5.1 Overview
This chapter follows from the discussion outlined in Chapter Four and utilises the structure of those findings as the basis for ordering these conclusions and recommendations. These include the YPIRAC Program strengths and challenges, and presents the rationale for a set of recommendations to enhance the future of the Program.
5.2 This review
In the Bilateral Agreements establishing this Program, the Commonwealth, State and Territory Governments agreed that the Mid-Term Review would assess whether the Program is achieving its stated outcomes in respect of the:
- Objectives
- Agreed interim performance targets
- State/Territory specific issues in each Bilateral Agreement.
As set out in the introduction of this report, this Mid-Term Evaluation has taken place within a context of:
- Implementation of the Program commencing at different times in each jurisdiction, due to Bilateral Agreements being concluded within a period between August 2006 and January 2007
- An initial emphasis being placed on the conduct of functional needs assessments of those people in the initial target group, being people aged under 50 years and currently in RAC.
The methodology as outlined in the terms of reference for this review included:
- Liaising with the government departments in each state and territory responsible for implementing the YPIRAC Program, to collect the required information, using existing data sets and reports wherever possible.
- Undertaking an analysis of that information.
- Reviewing the Program against the evaluation criteria as outlined.
The key review questions this Mid-Term Review aims to answer are:
- Were the Bilateral Agreements underpinning the Program designed to allow the objectives for the Program set out by COAG to be met?
- How is the Program being implemented in each State and Territory as set out in Bilateral Agreements, and what are the challenges and issues impacting on the Program?
- To what extent will the funding available to States and Territories meet the demand for support required by the YPIRAC initiative?
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5.3 Limitations of this review
There are two main limitations in the conduct of this review.
5.3.1 Extent to which Program funding will meet demand for support
This Review is unable to draw conclusions regarding the extent that the Program funding available to States and Territories will meet the demand for support required by the YPIRAC initiative.
While Program funding will be sufficient to support the achievement of the number of targeted net reductions as outlined earlier, a significant demand for services for YPIRAC will remain, particularly for clients with very high needs and for those in rural and remote locations. This is largely because the Program has little if any control over the numbers of potential clients of the Program who may be admitted to RAC over its duration.
Furthermore, factors such as the availability of suitable housing, planning and development constraints, overall service system capacity, allocations of and build time for capital works, and staffing availability, are all largely matters outside the control of the Program. The adequacy of funding amounts available for each placement, or to meet each objective cannot be assessed by this Review, as this would require both information not available to the Review team and a different methodology.
We recommend that the assessment of the adequacy of the funding for placement, diversion or enhancing quality of life be addressed at the conclusion of the initial five-years of implementation.
5.3.2 Quality of Life Indicators
It is noted that one of the original Program measures was intended to be the number and percentage of YPIRAC Program clients who report that the new arrangements have enhanced their quality of life.
It is understood that the Social Policy Research Centre (SPRC) was commissioned to identify a tool to measure quality of life outcomes for people involved in the YPIRAC Program. While this report has been informed by the May 2008 draft report from the SPRC, it is understood that to-date, the measurement tool has not been finalised. Quality of life data was therefore unavailable for the Mid-Term Review.
The delay in finalising the measurement tool has prevented the introduction of a standardised approach to gathering qualitative YPIRAC Program data across the jurisdictions.
When referring to Quality of Life outcomes, this Review has adopted the generic definition contained in the SPRC report which states that Quality of Life is influenced by a number of domains including material/financial wellbeing, health, personal relationships and social interactions, feelings of safety and socio/economic factors (social, leisure, workforce and educational participation). It is noted that the SPRC identifies community engagement as one of the key Quality of Life indicators for YPIRAC Program clients.
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5.4 Summary of review findings
While it has been noted that much of the early YPIRAC Program planning made assumptions about the client group, their level of support needs and whether they wanted to move from residential aged care, this mid-term review analysed information and data about the Program and consulted with jurisdictions to provide an analysis of the Program strengths and challenges.
A summary of findings in relation to the key evaluation questions is presented in Table 17.
Table 17 – Summary of review findings
| Key review question |
Summary of Program actual experience |
Summary of mid-term review findings |
| Were the Bilateral Agreements underpinning the Program designed to allow the objectives for the Program set out by COAG to be met? |
- Given the limited evidence available regarding the YPIRAC Program target group, Bilateral Agreements made a number of assumptions regarding Program targets and timeframes based on the best evidence available at the time of the Program inception.
- The inaccuracy of some of these early assumptions, particularly in relation to the levels of YPIRAC client needs, and the cost in providing support services, have created challenges for some jurisdictions.
- A number of jurisdictions have renegotiated their targets and/or the timing of funding to reflect the actual experience in implementing the Program.
- The Department of FaHCSIA has supported the review of targets and funding arrangements as needed.
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- The use of Bilateral Agreements for the Program engages the relevant agencies across levels of government and jurisdictions. They enable high level commitment from participating agencies and ensure that Minsters and relevant department heads are in agreement with the Program and its objectives.
- While it is always a judgement and sometimes an expectation that the means to achieve program objectives are detailed, the inherent flexibility required to meet the complex needs of YPIRAC clients demands an approach which allows each jurisdiction the means to achieve those targets over the life of the Program.
- It may have been more useful to provide overall targets for each jurisdiction, for example to achieve a net-reduction of 200 YPIRAC within five years, rather than specific targets for each PO and for each year of the Program implementation.
- The inclusion of PO3 in the bilateral agreements seems to contradict the Program’s primary focus of relocating YPIRAC or diverting people at risk of entry to RAC. PO3 does not support a net-reduction in YPIRAC.
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- How is the Program being implemented in each State and Territory as set out in Bilateral Agreements, and what are the challenges and issues impacting on the Program?
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In summary Program strengths are:
- Jurisdictions have benefited greatly form the flexibility in the Program design. Jurisdictions have been able to prioritise PO, define target groups and allocate funding to reflect their policy, legislative and service delivery environments. This has allowed for the development of the Program in a different way across jurisdictions – ensuring that Program implementation is efficient and reflective of local structures.
- Some jurisdictions have built on existing government structures and service delivery models to implement the Program in genuine ‘joined-up’ government settings. These approaches reflect the complexity of the Program’s operating environment and the necessary overlaps across the health, disability, housing, community services and aged care portfolios. These are good practice implementation approaches that will support sustainable outcomes for clients beyond the 5 year cycle of the Program.
- Given the complexity of the Program in responding to so many varying individual needs of clients and their families, many jurisdictions have implemented productive partnerships with NGOs who have the expertise and service infrastructure to support the client-group. This has produced efficiencies across the Program.
In summary, Program challenges are:
- The initial five-year funding period for the Program has been reported as a disincentive for participation by some YPIRAC. Similarly, the lack of recurrent funding has required jurisdictions to recruit Program staff on a temporary basis, making staff retention difficult.
- Jurisdictions have identified a shortage of staff experienced in transition planning to assist clients in their relocation from RAC to new accommodation, and to respond to their changing needs (particularly in degenerative illnesses).
- Given the large percentage of clients with ABI and the known importance of an ongoing rehabilitation regime in ensuring enhanced quality of life outcomes, the need for increased Program focus on this area has been identified by some jurisdictions as an important future Program direction.
- Many jurisdictions have invested resources in collating rich bodies of qualitative data regarding the needs and desires of individual Program clients. This investment has allowed the Program to identify and respond to the specific needs of clients and their families extremely successfully.
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- Significant progress has been achieved nationally in providing genuine individualised alternatives to inappropriate admission RAC for younger people with disability in a flexible and tailored service environment. This has been achieved through the development of strategic partnerships across/within governments and with the non-government sector, in a complex service interface between health, housing, aged care, disability, community services.
- Jurisdiction have developed strong informal and information sharing networks across the Program nationally, sharing experiences and resources in an environment of cooperation. This is producing efficiencies across the Program nationally, reducing the likelihood of duplication, and ensuring that solutions to common problems are shared.
In responding to identified Program challenges it is noted that:
- There are a number of good practice strategies adopted by individual jurisdictions that can be further promoted nationally, particularly in responding to the needs of YPIRAC Program clients in regional and/or remote locations. This includes the employment of YPIRAC regional coordinators, and the pooling of funding from a number of programs to create a larger client mass and support the establishment of service infrastructure.
- Clarification regarding Program continuance and exit arrangements for current YPIRAC clients and staff is needed to manage concern regarding the future beyond the initial five-year commitments.
- There is a need for further national Program support and training regarding transition planning.
- There is a need for the YPIRAC Program to ensure that people with ABI and their families continue to have clear access to the health and rehabilitation systems and specialist frameworks that have been designed to promote the wellbeing of this population
- The Program reporting focus, particularly from the perspective of the AIHW, has been on quantitative data. This makes it difficult to demonstrate Program achievements through the rich narratives of qualitative information that have been recorded by jurisdictions. These narratives demonstrate the complexity of the service delivery environment in which the Program is operating, and also provide tangible evidence of the significant positive impact the Program is having on individuals and their quality of life outcomes.
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To what extent will the funding available to States and Territories meet the demand for support required by the YPIRAC initiative? |
- The under 50 years of age target group has been identified as the priority Program target group in most jurisdictions, although YPIRAC terminology also includes the 50-65 years age cohort.
- Initial delays in meeting forecast targets. Some jurisdictions have significantly underperformed in meeting targets for PO1 and PO2 for the initial three years of Program implementation.
- Underperformance can be attributed to delays in understanding the needs of the target group, the development or modification of capital and contacting and/or engaging clients.
- Initial funding allocations in some jurisdictions, underestimated the large number of high need clients, and therefore the costs associated with providing support services.
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- It is expected that the target net reduction nationally will be achieved within the current funding allocation and timeframe.
- Given that in most jurisdiction, 62 per cent of funding is scheduled to be allocated in years four and five of the Program, it is expected that a significant increase in meeting PO targets will take place over this period.
- There is significant unmet need of YPIRAC, both in the under 50 years target group, and particularly the 50-65 years target group. While the Program will make a positive contribution to this previously neglected group, many YPIRAC will continue to have significant needs that cannot be met within current funding allocations. The Program has little control over the clients entering RAC over the life of the Program. This is particularly the case with YPIRAC in regional or remote areas, where the delivery of cost-effective services has been a challenge.
- A comprehensive cost-benefit Program analysis is needed to assess the initial and ongoing cost of the Program under each PO with particular attention to: future costs related to responding to changing client needs, the health and quality of life outcomes for Program clients and their families, and any efficiencies or savings that have resulted from the Program.
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5.5 Short-term implications for YPIRAC Program
Based on the analysis presented in this and the preceding chapters, this Mid-Term Review has identified a number of recommendations to inform the remaining two-years of Program implementation. These are presented below with an accompanying rationale.
5.5.1 Promoting good practice in responding to the needs of YPIRAC clients in regional and remote areas
The Program’s capacity to respond to the needs of YPIRAC in regional and remote areas is limited and has resulted in some clients remaining in RAC due to the lack of appropriate alternatives available locally.
The challenges in supporting YPIRAC in regional or remote locations are best summarised as:
- Availability of existing services in these locations which can cater for the target group.
- Cost-effectiveness of developing new service infrastructure or capital to support a small population.
This Review has noted that many jurisdictions have developed or utilised existing partnerships across government, or in the non-government sector, to support the implementation of the Program in various ways. Specifically in relation to supporting YPIRAC in regional or remote areas, the review has noted that:
- Some jurisdictions have employed regional coordinators to coordinate responses for clients in less centralised locations.
- Funding has been combined with other existing Programs in regional and remote areas to create a more sustainable pool of service delivery for a larger client group. In these, each funding Program contributes a proportion of funding based on their client needs.
In light of the good practice strategies being implemented across some jurisdictions and the challenges faced in others when responding to the needs of regional and remote Program clients, it is recommended that:
- The extent of unmet need of YPIRAC in regional and remote areas be determined in consultation with jurisdictions.
- The feasibility of employing, where appropriate, regional YPIRAC coordinators to support the development of tailored responses to YPIRAC clients, particularly in jurisdictions that are highly decentralised, be explored.
- Jurisdictions which have successfully developed funding pools with existing Programs in regional or remote areas be requested to share their experiences and the processes undertaken in establishing these.
5.5.2 Ensuring that YPIRAC Program clients and staff understand the future of the Program
There is concern by service users and YPIRAC Program staff, regarding the Program continuity beyond its initial five-year period.
Some jurisdictions have highlighted the need to provide clarification to existing and potential service users and staff regarding continuance or exit arrangements for the Program beyond the current five-year commitment. While the uncertainty regarding ongoing funding is inherent in any pilot program, given the high-level needs of clients, it is particularly important that clarification be provided on arrangements for existing Program clients should funding cease.
Jurisdictions reported that the lack of clarification has deterred potential service users from relocating from RAC and been an obstacle to the recruitment and retention of staff.
It is therefore recommended that:
- The Australian Government provide clarification to existing and potential service users and YPIRAC Program staff regarding continuance or exit arrangements for the program beyond the current five year commitment.
- If the Program does not continue beyond the current five-year commitment , recurrent funding is secured to ensure the needs of the current Program clients are met into the future.
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5.5.3 Supporting YPIRAC Program clients and their families through change
The YPIRAC Program client group is highly susceptible to change. It is likely that as conditions degenerate, or, people age, their needs will change and require the review of current service infrastructure. As has been discussed in previous chapters, transition planning has been identified by a number of jurisdictions as an important component of the Program into the future.
Transition planning presents two key challenges for the Program:
- Resourcing - increased client needs may require accommodation modification, increased specialist services or equipment. This will put further pressure on the limited pool of Program resources and funding. Consideration of future Program funding in this context is critical to reduce the likelihood of client re-entry to RAC.
- Skilled workforce – the need for staff to understand the importance and engage in transition planning so that the changing needs of clients and their families can be managed and responded to. Jurisdictions have identified limited community sector-wide experience in providing transition planning support.
Given the likely demand for transition planning support and services by YPIRAC Program clients, and the identified knowledge-gap in the community sector, it is necessary to develop strategies to ensure the Program can respond to the changing needs of clients.
- It is understood that the new National Disability Agreement has incorporated a significant sector-wide training component. In this context, it is also understood that there is scope to influence the national training agenda as part of the Commonwealth State and Territory Disability Agreement (CSTDA), and include transition planning as a sector-wide priority.
It is recommended that:
- Analysis of demographic projections is conducted to forecast the changing needs of YPIRAC Program clients and the resource implications of this over the next decade.
- The Australian Government provide support to YPIRAC Program staff to ensure that they understand and can respond to the transition planning needs of Program clients and their families.
- The provision of transition planning training for organisations and staff delivering services to YPIRAC be identified as a priority in the national training agenda developed as part of the CSTDA.
5.5.4 Analysing the rich narratives and stories that have been collected
While the AIHW NMDS reports provide a useful insight into the characteristics, clinical information and background of clients, the limited qualitative focus is inhibiting the ability to understand at a national Program level:
- The complexity of the Program’s interface between the health, aged care, housing and community services sectors.
- The significant narratives and positive quality of life outcomes for individuals involved in the Program.
Given that many jurisdictions have reported the collection of rich narratives, it would be beneficial for this data to be collated and analysed to enhance the understanding of the Program implementation to date. This would be particularly important to inform the Program evaluation at the five-year period.
It is therefore recommended that:
- In consultation with jurisdictions, a template be developed to support the consistent collection and reporting of qualitative data in the future intake of YPIRAC Program clients. Given that a number of jurisdictions are expecting a dramatic intake increase in years four and five of the Program, the development of this template should be completed as a priority.
- Jurisdictions be requested to forward to FaHCSIA, any particularly significant qualitative data collected to date, and that this be reviewed as part of the final Program evaluation.
5.5.5 Understanding the real cost and benefit of implementing the Program
While it is expected that the desired net reduction in YPIRAC will be achieved within current funding allocations, it is important to establish what the real Program costs, benefits and savings have been.
While it should be relatively easy for jurisdictions to report on the cost of providing services to YPIRAC Program clients under each objective, a much more complex and robust analysis is required to determine whether the diversion or relocation of YPIRAC is producing quality of life outcomes that are manifesting into cost-benefit savings in the treatment of clients.
- The evidence behind the development of this Program, as reflected in literature review, supports the fact that people who live in community settings have better health outcomes than those in RAC. Given this, it is reasonable to expect that this Program will produce a positive cost-benefit outcome for clients, service providers and governments.
It is therefore recommended that a cost-benefit analysis of the Program be commissioned, and that it considers:
- The adequacy of the funding for placement, diversion or enhancing quality of life of YPIRAC Program clients by comparing the level of YPIRAC service demand/need, and the cost of Program implementation.
- The health benefits and quality of life outcomes for people involved in the Program.
It is expected that this analysis will provide an evidence-base for the allocation of future Programfunding and prioritisation of objectives.
5.5.6 Ensuring the Program can respond to the needs of clients with ABI
The analysis in the preceding chapter has identified literature alongside jurisdictional experience that emphasises the benefits for clients with ABI to participate in an ongoing rehabilitation regime. It has also been noted that this is highly specialised, and usually provided in the context of specialised facilities/accommodation.
Jurisdictions have expressed concern that the relocation of YPIRAC Program clients from RAC (PO1) and at times diversions from hospitals as part of PO2, because the client is assessed as being ‘at risk’ of entering RAC, removes clients with ABI prematurely from structured environments that have been established to support their ongoing rehabilitation.
In this context it is recommended that further research into the specific needs of YPIRAC Program clients with ABI be undertaken to identify whether their entry into the Program has been beneficial, and how the Program can best ensure access to the rehabilitation services they require within a community setting
An important component in this assessment will be understanding how different jurisdictions are defining who is ‘at risk’ of entering RAC, and at what point they are recommending that clients with ABI particularly, relocate from hospitals or rehabilitation facilities to the YPIRAC Program. It is understood that there has been limited jurisdictional consistency regarding the definition of the ‘at risk’ target group.
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5.6 Long-term direction for YPIRAC Program
Based on the analysis presented in this and the preceding chapters, this Mid-Term Review has also identified recommendations to inform the Program beyond its initial five-years of implementation should it continue.
5.6.1 Maintaining the Program focus on net-reductions
Reflecting the Program focus, the Bilateral Agreements emphasise the overall Program aim of achieving a net-reduction in the number of YPIRAC.
Despite this primary focus, the Program’s PO3 reflects a focus on enhancing services for YPIRAC who do not relocate. In this context the Program aimed to acknowledge that alternatives cannot always be made available, and therefore the initiative included this option.
Achievements in meeting PO3 to-date, for example, highlight that jurisdictions have invested significantly in this target group. The cumulative target for the 2008-09 period was between 152-193 enhancements. By December 2008, 360 enhancements had been delivered nationally. In considering this data, it is acknowledged that some jurisdictions have reported that they are providing enhancements (PO3) to YPIRAC only in the short-term, until the development or modification of alternate accommodation is finalised for their relocation (PO1).
While the provision of enhancements within RAC can make a significant difference to the quality of life of people of YPIRAC, the focus of PO3 is on how RAC can be made more suitable to YPIRAC. This focus is very different from that of PO1 and PO2 – which concentrate efforts on relocating and/or diverting younger people from RAC.
In order to maintain the primary Program focus on achieving net-reductions in the number of YPIRAC, it may be more appropriate for PO3 to be implemented under a different Program structure. While ensuring outcomes for YPIRAC who do not relocate is important, its inclusion in the YPIRAC Program seems to contradict the foundation of the Program – RAC is an inappropriate accommodation alternative for younger people with disability, and other options should be available.
It is recommended that
- Future YPIRAC Program Bilateral Agreements refer only to the relocation of YPIRAC or diversion of younger people at risk of entry into RAC.
- The provision of enhancements for YPIRAC is continued under a different Program structure.
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5.7 Linking Mid-term review conclusions and key evaluation questions
This Mid-Term Review provides seven recommendations to enhance the implementation of the Program.
The recommendations have been structured to reflect the themes of the key evaluation questions.
Bilateral Agreements.
- See recommendation one regarding the need to provide clarification regarding the Program beyond five years.
- See recommendation two regarding the contradictory focus of PO3 in the current Program structure which prioritises a net-reduction in the number of YPIRAC.
Program strengths and challenges.
- See recommendation three regarding the sharing of good practice strategies to respond to challenges in providing services in regional and remote locations.
- See recommendation four regarding the need to develop strategies to ensure the Program can support transition planning and the changing needs of clients.
- See recommendation five regarding the Program benefits in analysing the rich narratives and qualitative data that have been collected by jurisdictions in assessing the needs of individual clients.
- See recommendation six regarding the assessment of the needs of Program clients with ABI and how the Program is responding to these.
Program funding and resourcing.
- See recommendation seven regarding the conduct of a cost-benefit analysis to assess the adequacy of Program funding in meeting the needs of the YPIRAC client group and assessing the Program’s value-for-money.