comparable and effective training strategies, attention will also need to be givento ensuring that there is compatibility with the required competencies for community careassessment as delineated by the Industry Training Advisory Boards in each jurisdiction.

8 AIHW (2004) The comparability of dependency information across three aged and community care programs . March 2004.

Australian Institute of Health and Welfare, Canberra, AIHW cat. no. AGE 36.National Community Services Data Committee (2006) Cutting the red tape. Preliminary paper detailing the problem of multiple dataentry and reporting by service providers . March 2004. Australian Institute of Health and Welfare, Canberra, AIHW cat. no. HWI 92.



It is recommended that, in addition to implementing the ACCNA as part of the proposedaccess points trials, a plan be developed for the progressive implementation of the ACCNAon a national basis. This could be either progressive implementation on a jurisdiction byjurisdiction basis or progressive implementation on an agency by agency basis.

The options for the implementation of the ACCNA were canvassed in Section 5.10 (page 61).

The primary aim of implementing the ACCNA is to identify the needs of clients and carers for thepurposes of service provision and improving coordination in a consistent way.

The more localised and immediate system requirements are that the ACCNA data elements beused to:

§ Assess the needs of potential and current care recipients

§ Collect client information that may be then send onto another ACCNA-capable agency as partof a standard referral

§ Use information collected in an ACCNA to organise a service response

§ Map and export information collected in an ACCNA into other assessment systems e.g., intothe CENA or into an ACAT assessment system.

The next stages of assessment reform and movement towards a consistent national approachshould recognise:

§ That the information technology issues are relatively easy compared to the cultural andorganisational factors involved in any systems change. The quality of training materials,documentation and the necessary resources for training and support in an ongoing (not justone-off) way are the major concern being expressed in the field, based on previous experiencewith implementing new systems.

§ The importance of building on investments already made is recognised in the field – agencieswant assurance of steady progress in implementing new systems, rather than having a stop-start approach to implementing reform.

Agencies in the field test have sophisticated systems in place or significant investments in the nearfuture on their work programs. Decision making at this stage has to take this into account. Theability to provide a greater degree of certainty for agencies that want to take the national agendaforward is crucial.

The longer-term requirement is the development of inter-agency protocols and business rules forsharing information that is more standardised, more useful and that has less redundancy. Theseneed to involve the participation of providers beyond community care and include those agencieswith a significant community care referral role. At a minimum, this would require the participationof general practitioners, hospitals, community health centres and aged care assessment services.

Not all organisations or services will use the full-range of ACCNA data elements. However, it iscritical that they all have the ability to exchange all of the data elements should they so require.This can only be done efficiently within a set of decisions taken on a national basis. The larger thescope of shared information, building out from community care programs to encompass a broaderrange of service types, the greater the potential benefits.



Attachment 1

Further assessments triggered by the ACCNA

The five highest frequency assessments triggered by the ACCNA were covered in the resultssection of the report. The other assessments triggered are reviewed below.

Home modifications

Nearly one in three (30.4%) clients who were assessed were triggered for a home modificationassessment. All of these clients were also triggered for an assessment for aids and appliances.This assessment was most frequently triggered by assessments conducted face to face (49.7% v33.1% for those by phone), and among those already receiving HACC or other services (40.6% v29.2% for those not receiving services). The proportion triggered for a home modificationassessment increased with age, from 6.3% among clients aged 19-40 years up to 43.1% amongclients aged at least 85 years.

This assessment was most commonly triggered for clients wishing to reduce the rate of decline intheir level of function and independence (45.4%) and least triggered for clients wishing to increasetheir level of function and independence (32.9%). Clients were most likely to have a medium levelof function (62.9%) and least likely to have a low level of function (11.0%). If triggered for thisassessment the key circumstance was more likely to be falls (14.4%) than if not triggered.

Medical

Four in ten (40%) clients assessed were triggered for a medical assessment. This assessmentwas most frequently triggered by assessments conducted over the phone (41.8% v 34.0% forthose face to face), among those considered by the assessor likely to benefit from rehabilitation(45.7% v 28.6%), and among those not receiving any services (45.3% v 30.1%).

This assessment was most commonly triggered for clients wishing to reduce the rate of decline intheir level of function and independence (53.6%) and least triggered for clients wishing to maintaintheir level of function and independence (24.9%). Clients were most likely to have a medium levelof function (53.4%) and least likely to have a low level of function (36.0%). If triggered for thisassessment the key circumstance was more likely to be concern about increasing frailty (37.4%)and less likely to be hospital discharge (21.7%) than if not triggered.

Cognitive

Nearly one in four (23.6%) of the clients assessed were triggered for a cognitive assessment. Thisassessment was most frequently triggered by assessments conducted face to face (63.4% v20.6%), among those considered by the assessor unlikely to benefit from rehabilitation (44.5% V24.6%), and among those already receiving HACC or other services (31.1% v 23.2%). Theproportion triggered for a cognitive assessment increased with age, from 10.4% among clientsaged 19-40 years up to 41.5% among clients aged at least 85 years.

This assessment was most commonly triggered for clients wishing to reduce the rate of decline intheir level of function and independence (47.0%) and least triggered for clients wishing to increasetheir level of function and independence (20.2%). Clients were most likely to have a medium levelof function (56.5%) and equally likely to have a high or low level of function (21.8%). If triggered forthis assessment the key circumstance was more likely to be carer burden (22.1%) or concernabout increasing frailty (32.2%), and less likely to be hospital discharge (15.9%) than if nottriggered.



Vision

One in two (48.0%) clients assessed were triggered for a vision assessment. This assessmentwas frequently triggered, but often over-ruled by the assessors. The proportion triggered for avision assessment mostly increased with age, from 10.4% among clients aged 19-40 years up to65.2% among clients aged 75-79 years, before declining among those aged at least 80 (aged 80-84: 53.8%; aged 85+: 56.9%).

This assessment was most commonly triggered for clients wishing to reduce the rate of decline intheir level of function and independence (62.8%) and least triggered for clients wishing to maintaintheir level of function and independence (46.7%). Clients were most likely to have a medium levelof function (57.4%) and least likely to have a low level of function (7.6%). If triggered for thisassessment the key circumstance was more likely to be concern about frailty (32.7%) or falls(7.8%) than if not triggered.

Hearing

One in five (19.5%) clients assessed were triggered for a hearing assessment. The proportiontriggered for a hearing assessment increased with age, from 2.1% among clients aged 19-40years up to 29.2% among clients aged at least 85 years. This assessment was most commonlytriggered for clients wishing to reduce the rate of decline in their level of function andindependence (38.3%). Clients were most likely to have a medium level of function (55.2%) andleast likely to have a low level of function (7.0%). If triggered for this assessment the keycircumstance was more likely to be concern about increased frailty (44.6%) or falls (8.6%), andless likely to be acute medical condition (9.4%) than if not triggered.

Speech

Only one in ten (10.6%) clients assessed were triggered for a speech assessment. Thisassessment was most frequently triggered by assessments conducted face to face (24.2% v8.4%), among those already receiving HACC or other services (16.0% v 8.3%). The proportiontriggered for a speech assessment increased with age, from 3.7% among clients aged 41-64 yearsup to 17.3% among clients aged at least 85 years. Clients were most likely to have a medium levelof function (55.7%) and least likely to have a high level of function (15.7%). If triggered for thisassessment the key circumstance was more likely to be carer burden (21.8%) or an acute medicalcondition (24.1%), and less likely to be concern about increased frailty (12.0%) than if nottriggered.

Behaviour

One in ten (10.1%) clients assessed were triggered for a behavioural assessment. The proportiontriggered for a behavioural assessment decreased with age, from 33.3% among clients aged lessthan 19 years down to 8.8% among clients aged at least 85 years. This assessment was mostcommonly triggered for clients wishing to reduce the rate of decline in their level of function andindependence (26.2%) and least triggered for clients wishing to maintain their level of function andindependence (7.9%). Clients were most likely to have a medium level of function (46.1%) andleast likely to have a high level of function (27.8%). If triggered for this assessment the keycircumstance was more likely to be carer burden (22.0%) or concern about increased frailty(37.0%), and less likely to be falls (0.8%) or hospital discharge (15.7%) than if not triggered.

Caring for others

One in ten (9.9%) clients assessed were triggered for further investigation because they werecaring for others while having needs for assistance themselves. This assessment was mostfrequently triggered among those considered by the assessor as likely to benefit from rehabilitation(16.4% v 9.8%). The proportion triggered for a ‘caring for others’ assessment fluctuated with age.



This assessment was most commonly triggered for clients wishing to reduce the rate of decline intheir level of function and independence (20.2%) and least triggered for clients wishing to maintaintheir level of function and independence (8.7%). Clients were most likely to have a medium level offunction (514.3%) and least likely to have a low level of function (17.7%). If triggered for thisassessment the key circumstance was more likely to be carer burden (13.0%) than if not triggered.

Carer

Relatively few clients (6.5%) assessed were triggered for a carer assessment indicating mostcarers were relatively healthy and with good functional abilities. This assessment was mostfrequently triggered among those considered by the assessor likely to benefit from rehabilitation(10.2% v 4.5%), and among those already receiving HACC or other services.

The proportion triggered for a carer assessment fluctuated with age. This assessment was mostcommonly triggered for clients wishing to increase their level of function and independence(10.8%) and least triggered for clients wishing to maintain or reduce their level of decline (both4.4%). Clients were most likely to have a medium level of function (63.9%) and least likely to havea low level of function (3.3%). If triggered for this assessment the key circumstance was morelikely to be falls (12.3%) or an acute medical condition (26.0%).

Mental health

In relation to the K10, 41.6% of those with a completed K10 (n=574) had a score of 16 or more(the trigger for a primary mental health assessment). 5.3% had a score of 30 or more, the triggerfor a specialist mental health assessment. It was this trigger of 30 that was built into the ACCNAto trigger a mental health assessment.

In total, few clients (5.3% with a completed K-10 or 2.4% of the total) assessed were triggered fora mental health assessment. This assessment was most frequently triggered by assessmentsconducted face to face (4.6% v 1.7%). The proportion triggered for a mental health assessmentdecreased with age, from 10.4% among clients aged 19-40 years down to 0.8% among clientsaged at least 85 years.

This assessment was most commonly triggered for clients wishing to increase their level offunction and independence after an acute illness/event (4.5%) and least triggered for clientswishing to maintain their level of function and independence (0.9%). Clients were most likely tohave a medium level of function (45.0%) and least likely to have a low level of function (25.0%). Iftriggered for this assessment the key circumstance was more likely to be an acute medicalcondition (22.2%) or carer burden (18.5%), and less likely to be concern about increased frailty(14.8%) or hospital discharge (11.1%) than if not triggered. Most clients cited other reasons as thekey circumstance (25.9%).

Child disability

Very few clients (1.5%) assessed were triggered for a child disability assessment. The numbersare consistent with what would be expected within the community care target population of theagencies in the trial. Clients were most likely to have a medium level of function (60.0%) and nonehad a low level of function. If triggered for this assessment the key circumstance was more likely tobe carer burden (20.0%) and less likely to be an acute medical condition (10.0%) than if nottriggered.



Attachment 2

Recommended ACCNA Data Elements

This table shows:

§ the Layer of each Domain,

§ the Data Element within that domain,

§ whether Assessor Judgement (AJ) is required to decide whether to ask the question

§ the type of information in the response

§ whether the element is an assessment item (AAS), or is information relevant for serviceresponse (ISR)

Table 26 Data elements in the ACCNA

Data element AJ Text / Date / Number / Codes ASS or ISR

LAYER 1

Initial contact

First name text ISR

Family name text ISR

Contact date date ISR

Assessment Purpose Initial

Re-assessment

ASS

Evidence of memory loss or dementia

(note: AJ made at any point in theassessment)

AJ Yes

No

Unsure

ASS

Referral Source Self

Family, significant other, friend

GP/medical practitioner—community based

Aged Care Assessment Team

Community nursing or health service

Hospital

Psychiatric/mental health service or facility

Extended care/rehabilitation facility

Palliative care facility/hospice institutionalsettings.

Residential aged care facility

Aboriginal health service

Other medical/health service

Other community-based service

Law enforcement agency

Other

ISR

Referrer First Name text ISR

Referrer Second Name text ISR

Organisation text ISR




Postal Address text ISR

Telephone text ISR

Fax text ISR

Email address text ISR

Referral Consent Yes

No

ISR

Comments AJ text ISR

Contact Reasons

Why has CR contacted this service? text ASS

Record Services Requested AJ Domestic assistance

Social support

Nursing care

Allied health care

Personal care

Centre-based day care

Meals

Other food services

Respite care

Assessment

Client care coordination

Case management

Home maintenance

Home modification

Provision of goods and equipment

Formal linen service

Transport

Counselling/support, information and advocacy(CR)

Counselling/support, information and advocacy(PC)

ASS

What were the key circumstancestriggering contact?

Hospital discharge

Falls

Acute medical condition

Carer burden

Concern about increasing frailty

Other

ASS

Comments AJ text ASS

How long has CR experienced thisproblem?

text ASS

Assessor, record codes AJ Since recent acute illness/event;

Gradual increase in needs over time

Long term disability

ASS

What is CR’s DOB? date ASS

What is CR’s age? text or Autocalc from DOB ASS




Is CR currently receiving services? Yes

No

Unsure

ASS

Agency text ASS

Service type Alternate Therapists

Aged Care

Alcohol and drug

Community health

Counselling

Dental care

Disability

Emergency accommodation

Family planning

Home care

Hospital inpatient

Hospital outpatient

Hospital emergency

Maternal and child health

Medical (GP)

Medical (specialist)

Men's health

Mental health

Palliative care

Rehabilitation

Residential Aged Care

Respite care

Self help groups

Sexual health

Women's health

Youth services.

ASS

Service Description text ASS


What does CR expect the outcome to be? text ASS

Assistance is required to: AJ Improve current level of function andindependence after a recent acute illness/event

Improve current level of function andindependence (other)

Maintain current level of function andindependence

Reduce rate of decline in level of function andindependence

ASS

Provisional Eligibility

If CR is referred from another HACCService, CR is eligible

AJ Yes

No

Not Sure

ISR




Is CR currently receiving HACC service/s? AJ Yes

No

Not Sure

ISR

Details text ISR

Is there any evidence that current healthor disability interferes with daily living andpotential for long-term disability alreadydocumented in contact reasons?

AJ Yes

No

Not Sure

ISR

Does CR have any problems managingactivities of daily living such ashousework, preparing meals, shopping orgetting to places out of walking distance?

Yes

No

Not Sure

ISR

Details

If Yes to any of the above CR is eligible

text ISR


Functional Profile

(Asked directly to the CR)

Can you do housework …

Without help (can clean floors etc)?

With some help (can do light housework butneed help with heavy housework)?

Or are you completely unable to do housework?

ASS

Can you get to places out of walkingdistance …

Without help (can drive your own car, or travelalone on buses or taxis)?

With some help (need someone to help you orgo with you when travelling)?

Or are you completely unable to travel unlessemergency arrangements are made for aspecialised vehicle like an ambulance?

ASS

Can you go out for shopping for groceriesor clothes (assuming you havetransportation)…

Without help (taking care of all shopping needsyourself)?

With some help (need someone to go with youon all shopping trips)?

Or are you completely unable to do anyshopping?

ASS

Can you take your own medicine … Without help (in the right doses at the righttime)?

With some help (able to take medication ifsomeone prepares it for you and/or reminds youto take it)?

Or are you completely unable to take your ownmedicines?

ASS

If not without help, is reason Physical

Cognitive

Both

ASS

Can you handle your own money … Without help (write cheques, pay bills etc)?

With some help (manage day-to-day buying butneed help with managing your chequebook andpaying your bills)?

Or are you completely unable to handle money?

ASS

If not without help, is reason Physical

Cognitive

ASS




Both

Do not ask the following 2 questions if theclient scored 3 on all of the above 5 items(ie, can do all 5 activities without help).

Can you walk …

Without help (except for a cane or similar)?

With some help from a person or with the use ofa walker, or crutches etc

Or are you completely unable to walk?

ASS

Can you take a bath or shower… Without help?

With some help (eg, need help getting into orout of the bath)?

Or are you completely unable to bathe yourself?

ASS

These 7 questions are qualified by

if CR has difficulty, who helps CR?

No-one

Carer

Service Provider

Other

ASS

(and) To what extent is this need met? N/A - no need

Fully met

Partially met

Completely unmet

ASS

Does the CR have any memory problemsor get confused?

Yes

No

ASS

Does the CR have behavioural problems(eg aggression, wandering or agitation)?

Yes

No

ASS

Comments AJ Text ASS

Confirmation of eligibility AJ Yes

No

ISR

LAYER 2

Registration

Preferred Name text ISR

Sex text ISR

Date of Birth Estimate Flag AJ Yes

No

ISR

Type of Address text ISR

Street number text ISR

Street name text ISR

Suburb/locality text ISR

State text ISR

Phone type text ISR

Phone number text ISR

Preferred phone flag Yes

No

ISR

Message flag Yes

No

ISR

Email text ISR

Info for Service Response Trigger




CR Born in Australia Yes

No

ISR

If Yes, ATSI status Aboriginal but not Torres Strait Islander origin

Torres Strait Islander but not Aboriginal origin

Both Aboriginal and Torres Strait Islander origin

Not indigenous

ISR

If No to Australia as COB, what is countryof birth

ABS list ISR

If Yes to Australia as COB, does CR haveCALD background

Yes

No

ISR

Info for Service Response Trigger - Variable

What type of accommodation does CRlive in?

Private residence – owned/purchasing (includesmobile home)

Private residence – private rental

Private residence – public rental

Independent living unit within a retirementvillage

Boarding house/private hotel

Short term crisis, emergency or transitionalaccommodation facility (includes Temporaryshelter within an Aboriginal community)

Supported accommodation or supported livingfacility (includes Domestic-scale supportedliving facility and Supported accommodationfacility)

Institutional setting

Public place/temporary shelter

Private residence rented from AboriginalCommunity

Other

ISR

Does CR live alone? Yes

No

ISR

Does CR receive an Australian GovtPension/Benefit?

Yes

No

ISR

Does CR have health insurance Yes

No

ISR

Are there other people that the agencycan contact?

Advocate

Carer

Case Manager

Emergency Contact

Friend

GP

Guardian

Next of kin

Relative

ISR

Is there any evidence of previousdifficulties between the CR and health and

AJ Yes

No

ISR




community service providers?


Trigger Questions

How much does CR's health interfere withCR's normal activities (outside and/orinside the home) during the past 4 weeks?

Not at all

Slightly

Moderately

Quite a bit

ASS

During the past 4 weeks…how often hasCR experienced any of the following:

• felt very nervous, down or lonely

• got sick and had to stay in bed

• needed someone to talk to

No, not at all

Occasionally

Sometimes

Most of the time

Not sure

ASS

Is the reason for the referral related (atleast in part) to the person’s financial orlegal situation?

AJ Yes

No

Not sure

ASS


If a CR needs are not being fully met(identified in functional profile), ask

Does CR need a Carer?

The CR cannot be left on their own at any time(whether by day or night)

The CR can only be left on their own for some,but not all, of the time (whether by day or night

No Carer required

ASS

If "No Carer required" do not ask thefollowing two questions. If a carer isrequired, proceed

AJ ASS

Does CR have a carer? Has a Carer

Has no Carer

Not Applicable – paid Carer

ASS

Is CR caring for another person? Yes

No

If yes, complete the following questions on theCR as a Carer

ASS

Care recipient as a carer

If yes, who Wife/female partner

Husband/male partner

Mother

Father

Daughter

Son

Daughter-in-law

Son-in-law

Grandchild

Other relative – female

Other relative – male

Friend/neighbour – female

Friend/neighbour - male

ASS





Is CR caring for a child with disabilities? Yes

No

ASS


Is the CR's caring role at risk because oftheir own needs?

AJ Yes

No

Not sure

ASS

Is this person a Carer who needs a Carerassessment?

AJ Yes

No

ASS


LAYER 3

Health Conditions

Include all relevant issues eg, allergies,acute medical conditions, disabilities,continence, dental developmental, mentalhealth

As reported by CR or carer

text ASS

Confirmed by health professional Yes

No

ASS

Current treatments/therapies text ASS

Medical diagnosis of dementia Yes

No

ASS

If yes, has there been a recent cognitiveassessment?

Yes

No

ASS


How much bodily pain has CR had duringthe past 4 weeks?

None

Very Mild

Moderate

Severe

Very Severe

ASS

If bodily pain, has CR seen a healthprofessional about this problem?

Yes

No

ASS

If not, is a referral warranted? Yes

No

Not sure

ASS


Has CR had a fall in the past 6 months? Yes

No

Not sure

ASS

If yes, record number of falls Number ASS

and what was the outcome? text ASS


Does CR use glasses? Yes

No

ASS




Is Blind

Is CR's eyesight for reading (with glassesif CR use them)?

Excellent

Good

Fair

Poor

ASS

Is CR's long distance eyesight (withglasses if CR uses them)?

Excellent

Good

Fair

Poor

ASS


Does CR use a hearing aid? Yes

No

Is Deaf

ASS

Is CR's hearing (with hearing-aid if CR useone)?

Excellent

Good

Fair

Poor

ASS

Does CR ever need help to communicate(to understand or be understood byothers)?

Yes

No

ASS

Has CR seen a health professional aboutthis?

Yes

No

ASS


Is CR currently using any aids andequipment?

Home modifications

Car Modifications

Self-care Aids

Communication Aids

Medical Care Aids

Aids for Reading

Hearing Aid

Support and Mobility Aids

Other (list):

ASS


Does assessor think that homemodifications may be required?

AJ Yes

No

Not sure

ASS

Does assessor think that the provision ofaids and/or equipment may be required?

AJ Yes

No

Not sure

ASS

Does the CR have the capacity to becomemore independent if provided withappropriate services or resources?

AJ Yes

No

Not sure

ASS


Is the CR receiving medication? Yes ASS




No

Does the CR generally look after and taketheir medication without reminding?

Reliable with medication

Slightly unreliable

Moderately unreliable

Extremely unreliable

ASS

Webster Pack or similar used formedicine?

Yes

No

ASS

What is the schedule for medication? text ASS

If CR has long-term disability, what is theprimary disability?

Developmental delay

Intellectual (including down’s syndrome)

Specific learning (including attention deficitdisorder)

Autism (including asperger’s syndrome)

Physical

Acquired brain injury

Deaf blind (dual sensory)

Vision

Hearing

Speech

Psychiatric

Neurological

Other

Not stated/inadequately described

ASS

Are there other disabilities? Yes

No

ASS

And, if so, what are they? (see above list) ASS

Social and Emotional Profile

During the past 4 weeks, was someoneavailable to help CR if Cr needed andwanted help? For example if CR

felt very nervous, lonely or blue

got sick and had to stay in bed

needed someone to talk to

as much as I wanted

quite a bit

some

a little

not at all

ASS


K10

In the past 4 weeks about how often didyou feel

tired out for no good reason?

nervous?

so nervous that nothing could calm youdown? not asked if the CR answered“none of the time”, to the precedingquestion)

hopeless?

restless or fidgety?

so restless you could not sit still? (not

AJ None of the time

A little of the time

Some of the time

Most of the time

All of the time

ASS




asked if the Cr answered “none of thetime”, to the preceding question)

depressed?

that everything was an effort?

so sad that nothing could cheer you up?

worthless?

Total score ASS

Comments AJ ASS

Financial and Legal Profile

What is CR's employment status? Employed/self employed

Sheltered

Child/Student

Home duties

Unemployed

Retired for age

Retired for disability

CDEP

Other

ASS


Who assists CR in making decisions? No-one

Significant Informal Assistance

Power of Attorney

Advance Health Directive

Person responsible or appointed guardian

ASS

Is CR capable of making their owndecisions?

AJ Yes

No

Not sure

ASS


Does the Mental Health Act affect CR? Yes

No

Not sure

ASS


Who assists with CR's financial decisions? No-one

Significant Informal Assistance

Power of Attorney

Parent or Guardian

Formal Financial Administrator or Manager

ASS

Does CR have enough financial resourcesto meet emergencies?

Yes

No

Not sure

ASS

If no or not sure, because of limitedincome, has CR during the last monthmade any trade-offs among purchasingany of the following: prescribedmedications, necessary medical care,adequate food, necessary home care,

Yes

No

ASS




necessary transport?

Are there any other relevant legal issues AJ Yes

No

ASS

Details AJ text ASS


Carer Profile

Primary carer (PC)-first name text ISR

PC -family name text ISR

Are there other people who provide care?(e.g. network of carers, shared caringarrangements)

Yes

No

Not sure

ISR

Type of assistance text ISR

Who from (eg family, friends) text ISR

How often (hrs/week) number ISR

Comments text ISR

PC residency Co-resident Carer

Non-resident Carer

ISR

Relationship of PC to CR Wife/female partner

Husband/male partner

Mother

Father

Daughter

Son

Daughter-in-law

Son-in-law

Other relative – female

Other relative – male

Friend/neighbour – female

Friend/neighbour – male

ISR

Does PC have someone to help them? Yes

No

Not sure

ASS

Does PC receive a Pension or Benefit? Aged pension

Veterans’ affairs pension

Disability support pension

Carer payment (pension)

Unemployment related benefits

Other government pension or benefit

No government pension or benefit

Carer allowance

Not stated/inadequately described

Not sure

ISR

Has PC been given information aboutavailable support services?

Yes ASS




No

Not sure

Does PC need practical training in lifting,managing medicine or other tasks?

Yes

No

Not sure

ASS

Current threats to PC-CR arrangements? PC – emotional stress & strain

PC – acute physical exhaustion/illness

PC – slow physical health deterioration

PC – factors unrelated to care situation

CR – increasing needs

CR – other factors

ASS

Are PC-CR arrangements sustainablewithout additional services or support?

AJ No, arrangements have already broken down

No, carer arrangements likely to break downwithin months

Yes, carer arrangements are sustainablewithout additional support

Not sure

ASS


Detailed Info for service response – fixed

If CR born overseas

What is migration status?

Citizen/Permanent resident

Business & Skilled Migrants

Temporary Protection Visa

General Sponsorship

Proposed Entrant

Humanitarian Refugee

Other

ISR

or has CALD background, what is CR'sethnicity and/or religion?

text ISR

If ATSI, what is skin/tribal name? text ISR

Main language spoken at home ABS list ISR

Interpreter required Yes

No

ISR

Preferred sex of interpreter No preference

Male

Female

ISR

Preferred language (if not spoken English) ABS list ISR


Detailed Info for service response – changeable

If CR does not live alone, who does CRlive with?

Lives with family

Lives with others

ISR


Does CR have concerns about their livingarrangements?

Yes

No

Not sure

ISR





Australian Government Pensioner/BenefitStatus

Aged Pension

Veterans’ Affairs Pension (complete detailsbelow)

Disability Support Pension

Carer Payment (pension)

Unemployment related benefits

Other govt pension or benefit

ISR

If other government pension or benefit,specify

text ISR

Health Care Card Number text ISR

DVA Card Status No DVA Card

Yes – Gold Card

Yes – White Card

Yes - Other DVA Card

ISR

If other DVA card, specify text ISR

Health Insurance type (select all thatapply)

None

Private health insurance – basic cover only

Private health insurance – including auxiliarycover for private dental and allied healthservices

Motor vehicle accident insurance

Workers compensation

Other 3rd party

Ambulance fund

ISR

Health Insurer Name text ISR

Health Insurer Card Number text ISR

Other contacts -type Advocate

Carer

Case manager

Emergency Contact

Friend

GP

Guardian

Next of kin

Relative

ISR

Title text ISR

Surname or Family Name text ISR

Given Names text ISR

Organisation text ISR

Address text ISR

Suburb/Town/Locality text ISR

Postcode text ISR

State/Territory text ISR




Phone text ISR

Mobile text ISR

Fax text ISR

E-mail text ISR


Action Plan

Are there any other risks or comments? AJ text ASS

Referral type Triggered Assessment

Triggered comprehensive assessment

ASS

Assessor override Yes

No

Assessor judged assessment

Assessor judged comprehensive assessment

Service

ASS

Agency to be referred to text ASS

Reason for referral text ASS

Referral text text ASS

Priority for referral Low - hold over during peak demand

Routine - attend in date order

Urgent - cannot wait

ASS

Consent for referral Yes

No

ASS

Referral Status Not Made

Sent

Accepted

Rejected

ASS

If referral not made, reason CR ineligible for service

Referred elsewhere

Advice / information provided. No further actionrequired

CR declines further referral or service

CR issues resolved. No further action required

Service not available

Requested service not accessible - long waitingtime

Requested service not accessible - inaccessiblelocation

Requested service not accessible - other

Other

ASS


What are the CR's primary care needs? AJ Acute health care needs

Palliative care needs

Rehabilitation needs

Needs for ongoing management of chronicconditions

ASS




Extended (long-stay in special-purpose facility)health care needs

Geriatric evaluation and management needs

Maintenance care needs

Other and unspecified needs

If answer to Q9 of FP indicateschallenging behaviour, what is the level ofsupport needed?

AJ High level of support required for behaviour

Medium level of support required for behaviour

Low level of support required for behaviour

No support required for behaviour

No challenging behaviour

ASS

Table 27 Triggers in ACCNA Version 1

Assessment Type Trigger

Self care function Score of less than 3 on either FP Item 6 or 7.

Rehabilitation Assistance is required to Reduce rate of decline in level of function and independence

If No GP, automatic referral to GP

OR

Medical

Referral for primary care mental health assessment if total K-10 score is 16-29

If the CR scored less than 3 on either Item 4 or Item 5 in the FP and the CR has nophysical disabilities or problems with English literacy that may account for the CR notbeing independent on these items

OR

If the CR scored 1 on Item 8 of FP

OR

Cognitive

If medical diagnosis of dementia in Health Conditions Profile AND has not been recentlyassessed by a doctor

Hearing Hearing (with hearing aid, if used) is fair or poor

If home modifications are suggested AND FP scores of either 1 or 2 on items 2 and/or 6

OR

Home modification

If CR has had 1 or more falls in the last 6 months

If provision of equipment is suggested AND FP scores of either 1 or 2 on items 2 and/or6

OR

Provision of goods andequipment

If CR has had 1 or more falls in the last 6 months

Speech CR needs help to communicate AND has not seen a health professional about this

Vision Vision (with glasses, if used) is fair or poor

Mental health A specialist mental health assessment if K10 score is 30 or more

Behaviour FP item 9 score is 1

Carer Needs Carer is needed and carer arrangements have broken down or are likely to break down

Child Disability CR cares for a child with a disability

Caring for other Assessor considers other person at risk



Figure 21 Algorithm for the ACCNA priority rating system

Psychosocial problems - K10 score of 30 or more AND/OR No personal and social supportOther problems - Significant behavioural problems OR Significant cognitive problems (diagnosis of dementia in Health Conditions Profile orcognitive problems OR decision-making problems)

Note: If the relevant profile is not completed, rate that the consumer has no problems. For example, if no Carer Profile is completed, rate theconsumer as having no carer risks.

Results of the functionalscreening profile?

High function -no cognitive or

behaviour problems,a score of 3 in 3 or

more domesticfunctions (items 1 to5) and a score of 3

on both items 6 and 7 Has no otherpsychosocial or other

problems

Prevention program,exit or refer elsewhere

Has psychosocialor other problems

Needs no CarerACCNA Priority

Rating 9

Needs a Carer

Has a Carer

Sustainabilityscore 3

ACCNA PriorityRating 9



Has no Carer or CarerSustainability score 1


Medium function - all others

Withoutpsychosocial orother problems


Rating 8

Needs a Carer

Has a Carer





Has no Carer orCarer Sustainability

score 1


With psychosocialor other problems


Rating 6

Needs a Carer

Has a Carer







Low function - total score on all 9items is <15 or totalfor items 6 & 7 is <4


Rating 6

Needs a Carer

Has a Carer









Attachment 3

Changes to the ACCNA from the version used in the field trial

Table 28 Changes from the field trial version

Domain Modification

Initial Client Contact Assessment Purpose – Initial or Re-assessment added.

Contact Reasons No change.

Provisional Eligibility No change.

Functional Profile Cognitive or Physical answer modified to Cognitive and/or Physical

“If Care Recipient has difficulty, who helps?” – responses should be no one or (carerand/or service provider and/or other).

Additional items about function removed.

Registration Agency Consent question removed.

“Date of birth estimate Flag” moved from Contact Reasons.

Information for ServiceResponse

Split into 4 domains:

§ Info for Service Response Trigger - fixed

§ Info for Service Response Trigger – changeable

§ Detailed Info for service response – fixed.

§ Detailed Info for service response – changeable

Info for Service ResponseTrigger - Fixed

“If Yes to Australia as COB, does CR have CALD background?” added.

Info for Service ResponseTrigger – Variable

Other contact types modified to

§ Advocate

§ Carer

§ Case manager

§ Emergency Contact

§ Friend

§ GP

§ Guardian

§ Next of kin

§ Relative.

Detailed Info for serviceresponse – Fixed

Added questions are

“If CR born overseas, what is migration status?

§ Permanent resident

§ Business & Skilled Migrants

§ Temporary Protection Visa

§ General Sponsorship

§ Proposed Entrant

§ Humanitarian Refugee

§ Other”

“or has CALD background, what is CR's ethnicity?”

“If ATSI, what is skin/tribal name?”

Detailed Info for service Standardised contact information provided for other contact types.



Domain Modification

response – changeable

Trigger Question “Is CR caring for another person?” Grandchild added to list.

“Is this person a Carer who needs a Carer assessment?” Moved from Summary.

Health Conditions “Health conditions – confirmed by doctor” changed to “ confirmed by healthprofessional”.

“Does CR ever need help to communicate (to understand or be understood byothers)?” (moved from Functional Profile)

“Has CR seen a health professional about this?” added

“Medical diagnosis of dementia” and “If yes, has there been a recent cognitiveassessment?” questions are added.

Vision – blind option added

Hearing – deaf option added

The following questions are added for inter-relationship with the CENA:

“Is the CR receiving medication?

§ Yes

§ No.”

“Does the CR generally look after and take their medication without reminding?

§ Reliable with medication

§ Slightly unreliable

§ Moderately unreliable

§ Extremely unreliable.’

“Webster Pack or similar used for medicine?

§ Yes

§ No.”

“What is the schedule for medication?”

“If CR has long-term disability, what is the primary disability?”

§ Developmental delay

§ Intellectual (including down’s syndrome)

§ Specific learning (including attention deficit disorder)

§ Autism (including asperger’s syndrome)

§ Physical

§ Acquired brain injury

§ Deaf blind (dual sensory)

§ Vision

§ Hearing

§ Speech

§ Psychiatric

§ Neurological

§ Other

§ Not stated/inadequately described.”

“Are there other disabilities?

§ Yes

§ No.”

“And, if so, what are they?”

Financial/Legal profile No change



Domain Modification

Carer Profile Questions added:

“Type of assistance?”

“Who from (eg family, friends)?”

“How often (hrs/week)?”

Social/emotional Profile Social support question removed.

Action Plan “Are there any other risks or comments?” moved from Summary.

Referral text added.

The following questions are added for inter-relationship with the CENA:

“What are the CR's primary care needs?

§ Acute health care needs

§ Palliative care needs

§ Rehabilitation needs

§ Needs for ongoing management of chronic conditions

§ Extended (long-stay in special-purpose facility) health care needs

§ Geriatric evaluation and management needs

§ Maintenance care needs

§ Other and unspecified needs.”

“If answer to Q9 of FP indicates challenging behaviour, what is the level of supportneeded?

§ High level of support required for behaviour

§ Medium level of support required for behaviour

§ Low level of support required for behaviour

§ No support required for behaviour

§ No challenging behaviour.”



Table 29 An example of inconsistencies in current code sets - source of referral codes forHACC and NRCP

HACC Referral Source NRCP Referral Source

Self


GP/medical practitioner—community based

Aged Care Assessment Team

Community nursing or health service

Hospital



Palliative care facility/hospice

Residential aged care facility


Other medical/health service

Other community-based service


Other:

Self


GP/medical practitioner – community based

Specialist aged or disability assessment team/service(e.g. ACAT)

Comprehensive HACC assessment authority

Community nursing service

Acute care hospital



Palliative care facility/hospice

Government residential aged care facility (nursinghome or aged care hostel)


Commonwealth Care Link Centre

Other community-based government medical/healthservice

Other government medical health service

Other government community-based services agency

Hospital (private)

Non government residential aged care facility

Other non-government medical/ health service

Other non-government community-based service


Carer respite/resource centre

Other

ACCNA Field Trial Final Report CHSD June 07 - UOW · study ... Level 1 – a Technical Field Trial...

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