Timeliness of access to aged care services in Australia

This technical note section accompanies the web report Timeliness of access to aged care services in Australia. The report describes the results of analyses examining elapsed time between approval for an aged care service and receipt of that service. Analysis of elapsed time for the Commonwealth Home Support Programme (CHSP, referred to in this report as ‘home support’) was excluded because the focus of this analysis is on individuals with higher care needs – Home Care Packages program or permanent residential aged care. These higher-level services are assessed and approved through comprehensive assessments for aged care services. However, home support is included in the analysis as an alternative service that people may use while waiting for entry to home care or residential aged care services at their approved level.

The technical notes outlines the data sources, analysis techniques and variables used to investigate elapsed time between first approval for aged care services (a home care package, permanent residential aged care, or both) and receipt of the approved service for those approved in the 2019–20 financial year. Supplementary tables and charts are provided which elaborate on analyses from the main report.

About the data sources

This analysis uses the Pathways in Aged Care (PIAC) 2022 link map and an additional data set ‘assigned home care package’ from the Aged Care Management Payment System (ACMPS, referred to in this report as ‘the payment system’).

The PIAC link map brings together information, from different aged care data sources, about the same person. This is achieved using privacy-preserving linkage techniques that assign a unique identifier for each person in each data source. The PIAC link map is a set of links to all aged care records for each person. This allows us to construct a chronological sequence of aged care events and present a more complete picture of aged care use, all the way from assessment and admission through to discharge and death.

The PIAC 2022 link map was used to create the following analysis data sets:

1. A recipient table with demographic data for each person
2. An events table, including data collected during aged care assessments, data about service use (including entry and exit dates where available), and deaths
3. A services table describing organisations providing aged care.

These tables are populated with data from:

• The National Aged Care Data Clearinghouse (NACDC, referred to in this report as ‘the data clearinghouse’), including aged care assessment data and aged care service use
• The National Death Index (NDI), including date and causes of death.

For more information about the PIAC link map, see the Pathways in Aged Care 2020: Technical Guide.

‘Assigned home care package’ data from the Aged Care Management Payment System

In 2017–18, the Home Care Packages Program was reformed so that the package would follow the person, rather than allocating places to care providers. As a result, providers were no longer required to report the actual date when care recipients received their package level. While the data capturing these changes existed for funding purpose in Aged Care Management Payment System, it was not initially included in the PIAC 2022 link map. It now has been updated through an additional dataset on ‘assigned home care package’ sourced from the payment system provided by the Department of Health and Aged Care. This publication’s reporting reflects the new data. All changes in home care package levels were recorded and reflected in this dataset.

It should be noted that the date of receipt for a first home care package or a change in home care package level in ‘assigned home care package’ data from the payment system is based on the date when the provider was funded to deliver that level of care (recorded as the ‘effective date’). It is likely that the person started receiving the home care service at any package level at a later date. This effective date was used as the best available proxy for the actual date of receiving a home care package. Therefore, all information on home care package events in the events table of the PIAC 2022 link map – sourced from the data clearinghouse – was replaced by the ‘assigned home care package’ records from the payment system.

Aged care assessment data

Assessment data used for this project were collected using the National Screening and Assessment Form (NSAF) – part of the data clearinghouse. The NSAF captures demographic factors and care needs at the time of assessment for aged care services. The data also includes approval outcomes, indicating which services the person is approved for, the date of approval, and the level of their approved service.

This report only focuses on comprehensive assessment approvals for a home care package and/or permanent residential aged care.

Aged care service use data

The National Aged Care Data Clearinghouse records episodes of aged care service use including for home support (CHSP and Home and Community Care), home care packages, permanent and respite (i.e. temporary) residential aged care, transition care, and short-term restorative care. For this report, data sourced from the clearinghouse included the start (entry) date of the service (where available) and the service type (including home care package level). For more information about the data clearinghouse, see National Aged Care Data Clearinghouse: User guide.

All information on home care package events in the events table of the PIAC 2022 link map, originally sourced from the data clearinghouse, was replaced by records from the ‘assigned home care package’ data sourced from the payment system.

Deaths data

The National Death Index (NDI) is a database developed and maintained by the Australian Institute of Health and Welfare (AIHW). The NDI contains person-level records of the date of all deaths occurring in Australia since 1980 obtained from the Registrars of Births, Deaths and Marriage in each state and territory. The NDI records are supplemented with cause of death information using data linkage with the National Mortality Database.

More information about the NDI can be found on the Australian Institute of Health and Welfare website.

About the analysis design

This was a longitudinal cohort analysis examining outcomes after approval for aged care services in 2019–20. The PIAC 2022 link map and the ‘assigned home care package’ data sourced from the payment system were used to analyse the pathways of these people to determine whether they had received the approved service, or alternative services, in the time up to and including 30 June 2022 (the follow-up period).

Descriptive statistics were used to determine how many people received their approved aged care service (a home care package and/or permanent residential aged care) in the follow-up period. Time-to-event analysis was used to examine the demographic and clinical factors associated with elapsed time between approval for a service and receipt of that service. As there are other events that can happen instead of receiving an approved service, competing-risks regression was used for this analysis.

Analysis was undertaken in three stages, outlined below.

Stage 1: Establishing the cohort of interest

Assessment data were taken from the NSAF, with the cohort of interest being anyone who had their first comprehensive assessment between 1 July 2019 and 30 June 2020, and who were approved for a home care package, permanent residential aged care only, or both during that assessment. A person’s comprehensive assessment was flagged as their first if they did not have a record of a prior comprehensive assessment between 1 July 1997 and 30 June 2019.

Stage 2: Assigning people in the cohort to an aged care service use outcome

Data from the clearinghouse, National Death Index, and ‘assigned home care package’ data sourced from the payment system were used to determine the pathways of people after their aged care approval, including the aged care services they ended up using and whether they had died without receiving an approved service, or died without receiving any interim service.

For a descriptive analysis of aged care service use outcomes after an approval for aged care services, aged care service outcomes were grouped into 7 mutually exclusive categories (that is, each individual was coded with only one outcome), and were assessed in order from 1 to 7. Aged care service use outcomes were identified using service use and deaths data between time of first comprehensive assessment (during 2019–2020) and 30 June 2022 for each individual in the cohort.

The aged care service use outcomes include:

1. Received the approved service at the approved level
2. Received an ‘interim’ home care package.¹An ‘interim’ home care package was defined as:
   1. lower-level home care package than was approved for individuals approved for ‘a home care package only’
   2. any home care package for individuals approved for ‘permanent residential aged care only’ (they must have undertaken a further comprehensive assessment to receive approval for a home care package)
   3. lower-level home care package than was approved for individuals approved for ‘both a home care package and permanent residential aged care’.
3. Entered permanent residential aged care without receiving a home care package. This outcome was only assessed for people initially approved for ‘a home care package only’ (they must have undertaken a further comprehensive assessment to receive approval for permanent residential aged care).
4. Received home support but no home care package or permanent residential aged care
5. Died without receiving a home care package, permanent residential aged care, or home support
6. Alive at 30 June 2022 without receiving a home care package, permanent residential aged care, or home support, but had a further comprehensive assessment
7. Alive at 30 June 2022 without receiving a home care package, permanent residential aged care, home support, or a further comprehensive assessment (timed out).

1 Since May 2022 interim packages have not been allocated. This is because during 2021–22 and 2022–23 an additional 80,000 home care packages were released and wait times reduced to a point where interim packages were not required.

Further information on the aged care service use outcomes for each aged care approval group is available in Table 1.

Descriptive statistics were analysed to determine how many people received their approved aged care service or any other aged care service use outcomes within the follow-up period.

*Home support includes receipt of services through the Commonwealth Home Support Programme and its pre-2015 predecessor Home and Community Care (HACC).

Outcome 1 represents receiving the approved care service. Outcomes 1–4 represent receiving any care service (does not include informal care or other care types, such as transition care, short-term restorative care, multi-purpose services, and National Aboriginal and Torres Strait Islander Flexible Aged Care program).

Stage 3: Measuring elapsed time

Median elapsed times to receipt of approved service

Elapsed time between aged care assessment and outcomes were analysed with median elapsed time reported for aged care service use outcome 1 – received the approved service at the approved level. The elapsed time was defined as the number of days from approval for a service to receipt of that service at the approved level, and months is calculated by dividing the number of days by 30.4. Median elapsed time is the length of time that falls in the middle of all elapsed times for each approval group in aged care service use outcome 1 (received the approved service at the approved level), dividing the group into two equal halves – half of the group had shorter elapsed time and half had longer elapsed time.

Many people approved for aged care services in the 2019–20 did not receive their approved aged care service but instead received an interim package, home support, a further comprehensive assessment, or died. None of these people were included the calculation of the median elapsed times.

Time-to-event analysis

For the analysis of factors related to elapsed time to approved care, other events that occur that would preclude the person from receiving their approved care are referred to as ‘competing risk events’ (see Table 2). Time-to‑event analysis was undertaken using a competing-risks regression approach which factors in all competing outcomes. Competing-risks regression (Fine and Gray 1999) produces subdistribution hazard ratios or ‘hazard rate ratios’. These ratios are similar to the hazard ratios estimated in a Cox regression, which measure the impact of a variable on the time to an event occurring. Subdistribution hazard ratios estimate the effect of certain variables in the presence of competing risk events.

In the context of this report, where the outcome of interest (receiving a care service at the approved level) is a positive outcome (rather than a ‘hazard’) coefficients are referred to in this report as 'event rate ratios’ instead of ‘hazard rate ratios’ or ‘hazard ratios’.

For the analysis of the group approved for ‘permanent residential aged care only’ and for ‘both a home care package and permanent residential aged care’, the competing event was death.

For the analysis of the group approved for ‘a home care package only’, the competing events were death and entry into permanent residential aged care. Although there are a few exceptional cases where individuals admitted to permanent residential aged care may leave the service and receive home care, for the vast majority of cases and for almost all practical purposes, entry into residential aged care precludes the home care package outcome from occurring.

All results presented in the report are from multivariate modelling including (and controlling for) all variables in the model. Individuals were removed from the analysis where they had one or more missing data points (1.1% for those approved for ‘a home care package only’, 2.7% for those approved for ‘permanent residential aged care only’, and 1.5% for those approved for ‘both a home care package and permanent residential aged care’).

Variables used in the analysis

Table 3 describes the variables used for this analysis.

MMM: Modified Monash Model; NSAF: National Screening and Assessment Form; PPN: project-specific person number

Assessment of bias/limitations

The results of the analysis should be interpreted in the context of important methodological and data limitations.

• The National Aged Care Data Clearinghouse data are collected through information and payment systems operated by the Department of Health and Aged Care, Services Australia and the Department of Social Services. The AIHW has limited capacity to independently validate data quality.
• Data included in the data clearinghouse is for government-funded aged care programs only so some service use is not included in analysis, including privately funded in-home care or retirement villages, so some service use is not captured in our analysis.
• Demographic and clinical characteristics collected at the time of assessment may change between the assessment and the receipt of service or during program use.
• This analysis reports on the overall elapsed time from approval for a service to receipt of the service at the approved level. The data do not allow for examination of the reasons for waiting. There are many reasons for an elapsed time between approval for an aged care service and receipt of that service, including, for example, waiting for a service to become available, organising financial arrangements necessary to accept care, or choosing not to accept care when it is offered. An individual may also be receiving services outside the scope of the PIAC 2022 link map, which cannot be included in this analysis.
• All changes in home care package levels are recorded and reflected in the ‘assigned home care package’ data from the Aged Care Management Payment System. However, it is not entirely clear whether the date of receipt of the first home care package or a change in home care package level is the same as the home care package level change ‘effective date’ – the date when the provider was funded to deliver that level of care. Delays may continue to occur at the provider level. Since no additional data is available, the effective date is used as the best available estimate for the actual date of receiving a home care package.
• The PIAC link map included aged care data up to 30 June 2022. We are therefore unable to examine outcomes that occurred after this date, including the impact of policy and services changes that have occurred since this time.