Author: Norma Brenda Bulamu
Bulamu, Norma Brenda, 2019 Consumer Directed Care in The Community Aged Care Sector: A Health Economics Perspective, Flinders University, College of Medicine and Public Health
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Aged care policy reform in Australia in August 2013 led to the introduction of a consumer directed care (CDC) model of service delivery and heralded unprecedented changes for the community aged care sector. Consumer directed care is a model of service delivery that allows consumers to have greater control over their care by incorporating their choices about the type of care and services received, including who delivers these services and when they are delivered. From July 2015, all community aged care services in Australia are delivered under a CDC model.
This research was conducted as part of an Australian Research Council Linkage project that applied a health economic perspective to the development and evaluation of a consumer directed care model of services. The project focused on the change in policy to move towards a more flexible and consumer directed approach to the design and delivery of community aged care services. Initially, a major goal of this research was to present existing evidence of the cost effectiveness of this model of service delivery worldwide before undertaking a cost effectiveness analysis of the model with an Australian context. However, due to the rapid pace of change in policy and practice in the Australian community aged care sector (the timing of which coincided with the work conducted and reported upon in this thesis), only the former was undertaken. It was not possible to conduct a traditional economic evaluation as originally envisaged, by comparing the costs and outcomes associated with a cohort of participants in receipt of services under CDC with a matched cohort of participants receiving a traditional provider directed care model (PDC). This was because there was no longer a distinction between the CDC and PDC arms at follow-up as all study participants switched to a CDC model during the study. However, it was possible to employ a health economic approach to assess the impact of the introduction of a CDC model of service delivery in the aged care sector focusing upon the main cost drivers associated with the provision of services and factors that explain variation in the quality of life of older people receiving community aged care services (CACS) through a series of cross-sectional studies.
The overall aim of this research was to investigate the changes in quality of life associated with receipt of a CDC model of CACS and the costs associated with this model of service delivery. It was undertaken by applying a health economic perspective to the analytical framework for evaluating quality in the delivery of service innovations in health systems (comprising three main inter-linking elements namely structure, process and outcomes) first proposed by Avedis Donabedian. The structure of aged care and the process of service delivery were theoretically analysed within the context of market failure and product/service differentiation while the outcomes/impact of care were assessed within extra-welfarism theory through the measurement of changes in quality of life and capability. Two cross-sectional empirical studies were undertaken at different time points (early and late phase) reflecting the implementation of CDC in Australia to investigate the impact of CDC services on quality of life and capability using the 5-level version of the EuroQoL 5 dimensions (EQ-5D 5L) and ICEpop CAPability measure for Older people (ICECAP-O) instruments, respectively. A third empirical study was conducted to understand the costs associated with provision of a CDC model of service delivery.
Analysis of the structure and process of care delivery within the community aged care sector illustrates the presence of market failure and competition in the sector through product differentiation. The first empirical study conducted during the earliest stage of the reforms (December 2013) compared quality of life and capability between a cohort of participants receiving the newly initiated CDC services to a cohort of participants in receipt of PDC. The results revealed that overall quality of life was broadly similar for both models of service delivery. However, investigation at the quality of life dimension level revealed that, commensurate with the overarching philosophy of CDC ‘more control to clients’, the cohort of participants receiving a CDC model of service delivery reported higher levels of control/independence on the ICECAP-O relative to those receiving PDC and these differences were statistically significant (p=0.017). The second empirical study was undertaken between December 2015 and February 2016, following the system-wide transition of all CACS to a CDC model which took place in July 2015. This study focused on variations in quality of life and capability according to the time participants were in receipt of a CDC type of service. Higher scores were observed for both the EQ-5D-5L and ICECAP-O among older people in receipt of a CDC mode of service delivery for a shorter period (0-12 months) compared with a longer period (more than 12 months). This study demonstrated early evidence of the potential for improvements in capability outcomes for older people as service providers become more engaged with CDC and as this new model of service delivery becomes more established. The third empirical study was a costing study which found that the main cost drivers associated with the provision of a CDC model of service delivery for older people were the provision of care services, administration and care coordination/case-management. The proportion of home care package expenditures allocated to the provision of care services was approximately 50% whilst approximately 40% was allocated to administration and case-management. The key cost drivers were the level of the home care package and the hours of formal care support received within the home care package.
Overall, it will take some time for the full impact of CDC in relation to the key cost drivers and the key outcomes of health, quality of life and capability for older people to be realised in practice. Further research, including health economic evaluation evidence reflecting longitudinal assessment to track changes in costs and quality of life and capability outcomes over time, is recommended as CDC becomes more established in the community aged care sector in Australia.
Keywords: Consumer directed care, community aged care, older people, quality of life
Subject: Public Health thesis
Thesis type: Doctor of Philosophy
Completed: 2019
School: College of Medicine and Public Health
Supervisor: Professor Julie Ratcliffe