A Healthier Future for all Australians - Final Report June 2009

Connecting Care

Comprehensive care for people over their lifetime

Creating strong primary health care services for everyone

16. We recommend that, to better integrate and strengthen primary health care, the Commonwealth should assume responsibility for all primary health care policy and funding.
17. We recommend that, in its expanded role, the Commonwealth should encourage and actively foster the widespread establishment of Comprehensive Primary Health Care Centres and Services. We suggest this could be achieved through a range of mechanisms including initial fixed establishment grants on a competitive and targeted basis. By 2015, we should have a comprehensive primary health care system that is underpinned by a national policy and funding framework with services evolving in parallel.
18. We recommend that young families, Aboriginal and Torres Strait Islander people, and people with chronic and complex conditions (including people with a disability or a long-term mental illness) have the option of enrolling with a single primary health care service to strengthen the continuity, coordination and range of multidisciplinary care available to meet their health needs and deliver optimal outcomes. This would be the enrolled family or patient's principal 'health care home'. To support this, we propose that:
    • there will be grant funding to support multidisciplinary services and care coordination for that service tied to levels of enrolment of young families and people with chronic and complex conditions;
    • there will be payments to reward good performance in outcomes, including quality and timeliness of care, for the enrolled population; and
    • over the longer term, payments will be developed that bundle the cost of packages of primary health care over a course of care or period of time, supplementing fee-based payments for episodic care.
19. We recommend embedding a strong focus on quality and health outcomes across all primary health care services. This requires the development of sound patient outcomes data for primary health care. We also want to see the development of performance payments for prevention, timeliness and quality care.
20. We recommend improving the way in which general practitioners, primary health care professionals, and medical and other specialists manage the care of people with chronic and complex conditions through shared care arrangements in a community setting. These arrangements should promote good communication and the vital role of primary health care professionals in the ongoing management and support of people with chronic and complex conditions in partnership with specialist medical consultants and teams who provide assessment, complex care planning and advice.
21. Service coordination and population health planning priorities should be enhanced at the local level through the establishment of Primary Health Care Organisations, evolving from or replacing the existing Divisions of General Practice. These organisations will need to:
    • have appropriate governance to reflect the diversity of clinicians and services forming comprehensive primary health care;
    • be of an appropriate size to provide efficient and effective coordination (say, approximately 250,000 to 500,000 population depending on health need, geography and natural catchment); and
    • meet required criteria and goals to receive ongoing Commonwealth funding support.

Nurturing a healthy start

22. We recommend an integrated strategy for the health system to nurture a healthy start to life for Australian children. The strategy has a focus on health promotion and prevention, early detection and intervention and management of risk, better access to primary health care, and better access to and coordination of health and other services for children with chronic or severe health or developmental concerns.
    We recommend a strategy for a healthy start based on three building blocks:
    • most importantly, a partnership with parents, supporting families - and extended families - in enhancing children's health and wellbeing;
    • a life course approach to understanding health needs at different stages of life, beginning with pre-conception, and covering the antenatal and early childhood period up to eight years of age. While the research shows that the first three years of life are particularly important for early development, we also note the importance of the period of the transition to primary school; and
    • a child and family-centred approach to shape the provision of health services around the health needs of children and their families. Under a 'progressive universalism' approach, there would be three levels of care: universal, targeted, and intensive care.
23. We recommend beginning the strategy for nurturing a healthy start to life before conception. Universal services would focus on effective health promotion to encourage good nutrition and healthy lifestyles, and on sexual and reproductive health services for young people. Targeted services would include ways to help teenage girls at risk of pregnancy. In the antenatal period, in addition to good universal primary health care, we recommend targeted care for women with special needs or at risk, such as home visits for very young, first-time mothers.
24. We recommend that universal child and family health services provide a schedule of core contacts to allow for engagement with parents, advice and support, and periodic health monitoring (with contacts weighted towards the first three years of life), including:
    • the initial contact would be universally offered as a home visit within the first two weeks following the birth. The schedule would include the core services of monitoring of child health, development and wellbeing; early identification of family risk and need; responding to identified needs; health promotion and disease prevention (for example, support for breastfeeding); and support for parenting;
    • where the universal child and family health services identify a health or developmental issue or support need, the service will provide or identify a pathway for targeted care, such as an enhanced schedule of contacts and referral to allied health and specialist services; and
    • where a child requires more intensive care for a disability or developmental concerns, a care coordinator, associated with a primary health care service, would be available to coordinate the range of services these families often need.
25. We recommend that all primary schools have access to a child and family health nurse for promoting and monitoring children's health, development and wellbeing, particularly through the important transition to primary school.
26. We recommend that responsibility for nurturing a healthy start to life be embedded in primary health care to ensure a comprehensive understanding of a child's health needs and continuity of care. Families would have the opportunity to be enrolled with a primary health care service as this would enable well integrated and coordinated care and a comprehensive understanding of the health needs of children and their families.

Ensuring timely access and safe care in hospitals

27. We recommend development and adoption of National Access Targets for timeliness of care. For example:
    • a national access target for people requiring an acute mental health intervention (measured in hours);
    • a national access target for patients requiring urgent primary health care (measured in hours or days);
    • national access targets for people attending emergency departments (measured in minutes to hours);
    • a national access target for patients requiring coronary artery surgery or cancer treatment (measured in weeks/days); and
    • a national access target for patients requiring other planned surgery or procedures (measured in months).
    These National Access Targets should be developed incorporating clinical, economic and community perspectives through vehicles like citizen juries and may evolve into National Access Guarantees subject to ensuring there is no distortion in allocation of health resources.
28. A share of the funding potentially available to health services should be linked to meeting (or improving performance towards) the access targets, payable as a bonus.
29. We recommend there be financial incentives to reward good performance in outcomes and timeliness of care. One element of this should be for timely provision of suitable clinical information (such as discharge information) including details of any follow-up care required.
30. We recommend the use of activity-based funding for both public and private hospitals using casemix classifications (including the cost of capital), which means:
    • this approach should be used for inpatient and outpatient treatment;
    • emergency department services should be funded through a combination of fixed grants (to fund availability) and activity-based funding; and
    • for hospitals with a major emergency department service the costs of maintaining bed availability to admit people promptly should be recognised in the funding arrangements.
31. We recommend that all hospitals review provision of ambulatory services (outpatients) to ensure they are designed around patients' needs and, where possible, located in community settings.
32. To support quality improvement, we recommend that data on safety and quality should be collated, compared and provided back to hospitals, clinical units and clinicians in a timely fashion to expedite quality and quality improvement cycles. Hospitals should also be required to report on their strategies to improve safety and quality of care and actions taken in response to identified safety issues.
33. To improve accountability, we recommend that public and private hospitals be required to report publicly on performance against a national set of indicators which measure access, efficiency and quality of care provided.
34. To better understand people's use of health services and health outcomes across different care settings, we recommend that public and private hospital episode data should be collected nationally and linked to MBS and PBS data using a patient's Medicare card number.
35. We recommend that the future planning of hospitals should encourage greater delineation of hospital roles including separation of planned and emergency treatment, and optimise the provision and use of public and private hospital services.
36. We recommend a nationally led, systemic approach to encouraging, supporting and harnessing clinical leadership within hospitals and broader health settings and across professional disciplines.

Restoring people to better health and independent living

37. The visibility of, and access to, sub-acute care services must be increased for people to have the best opportunity to recover from injury or illness and to be restored to independent living. To do this, we recommend:
    • funding must be more directly linked to the delivery and growth of sub-acute services;
    • a priority focus should be the development of activity-based funding models for sub-acute services (including the cost of capital), supported by improvements in national data and definitions for sub-acute services; and
    • the use of activity-based funding complemented by incentive payments related to improving outcomes for patients.
38. We recommend that clear targets to increase provision of sub-acute services be introduced by June 2010. These targets should cover both inpatient and community-based services and should link the demand for sub-acute services to the expected flow of patients from acute services and other settings. Incentive funding under the National Partnership Payments could be used to drive this expansion in sub-acute services.
39. We recommend that investment in sub-acute services infrastructure be one of the top priorities for the Health and Hospitals Infrastructure Fund.
40. We recommend planning and action to ensure that we have the right workforce available and trained to deliver the growing demand for sub-acute services, including in the community. Accordingly, we support the need for better data on the size, skill mix and distribution of this workforce, including rehabilitation medicine specialists, geriatricians and allied health staff.
41. We recognise the vital role of equipment, aids and other devices in helping people to improve health functioning and to live as independently as possible in the community. We recommend affordable access to such equipment should be considered under reforms to integrated safety net arrangements.

Increasing choice in aged care

42. We recommend that government subsidies for aged care should be more directly linked to people rather than places. As a better reflection of population need, we recommend the planning ratio transition from the current basis of places per 1000 people aged 70 or over to care recipients per 1000 people aged 85 or over.
43. We recommend that consideration be given to permitting accommodation bonds or alternative approaches as options for payment for accommodation for people entering high care, provided that removing the regulated limits on the number of places has resulted in sufficient increased competition in supply and price.
44. We recommend requiring aged care providers to make standardised information on service quality and quality of life publicly available on agedcareaustralia.gov.au, to enable older people and their families to compare aged care providers.
45. We recommend consolidating aged care under the Commonwealth Government by making aged care under the Home and Community Care (HACC) program a direct Commonwealth program.
46. We recommend development and introduction of streamlined, consistent assessment for eligibility for care across all aged care programs. This should include:
    • transferring the Aged Care Assessment Teams to Commonwealth Government responsibility;
    • developing new assessment tools for assessing people's care needs; and
    • integrating assessment for Home and Community Care Services with more rigorous assessment for higher levels of community and residential care.
47. We recommend that there be a more flexible range of care subsidies for people receiving community care packages, determined in a way that is compatible with care subsidies for residential care.
48. We recommend that people who can contribute to the costs of their own care should contribute the same for care in the community as they would for residential care (not including accommodation costs).
49. We recommend that people supported to receive care in the community should be given the option to determine how the resources allocated for their care and support are used.
50. We recommend that once assessment processes, care subsidies and user payments are aligned across community care packages and residential care, older people should be given greater scope to choose for themselves between using their care subsidy for community or for residential care.
    
    Notwithstanding this, we note that, given the increase in frailty and complexity of care needs, for many elderly people residential care will remain the best and only viable option for meeting their care needs. The level of care subsidies should be periodically reviewed to ensure they are adequate to meet the care needs of the most frail in residential settings.
    
    In the lead up to freeing up choice of care setting, there should be a phased plan over five years to enable aged care providers to convert existing low care residential places to community places.
51. We recommend that all aged care providers (community and residential) should be required to have staff trained in supporting care recipients to complete advance care plans for those who wish to do so.
52. We recommend that funding be provided for use by residential aged care providers to make arrangements with primary health care providers and geriatricians to provide visiting sessional and on-call medical care to residents of aged care homes.
53. The safety, efficiency and effectiveness of care for older people in residential and community settings can be assisted by better and innovative use of technology and communication. We recommend:
    • supporting older people, and their carers, with the person's consent, to activate and access their own person-controlled electronic health record;
    • improved access to e-health, online and telephonic health advice for older people and their carers and home and personal security technology;
    • increased use of electronic clinical records and e-health enablers in aged care homes, including capacity for electronic prescribing by attending medical and other credentialled practitioners, and providing a financial incentive for electronic transfer of clinical data between services and settings (general practitioners, hospital and aged care), subject to patient consent; and
    • the hospital discharge referral incentive scheme must include timely provision of pertinent information on a person's hospital care to the clinical staff of their aged care provider, subject to patient consent.

Caring for people at the end of life

54. We recommend building the capacity and competence of primary health care services, including Comprehensive Primary Health Care Centres and Services, to provide generalist palliative care support for their dying patients. This will require greater educational support and improved collaboration and networking with specialist palliative care service providers.
55. We recommend strengthening access to specialist palliative care services for all relevant patients across a range of settings, with a special emphasis on people living in residential aged care facilities.
56. We recommend that additional investment in specialist palliative care services be directed to support more availability of these services to people at home in the community.
57. We recommend that advance care planning be funded and implemented nationally, commencing with all residential aged care services, and then being extended to other relevant groups in the population. This will require a national approach to education and training of health professionals including greater awareness and education among health professionals of the common law right of people to make decisions on their medical treatment, and their right to decline treatment. We note that, in some states and territories, this is complemented by supporting legislation that relates more specifically to end of life and advance care planning decisions.