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Reflections on the transformation of agencies in a Consumer Directed Care (CDC) environment

Jane Sherwin, Sherwin & Associates www.sherwinconsulting.com.au

These thoughts have emerged from work over the past three years with Managers, Coordinators and Senior Support workers from a number of agencies who work with older people in their homes. It is also based on many years of work in the lives of people with disabilities. I hope it is of some help to your own thinking.

‘If you ask an elderly person where they think they might be in 5 years time, the majority of them will probably answer with - hopefully still living in my own home. This to me is what makes the CDC so important, it gives these people the opportunity to do so but in a way that is more beneficial to them and they have more say and more control over what happens in order to achieve this. It will therefore enable people to stay at home longer with the right care and home support that will suit them. It may also increase that person’s quality of life.’

(from a participant in a CDC transformation initiative)

What I love about this quote is that it paints the picture of the intention of CDC: better lives for older people through the right sort of help. In the early stages of a transformation process, many workers know that ‘something’ needs to be different. It seems to me that many of the ‘somethings’ often focus on the business end of a service. For example, for some agencies the pursuit is of the ‘best’ computer-based financial system. Yes it is true that there are implications for finance systems, however CDC is more than a new funding process. For others, there is concern that, without increased marketing, their long-term viability will be threatened since people will have more choice. For others, it is an awareness that the ‘assessments’ and conversations need to be different.

My own experience is that the crucial transformation points are in the hearts, minds and practices of the management and key leaders of an agency. Unless there are changes in the design of service responses and in the nature of the relationship between server and served, CDC will be little more than a business opportunity and the potential of CDC in the lives of older people will be squandered.

The intention of transformation work is to:

(i) enable key staff to have future oriented conversations and capacity building conversations, that …

(ii) … create a power-with relationship between server and served,

(iii) and that reinforces the natural authority of each older person, so that it is possible to …

(iv) … build the capacity of themselves and their unpaid allies to:

a. make arrangements for a meaningful home and community life that is sustainable even when dependency is high and

b. engage in a power-with relationship with a service to design and deliver the assistance that is needed.

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A recent transformation project consisted of two stages. The first stage equipped key staff to be able to design (which is more than ‘planning’) a set of responses to the needs of an older person, which would enable them to lead a fulfilling life. This helps with the transformation from a menu based service. The second stage focused on exploring and refining the ways that individual staff enacted their relationships with older people. The following is a very brief summary of three of the key transformation ‘pivots’: in perceptions, in thinking and in designing/planning that is transacted through new forms of relationships.

Help key staff perceive older people differently

Shifts in perceptions of older people are key. For example, one participant described learning about ‘the essence of a person’. This picked up the theme of the importance of understanding the fundamental needs of each older person, which can only come from appreciating the identity of the person beyond their deficits. Another participant reflected on the shifts in perception from a deficit based orientation to an orientation where there is a perception that older people have potential and a life to live and that that is possible if their needs are met well.

Help key staff think differently

Ideally, in order to embed personalised responses, transformations of vision (that is, what is thought possible), mindsets towards clients and about the role of service, the theoretical base and the practice base are required.

One participant said, ‘My role has and will change quite a lot. We won’t be going in telling a client what they can have and we will be more involved in the assessment process than we have been so far. I will be working alongside that person in a [power with] relationship (partnership between the service provider and the person) instead of a [power over] relationship which is mainly how it works now. I will be working with that person to work out what they need, and working out the best way to meet those needs. That does not necessarily have to be from a service provider and we can work together to see who else can be involved in this. We will be having more conversations with these people to gather information instead of just going in and putting services in place as recommended by ACAT or other. Part of the process is discovering ways of improving the person’s situation. We will then, as a result of our information gathering, along with the person, work out the priority of their needs and how best to meet each need - be it by the person themselves - by others or by service providers. We will be helping the person decide about the things that matter to them and having control over the right things in their own life. Each person is an individual and this means that their needs will be specific to them.’

Help key staff design responses based on what needs must be met in order for the older person to have a good home and community life that enables them to stay at home

An observation that I make is that services have been so used to providing options from a menu (personal care, domestic care, gardening and so on), that it requires a new theoretical framework to help CDC implementation be as fruitful as possible. It requires a move away from deficit thinking, menus and the assumption that only paid support by a formal service can meet people’s needs.

One participant accurately provided a summary, ‘Ultimately the goal of consumer directive control is to enable service users to craft better lives and reduce dependency on services.’ This was illustrated by another participant who, in the

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course of the project, developed a diagram depicting a ‘discovery’ (of the older person’s identity, vision and needs) phase. The diagram of the subsequent design phase was of a ‘bucket’ of resources included the wisdom, knowledge and experiences of the older person, as well as resources such as those from the family, neighbours and friends. Financial resources were seen to be simply one element in this ‘bucket’. In addition, the advice and expertise from service workers are one legitimate and important resource.

Another observation is that many services take the position that moving into a residential environment is inevitable. I suggest that it is possible to do good forward planning and to put safeguards in place so that the fracturing of relationships and with the home environment less likely or, at least, minimised. This is less possible if a service is offering a menu-based design process and more possible if designing person-by-person in a way that creates fulfilling lifestyles.