8.5.3 Transition plan for clients who have been receiving long term attendant care services from a partner, relative or friend

Any decisions on whether it is appropriate for clients to continue to receive attendant care services provided by a partner, relative or friend must be informed by evidence of the client's current needs and circumstances. It is important that where clients have been receiving attendant care services for a long period of time, particularly where that support is provided by family that decisions are not made to immediately cease or change services.  Instead, delegates are requested to contact rehabilitation@dva.gov.au for advice before a decision is made.

Prior to the expiration of a client’s attendant care approval period, Rehabilitation Coordinators are required to organise a whole of person assessment in the client's home, by an Occupational Therapist or other suitably qualified health professional. The assessment should consider attendant care, household services and the provision of aids and appliances or home alterations that may assist the client to be more independent in self managing the impact of their accepted conditions.

The Rehabilitation Coordinator must also gather evidence about whether exceptional circumstances apply, by seeking evidence from the client’s treating health professional, who has a good understanding of the client’s health status, current needs and circumstances. Rehabilitation Coordinators must follow the guidelines in section 8.5.1 of this Guide when gathering evidence and making decisions about the ongoing care arrangements for clients who have been receiving care from a partner, relative or friend.

Depending on the client's individual circumstances, community nursing services may need to be considered. Where this occurs, please contact rehabilitation@dva.gov.au and the rehabilitation policy section will liaise with the Community Nursing Program.

Where there is no evidence that exceptional circumstances apply, the client should be carefully and gradually transitioned to an external attendant care provider. The transition to an external provider must be managed sensitively. To ease the transition process, the client's rehabilitation provider should assist with finding a suitable external provider with the skills, qualifications and experience to meet the client's needs, and with gathering quotes for services, based on the recommendations of the home assessment.

The transition plan should be negotiated with the new external provider so that the client can slowly become used to the new care arrangements. For example, the external provider may initially provide care for one day or two days a week (and be paid accordingly) in order to provide respite support for the partner, relative or friend. The partner, relative or friend would therefore be paid for the balance of the attendant care services that they provide. Once the client is comfortable with the external provider, then the provider could build up to taking over the person's total attendant care needs.

Any transition should be closely monitored by the rehabilitation provider and issues should be dealt with sensitively as they arise. These arrangements should be clearly communicated to the client so that they understand that this approach is time limited and that by the end of the six month period it is expected that the external provider will be providing all of the client's attendant care services.