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Assessment in the HACC Program
Page contents: Introduction | Framework for assessment... | Active Service Model in HACC | Streamlining assessment... | Strengthening assessment | People with dementia and their carers | Short term case management... | Recording via MDS | Download documents
Assessment is the gateway to HACC Services. It establishes the expectations and understandings of the person and their carer and sets up the initial pathway through the service system that best meet their needs.
People seeking HACC services can approach any HACC funded organisation and receive a service specific assessment for the HACC services they provide. This approach – no wrong door – is a key feature of the Victorian health and community care system and is embedded in the philosophy of HACC service delivery. Initial screening will determine if the person is in the HACC target group, and identify the person’s need and priority for the services that the HACC organisation provides. If other needs are identified, the organisation will refer the client on to other service providers that can meet that identified need.
In addition to this, HACC Assessment Services are funded to provide assessments that are broader and more comprehensive. These are called Living at Home Assessments. A Living at Home Assessment takes place, wherever possible in the client’s home and assists people to explore a range of ways to live independently and remain active members of their community. Clients can refer themselves to a HACC Assessment Service or be referred by a GP, health service or community organisation.
The Framework for Assessment in the Home and Community Care Program June 2007 (the Framework) sets out the revised program policy for Assessment as a HACC funded activity. It details the requirements for the delivery of Living at Home Assessments which include home-based holistic assessment of need, care planning and care coordination as key components. The Framework also describes approaches to assessment for specific client groups, such as Access and Support.
The Framework for Assessment in the HACC Program in Victoria replaces Section 7.3 Assessment and Care Management in the Victorian HACC Program Manual.
The first step in implementation of the HACC Assessment Framework was to designate 100 HACC funded organisations as HACC Assessment Services. A mix of local councils, health and community health services, nursing services, Aboriginal community controlled organisations and community service organisations were designated in early 2008. HACC Assessment Services are funded to carry out Living at Home Assessments for HACC eligible clients. A list of designated HACC Assessment Services in each region is available below.
The Active Service Model (ASM) is a quality improvement initiative based on the premise that HACC services should, wherever possible, assist clients to improve their capacity and enable them to live independently at home for as long as possible. Assessment approaches that build on client and carer strengths and abilities with a focus on improving their quality of life, social participation and functional capacity are fundamental to the implementation of the ASM approach.
HACC Assessment Services will be key agents in the implementation of the ASM initiative. Further information can be found in the Active Service Model section of this website.
The Assessment Framework and ASM are built on the premise that organisations need to work collaboratively in order to provide a streamlined approach to assessment and service delivery. HACC assessment services are required to build effective links with key organisations such as ACAS, community health, nursing services and access and support organisations to enable this to happen. Resources to support partnering and streamlined assessment pathways can be found below.
In 2008 funding was made available to six HACC organisations for partnering development pilot projects. The Evaluation of the Partnering Development Pilot Projects focussed on the effectiveness of the different partnering models; the sustainability and transferability of each project; and benefits and outcomes resulting from the partnerships.
Guidelines for Streamlining pathways between ACAS and HACC assessment services 2011 provide recommended referral pathways to ensure that frail older people receive the right assessment at the right time. Triggers for referral to ACAS versus HACC assessment are described.
The following resources have been developed to support consistency of practice in the implementation of Living at Home Assessments.
Two resources have been developed to improve assessment and care planning for people with dementia and their carers.
Strengthening assessment and care planning: Dementia practice guidelines for HACC assessment services 2012 is a companion document to Strengthening assessment and care planning: A guide for HACC assessment services. The Dementia practice guidelines provide a ‘dementia lens’ to assessment and care planning in the HACC program.
A Guide to services for people with dementia and their carers 2012 provides an overview of services across health and aged care that support people with dementia and their carers in the four stages of dementia management.
HACC assessment services in Victoria are funded to provide Living at home assessments and undertake care coordination for a sub-group of people with complex needs and circumstances. In an active service model environment it can be argued that some people will require significantly more time and intensive support to achieve their goals than can be offered through Living at home assessments.
Short term case management (STCM) was piloted in the Victorian HACC program in six HACC assessment services in 2011-2012 to test the proposition that STCM supports the active service model objectives.
The department contracted the Australian Institute for Primary Care & Ageing (AIPCA) to conduct an evaluation of the pilot in 2012. The evaluation of the pilot project showed that STCM had a considerable impact on most clients with 90 per cent achieving some or all of their goals by the end of the 12 week or 30 hour period. This included a significant increase in clients’ functional status in key activities of daily living: housework, transport, shopping and meal preparation.
As a result of the evaluation STCM as a HACC funded activity will be expanded to targeted agencies in subsequent HACC growth funding rounds.
HACC assessment services are expected to use the HACC MDS to record hours of assessment and care coordination and to include this information in the normal quarterly extracts of the MDS.
The HACC MDS Counting Rules for HACC assessment services bulletin provides advice on countable hours for assessment and care coordination. It also provides advice on completing Date of Last Update and Functional Status MDS data items.
Department of Health contacts for further information: