By Dr Y. Gavriel Ansara, National LGBTI Health Alliance
Gávi is a member of the NACA Home Care CDC Working Group and the COTA National CDC Project Consultation Group.
The shift in the Australian aged care sector to a Consumer-Directed Care (CDC) model, which is based on a ‘self-directed’ or ‘person-directed’ approach, has been a key component of the Commonwealth Living Longer Living Better (LLLB) aged care reform initiatives to promote healthy ageing and improved health outcomes. From 1 August 2013, all new Home Care Packages (including all of the packages allocated to providers in the 2012-13 Aged Care Approvals Round) have been required to provide services on a CDC basis. From July 2015, following two years of close monitoring and trialling of these packages, all Home Care Packages will operate on a CDC basis.
The concept of “person-centred” care stems from Rogerian psychotherapy. The person-centred care approach in aged care and dementia services has been a response to complaints that the one-size-fits-all approach of previous care models was often experienced as dehumanising and failed to consider people’s own understanding of their health needs and experiences. Until the recent aged care reforms, many Australian aged care service providers aimed to use a person-centred approach to service delivery.
Consumer-Directed Care (CDC)
In Consumer-Directed Care (CDC), also known as ‘self-directed’ or ‘person-directed’ care, older people have authority for making care-related decisions about their own lives, to the extent that they desire and are able to do so. This means that older people who receive CDC can make a variety of care decisions that have historically been decided by care providers.
Consumer-Directed Care (CDC) vs. Person-Centred Care
- Some Key Similarities
These two approaches share some common aspects:
Unlike some older models of aged care that rely mainly on determinations made by clinicians and service providers, both of these ways of delivering services aim to consider people’s own wishes.
Both person-centred and person-directed care models treat people’s own understanding of their health needs as important, regardless of whether they may have dementia or disability labels. In both models, people are viewed as individuals with their own social and relationship experiences, and both models strive to make care decisions based on an assessment of the person’s own perspective.
- Some Key Differences
There are some important differences between person-centred and person-directed care perspectives on choice, decision-making, and autonomy. In a person-centred care approach, decisions are typically made by clinicians and service providers, whose decisions are based on their interpretation of what older people want. In this model, an aged care staff team might consider an older person’s self-reported needs, but the authority for care decisions resides with the staff team.
In contrast, a person-directed approach aims to identify and provide the assistance needed to enable people to make their own decisions about their care. In this model, clinicians and service providers might contribute their professional expertise and guidance as part of the decision-making process, but the older person would have the final say over decisions about their care.
Due to the greater control that older people can choose to exercise over their care in a person-directed approach, the CDC model places much greater emphasis on improving older people’s health literacy, a term that describes a person’s knowledge and understanding of their own health issues, needs, and treatment options. In the case of someone with cognitive impairment due to dementia or illness, the service provider team might focus on identifying ways to help the person make their own decisions within their cognitive limitations.
A CDC approach respects the right of people with cognitive impairment to make decisions about their care to the greatest extent possible. It is important to remember that CDC does not impose control over care decisions on older people who do not want this responsibility. An older person who receives CDC can choose to delegate decision-making authority in some or all aspects of their care to particular individuals on a temporary or ongoing basis.
Whereas a person-centred approach asks providers to adopt the perspective of the older person when making care decisions, a person-directed approach allows an older person to represent themselves directly rather than in an indirect way that is filtered by the subjective interpretations of their care providers.
Although both approaches aim to increase the amount of control that older people have over their lives, the person-directed approach provides older people with greater autonomy.
How CDC can benefit older LGBTI people
The CDC approach represents significant changes to cultural views about ageing and aged care. Instead of asking older people to select choices from a list of services that have been pre-determined by service providers, the CDC approach strives to enable older people to write their own menu for how they want to manage their lives. Older people can then identify their own goals for their care outcomes and get assistance to achieve their desired level of independence. These goals will serve as the foundation for Home Care Agreements and care plans. This approach can increase LGBTI inclusion by including LGBTI-specific care needs that may not have been addressed or included in the previous list of care options.
Example: A woman of trans experience may request in-home intimate care services for grooming or vaginal dilation. A man of trans experience might request help at home with personal care help to bind his chest.
CDC also promotes healthy ageing beyond the limited framework of service delivery. CDC involves working with older people to achieve their desired level of participation in civic and community activities whenever possible. This engagement may be particularly important for older LGBTI people, who may require support services to continue participation in community activities and social support networks related to their sexuality, relationship, gender identity, or intersex status. Thus CDC can facilitate the ongoing work of older LGBTI people in activism and social change efforts. CDC can also reduce social isolation.
Example: A gay man who is active in drag culture may request assistance with transportation and grooming to facilitate his attendance at weekly drag shows. A same-gender couple request assistance with preparing a date night to celebrate their anniversary.
Whereas the person-centred model relied on providers to understand people’s potential needs well enough to make decisions on their behalf, the person-directed model places control over the care menu in the hands of LGBTI people. This means that older LGBTI people will have more opportunities than ever before to address some of their LGBTI-related needs that have often been invisible or unaddressed.
The CDC approach promotes flexible and responsive aged care services that allow for smooth transitions between higher and lower levels of care. This framework is based on an acknowledgement that older people are entitled to individualised care and support services and that people should be able to choose the extent to which they are able and willing to decide the types of care services with which they wish to engage, the manner in which services will be delivered, the characteristics of carers who will deliver these services, and the timing and frequency of these services.
Example: An older lesbian could request a woman care provider or even ask for a lesbian carer. An intersex person might ask for a community visitor from an intersex organisation.
Under CDC, LGBTI people have the right to make requests that address their LGBTI-related needs. Although many providers may not yet have the resources or LGBTI community links to provide these services, these requests will create better dialogue between older people engaging with services and their service providers. The identification of these needs in CDC could lead to more inclusive services and resource allocation in the future.
For older LGBTI people, if you are receiving packages from a provider whom you feel is not supportive to your LGBTI-related needs, you are entitled request to have services delivered by another provider instead.
As this new model is implemented, it will be important to make sure that older people are aware of their new rights and options, that aged care services train staff to provide CDC, and that organisational policies and practices are updated to comply with a CDC approach. It is important to note that CDC is a significant step but not an endpoint in the process of aged care reforms.