The Community Based Support programme provides a range of services such as home help, home care packages, meals-on-wheels and day respite care. These supports are either provided directly by the HSE or in partnership with non-statutory agencies.
14.4.1 Rationale, Objective and Continuing Relevance
Community based supports are a key component in the overall strategic provision of health and personal social services. In particular, they impact positively on acute hospital delayed discharges, and are part of the wider primary care multi-disciplinary provision. Such supports also complement the wider Strategy for Older People, including separate services provided by other Departments and agencies to older people (e.g. housing, transport, social inclusion, etc)
It is estimated that, overall, in the region of 100,000 vulnerable older people (around 20%
of the >65 national cohort) receive some form of community based supports annually from the State. A recent Department evaluation indicated that the majority (77%) of home care package recipients are over age 75, and around 40% are over age 85. Most are female (63%) and 89% of all recipients have a medical card. The service is expected to become more essential given the changing demographics and capacity limitations in the long-term care and acute hospital systems and is a fundamental component in ensuring integrated service delivery.
The key objectives of the programme are:
• To provide the appropriate level of community supports required in order to assist in achieving the target of 95% of older people living at home and in their communities rather than in acute or long term care.
• To reduce inappropriate admission to acute hospitals and admission to residential care earlier that might be required among the over 65s.
The Programme for National Recovery 2011–2016 (p. 36) committed to further develop services for older people in the community.
14.4.2 Programme Effectiveness
The objective of supporting older people to remain at home is being largely achieved, with 95% of over 65s living in their own homes. This has been facilitated through the expansion of the mainstream home help service and the introduction of home care packages. Delayed discharge data suggests that very few people are awaiting home care packages/home help and, despite reductions in overall acute bed numbers, delayed discharges have not risen.
This indicates that applications for such support are being processed quickly.
No specific benchmark measures exist to compare performance with that in other countries.
However, the services have been the subject of limited peer review at EU level with Ireland generally comparing favourably with similar jurisdictions in such reviews.
14.4.3 Programme Efficiency
The level of expenditure associated with Community Based Supports has increased between 2006 and 2011, particularly in the area of home care packages. The tables below set out the trend in expenditure in relation to two key elements of community support.
Table 14.3: Trend in Expenditure - Home Help Services 2006-2011 2006
(€m)
2007 (€m)
2008 (€m)
2009 (€m)
2010 (€m)
2011 (€m) (Target)
Total Expenditure 185 206 211 211 211 211
Table 14.4: Trend in Expenditure - Home Care Packages 2006-2011
Total Expenditure 55 110 120 120 130 138
The HSE Service Plan indicates WTEs for Services for Older People overall but does not differentiate community based services from other services. However, the Department is aware that approx 300 of 370 WTEs approved for the HCP Scheme were filled and that there are approx. 4,000 WTE posts equating to some 10,000 Home Helps/Home Care Assistants in the system.
The outputs associated with home help services and home care packages have increased in line with increased expenditure and are set out below:
Table 14.5: Trend in Outputs - Home Help Service Outputs 2006 - 2011
Activity 2006 2007 2008 2009 2010 2011
(Target)
Hours provided (million) 10.80 11.78 11.96 11.97 11.68 11.98
No. of clients benefiting at 31 Dec each
year 49,578 54,736 55,366 53,791 54,011 54,500
Table 14.6: Trend in Outputs - Home Care Packages 2006 - 2011
Activity/Funding 2006 2007 2008 2009 2010 2011
(Target)
The Department, in conjunction with the HSE, has initiated various improvements relating to community based service provision. Arising from an independent Evaluation of HCPs, published by the Department in December 2009, the HSE has progressed new guidelines relating to (i) Home Help, (ii) Home Care Packages, and (iii) Quality for Home Care services. In addition, the HSE has recently initiated a new Procurement Framework for Home Care services. The purpose of these measures is to promote quality and safety and also promote a more standardised and cost effective approach to provision nationally, whether direct by the HSE, or those providing services on its behalf. It is anticipated that any savings generated would be used to fill unmet need in view of increasing demographic pressures. It should be noted that the Department evaluation, which was limited in nature, recommended that, in addition to the above initiatives, a VFM assessment be undertaken.
The focus since then has been to progress the various initiatives outlined above. The question of possible regulation of these services is also being progressed. The VFM Study is scheduled to commence in 2012.
Performance management improvements have been agreed recently in the context of the overall corporate development of performance indicators and metadata. Also, the various operational initiatives indicated above are intended to strengthen performance measurement across these community based services to inform policy and service developments in the future. In particular, a clearer definition between mainstream and enhanced service (ie between Home Help and HCP recipients), on a standardised basis nationally, will lead to
improvements in the areas of governance, operational delivery, performance management, and funding.
The HSE has recently identified the potential for improved efficiency in community supports for older people with the publication of a report on the use of Assistive Technology for Older People. It is intended that the potential to maximise such technology across all HSE community services as appropriate, involving possible partnership arrangements with the private sector, will be progressed.
The Department and HSE are also considering the changes in delivery mechanisms as part of progressing on-going operational improvements. This includes examining the extent of future potential private sector involvement when the Procurement Framework is finalised later this year. This may facilitate a reduction in WTEs associated with the programme. A March 2009 FÁS Study (through HR) by J. Behan et al. drew attention to the notably older age of home help employees, compared with the average age of people in employment.
Therefore, a significant proportion of HSE home help employees are consequently likely to be approaching retirement age, and the non-filling of retirement-related vacancies would contribute to a reduction in WTEs. Any such outsourcing (e.g. Home Help) may yet involve Croke Park though it will not be possible to make a clear decision until the current HSE procurement process is completed.
The McCarthy Report (2009) proposed charges for HCPs. This would involve considerable practical and resource implications at present for the HSE. The question of charges is being examined by the Department in the wider context of eligibility for community based services for older people.
14.4.4 Conclusions
Without the Community Supports for Older People programme, many older people would experience inappropriate admission to acute hospitals or would be admitted to residential care earlier that might be required. This is a cost effective and socially desirable service that will be increasingly needed in the future, both from an individual recipient and systems wide perspective. The importance attached to community based supports is reflected in the additional funding provided in recent Budgets (despite reduced funding across the system).
The key reforms to be achieved under this programme in the period ahead are:
• Greater consistency in needs assessment and monitoring across the country to ensure that limited resources are deployed equitably based upon client need.
• Closer integration between assessment and entitlement for community support and nursing home care (ie Fair Deal) at both the policy and operational levels to ensure that older people are supported in the most appropriate setting.