The Tweed Transitional Aged Care Service has been operational since January 2006. Brokerage funds have been used to provide personal care assistance to the clients on the program. This expenditure has been found to be costly to the service, and the brokered service delivery focussed on maintenance of personal care status, instead of the retraining of these skills. In order to better manage the financial resources, and the needs of the clients, two AIN's were employed to provide a personal care service. Evaluation of this new service has shown cost efficiencies and additional service provision for the Transitional Aged Care Service, while maintaining service delivery to the clients.

The project aim was to:

• Implement a strategy to manage the brokerage costs of the TACS service more effectively to ensure financial sustainability.
• Increase flexibility of service provision for alternative models of care.

The Tweed Transitional Aged Care Service (TACS) provides short-term therapy, home support and case management for older clients post discharge from hospital. The TACS service is individualised for each client and aims to improve client functioning in the areas of physical and cognitive functioning and psychosocial adjustment (Transitional Aged Care Program Guidelines, 2005). Brokerage funds are utilised to purchase a range of services from external agencies, such as domestic help, personal care, shopping and transport. This practice was not cost effective.

The brokerage of personal care assistance was found to have negative impacts on the TACS program, for two main reasons:

1. Brokered personal care services were calculated to have cost TACS approximately $31 000 per annum. Hourly rates of brokered personal care services cost significantly more than if a similar designated position was employed by TACS to undertake this role.
2. The TACS team has had little control over type/level of personal care being provided, and little feedback from service providers into client's problems and improvements. This also results in a conflict of interest as Brokered services rely on an ongoing client group, and therefore may not facilitate the client to develop independence in personal care tasks. This is in contrast to the primary function of TACS, which aims to improve the functional independence and safety of the clients, and potentially limits the needs for ongoing support services in the community. This has resulted in difficulties for the Occupational Therapists in directing and monitoring of the personal care retraining programs, and therefore the functional improvements of the clients.

This project relates primarily to the NSW Health & NCAHS strategic directions, namely:

• Make smart choices about the costs and benefits of health services.
• Create better experiences for people using health services.

In particular the employment of AIN's will build capacity in the existing workforce by better utilising existing funding to provide a superior service to TACS clients (ie- same service for less money/hour and/or additional service availability for the same amount / annum) and potentially allow flexibility in service provision for inpatients awaiting discharge from The Tweed Hospital.

The planning and implementing of the AIN service was conducted through:

1. Team members identified issues relating to the amounts per hour being charged by brokered services for personal care (in particular weekends and public holidays). The Occupational Therapists also highlighted ongoing difficulties in improving a client's performance due to the limited control over personal care retraining.
2. Costings of the different models of personal care assistance, ie: Brokerage versus employment of Assistants in Nursing (AIN) were completed, which potentially demonstrated a significant cost savings via the employment of own AIN staff, instead of the continued practice of utilising brokered services.

3. Consultation with the key members in the TACS team, the Tweed Community Health Nursing Unit Manager, Transitional Aged Care Service Manager and the Tweed/Byron Community and Allied Health Manager.
4. A brief was written for NCAHS Executive approval for the employment of two part-time Assistants in Nursing for the Tweed TACS service. Approval gained in late 2007.

Two AIN staff were appointed to the Transitional Aged Care Service.  A snapshot audit of AIN occasions of service was conducted to capture the activity of the new AIN staff. Details are provided below:

AIN activity during this snapshot period was 138 occasions of service in 87.2 contact hours. Wages for this time period were approximately $2955.20 (based on 4 hours per day, for 33 weekdays at $16.60 p/h, and 7 Saturdays at $27.32 p/h).

If the AIN service had not been in place for this time period, the following costs would have been incurred:

This equates to a cost for the AIN’s of $33.89 per client contact hour, compared to a cost of $41.04 per client contact hour for brokered services.  This represents a saving of $7.15 per client contact hour by using NCAHS employed AIN's.

Similarly, this resulted in AIN's completing 138 occasions of service within 87 hrs of client contact. If this was completed by a brokered service, only 87 occasions of service would have been completed due to the current minimum hourly charge rates of local brokered services.  Therefore, by using NCAHS employed AIN's, this resulted in gaining an additional 51 occasions of service in the audited time frame, with a small cost savings to the NCAHS of $623.50. If these savings were continued across the financial year this would equate to 380 additional occasions of service per annum with a savings of approximately $4632.00.

Functional improvements of clients have also been noted since the introduction of the AIN service. The Modified Barthel Index (MBI) is 100 point functional assessment tool which evaluates a patient’s level of independence in self care tasks. Initial and discharge MBI scores are collected on every patient. A snapshot of these scores highlights there has been a slight improvement in the clients’ functional status since the introduction of this new service.

Average improvement in scores between initial and discharge MBI scores:

• Pre AIN Service: = 9.3 points (n=17)
• Since commencement of AIN service = 12.8 points (n=15)

A data collection process has been implemented which will inform our regular audit process. Further to this, more comprehensive data regarding client outcomes in self care tasks (Modified Barthel Scores) is being captured.

A system of supervision, accountability and delegation to the AIN's is in place with the Registered Nurse and communication systems exist with the Occupational Therapist to ensure the client-centred therapy programs are implemented and reviewed.

At this time AIN's are available for 24 hrs per week (6 days / week service) in a limited geographic area of NSW surrounding The Tweed Hospital (TTH). Clients/patients of the Murwillumbah District Hospital or those residing outside the limited TTH catchment area are not able to receive personal hygiene/care post discharge. An opportunity exists for the AIN service to be expanded to offer a short term personal care service to these clients. Additional permanent appointment of AIN’s would provide a superior service to clients/patients and potentially allow flexibility in service provision for inpatients awaiting discharge from TTH and MDH.

• North Coast Area Health Service, 2007. A New Direction for North Coast: Health Service Strategic Plan Towards 2010, Lismore.
• Transitional Aged Care Program Guidelines, 2005. Australian Government Department of Health and Ageing.