Aging in place

A multi-disciplinary research project by Dr Julie Harrison (Accounting and Finance), Professor Matthew Parsons (School of Nursing), Professor Paul Rouse (Accounting and Finance), Associate Professor Laszlo Sajtos (Department of Marketing) and others.

Developing a new funding model for home-care services in New Zealand

Demographic projections indicate that by 2050, the percentage of New Zealanders over 65 will double from 12 percent to 25 percent and over 75 year-olds will increase fourfold. The implication is that not only will there be a larger number of older people, but fewer people to support them, which means that increasing healthcare costs will need to be spread across fewer (working) taxpayers.

Ageing in Place is a New Zealand policy directive, established in 2002, that aims to support older people to feel safe and secure in their choice of home and to remain living at home instead of entering residential care. Under the Ageing in Place policy, New Zealand District Health Boards (DHBs) contract for support services to be provided to older people in their own homes based on their level of need.

Collectively referred to as “Home-Based Support Services” (HBSS), these services provide the platform for an alternative to institutionalisation. However, previous funding models that facilitate a responsive, flexible approach were lacking, with the traditional method for funding home-care services being fee-per-hour. The fee-per-hour model is disadvantageous as it provides no incentives for service workers to report improvement in client functionality (as it would render their services superfluous) and further, changes in hours of input would normally require reassessment resulting in reduced flexibility in service delivery. The system that this project explored was Casemix.

Casemix classification is a systematic approach to quantifying the relationship between patient-driven variables and resource use. It places healthcare cases into groups where members of the group are clinically similar and use similar amounts of care. The challenge was to develop a Casemix solution by adapting it from a well-established hospital system to home-care services through meaningful client profile groups and supporting pathways.

The project team was tasked with exploring a new funding and service delivery model for home-care services for the elderly in New Zealand.

In contrast to hospital case mix systems where a patient is assigned to a group based on diagnoses or procedures, usually with a fixed length of stay, this required a formal assessment of each client’s needs in a setting where services are likely to be provided until either death or entry to residential care. Unique assessments for 3,135 older people with both complex and non-complex needs were collected from two health board regions in 2012, together with weekly data on hours of service provision.

The Casemix model for allocating home-care services was developed through the interplay of expert clinical opinion and statistical analysis. For non-complex clients, a total of three main groups were developed, each one further classified into stable and flexible groups. The analysis of the complex clients generated 33 clusters, organised through four “lead” groups comprising eight disability “sub” groups and one lead group without sub groups. A good relationship was found between increasing complexity of client needs capture by the case mix categories and service hours.

A big advantage of the Casemix model is that the categories provide less variability and more consistency within each group, which in turn leads to better alignment of resource to client need and consequently more effective cost management. Each group provides the lens through which care pathways can be developed along best practice principles.

Since its implementation, Casemix has facilitated a more appropriate response to the changing needs of older people. It includes pathways of care tailored to New Zealand settings and to date has been adopted by ten of the largest DHBs effectively covering the majority of the population. Finally, the developed Casemix system has recently been identified by the Ministry of Health as the preferred method of funding home-care services.

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