Achieving the gold standard in CDC

By Greg Adey.

While it is clear that great progress is underway in strengthening home care services and using Consumer Directed Care as one of the principle drivers of this, the challenge now is to develop innovations which focus less on budget redistribution and more strongly on evidence-based healthy ageing.

We can settle for CDC ‘Lite’ with its minimalist approach to choice and control, or reach for CDC ‘Gold’, a premium strategy which optimises empowerment, wellbeing and healthy ageing.

CDC evidence 

In designing CDC ‘Gold’ we need to firstly look at what the evidence tell us:

• While older people naturally want to stay in their own homes for as long as possible, this decision often comes at a severe cost to their health and chronic illness. 
• Home care services are helping people stay longer in their homes, but rarely address preventable functional decline. Researchers frequently criticise the biomedical and ADL task models of aged services, and their inattention to health enabling practices and interventions. 
• CDC programs demonstrate increased consumer satisfaction, but no significant improvement in wellbeing outcomes. (see ‘Evaluation of the consumer-directed care initiative’ final report, KPMG 2012).
• The current CDC model lacks a unified framework or targeted policies to drive evidence-based health promoting approaches and wellbeing goals. 
• CDC consumers largely rely on their coordinator to make suggestions and provide options, and few take a substantial self-management role. 
• Most CDC models are usually dependency-based, and pay insufficient attention to an individual’s healthy ageing 
• People (ourselves included) don’t always know or choose what is best for them (a heretical but unfortunate truth). 

A new perspective 

As Bette Davis said, “growing old ain’t for sissies”. She understood that successful ageing requires constant commitment and hard work to avoid the passivity and learned helplessness that contributes to poor health and low motivation. Wellbeing has been described as an active, lifelong process of assuming personal responsibility that empowers the individual to take informed actions towards a fulfilling life.

We devalue older people by having or accepting low expectations of their restorative and wellbeing capacity. To avoid this passive paternalism, we need to consider a bolder partnership of shared expectations and responsibilities. The indigenous leader Noel Pearson proposed that, properly understood, self-determination (that is, control and choice) is the power to take responsibility.

Preventing avoidable functional decline starts with health promotion, which requires health literacy and informed choice. Older people can’t lead the CDC decision-making process without adequate information and understanding. Under the WHO Ottawa Charter (1986) we have an international obligation to redesign health services around health promotion to optimise healthy ageing for older Australians. We are required to embed health promotion in every aspect of our aged services. CDC choices must be informed choices if we are to truly optimise health, independence and well-being.

DoHA CDC guidelines 

Under the Department’s CDC approach, “consumers are encouraged to identify goals around health, independence, wellness and restoration which will form the basis of the Home Care Agreement and care plan. They should be empowered to continue to manage their own life by having control over the care and support they receive. This requires the provision of, and assistance to access, information about service options that enables consumers to build a package that supports them to live the life they want, and potentially reduce the need for ongoing and/or higher levels of service delivery”.

Sounds great, but how? Where are the evidence-based policies and practice guidelines which clearly articulate strategies and interventions which providers should be using to optimise this empowerment, wellbeing and healthy ageing? How are we going to build a ‘gold’ standard CDC, not just the ‘lite’ version or something in between?

The innovators 

Fortunately, innovators across Australia are already building world-class frameworks for healthy ageing and enhanced well-being which have been adapted for aged services. They have researched the international evidence to develop practical strategies, interventions and tools that work in the real world, and are constantly refining the models using action research and new learnings.

Their approach includes:

• health literacy education 
• raised expectations of what’s possible 
• shifting the emphasis from traditional ADL support to target deconditioning and functional decline 
• exercise and activity prescriptions which challenge our ageist concept of ‘gentle exercise’ 
• cognition strengthening programs 
• wellbeing programs based on the positive psychology PERMA evidence, and 
• early intervention multidisciplinary programs to address increased frailty or acute episodes of ill-health. 

And the research unequivocally supports this approach. Restorative and re-ablement home care packages are associated with significant improvement in quality of life, significant improvement in performing ADLs and a significant reduction in the use of services. Researchers also note that by focusing on the enablers of healthy ageing, older people achieve more choice, control, independence and wellness.

The healthy ageing framework 

This healthy ageing framework is built on a number of essential requirements:

• a shared partnership of responsibilities and expectations 
• health promotion and health literacy to support informed choices 
• role models and coaching 
• preventative and restorative interventions using a strengths-based model 
• simple and effective tools and resources (such as ‘appreciative inquiry’ goal-setting tools, ‘My Well-Being Plan’, ‘My Perfect Week’ and learning logs), and 
• continuous evaluation and refinement based on evidence-based learning. 

A crucial requirement is to invest in educating staff about healthy ageing and what they need to do differently, which has been made easier by teaching staff about their own wellbeing and health enablers.

Key features of CDC ‘Gold’ 

A CDC ‘Gold’ approach:

• delivers a bigger win for older people – optimum wellbeing, healthy ageing and empowered choices. It doesn’t just delay a transition to residential care, but uses restorative strategies to increase healthy life expectancy, and reduce dependency on services.
• understands that a genuine person-centred approach involves a greater expectation of the older person to assume reasonable responsibility for health enabling actions and health promoting changes to their lives. It provides clear roles and responsibilities for the older person, family, friends, staff and other agencies.
• is not about providers relinquishing budget input, reducing the critical role of coordination, or ceasing interventions based on ADL assistance, treatment and social supports. The provider partnership remains critical in building a premium home services program focused on aspirational outcomes for older people, even for those who are extremely frail, ill or palliative.
• CDC programs must avoid the risk of becoming little more than a budget-sharing exercise with a tick-the-box approach to choice and control. By developing a clear healthy ageing policy framework and implementing evidence-based strategies, we can learn from our innovators who are leading the way in partnering with older people to optimise their health, independence and wellbeing.

Greg Adey is director of g88 consulting, a specialist aged services advisory business.

Some useful references

Baker, D (2006) ‘The Science of improving function: implications for home care’ Journal for Healthcare quality 28(1).

Glendinning et al (2010) ‘Home care Re ablement Services: investigating the longer-term impacts, York: Social Policy Unit, The University of York.

Unwin (2011) Exercise & Rehabilitation of older adults.

Hill, R (2008) Seven Strategies for Positive Ageing.