Development of person‐centred quality indicators for aged care assessment services in Australia: A mixed methods study

Abstract Introduction This study developed a proposed set of person‐centred quality indicators (PC‐QIs) for services that assess older adults' care and support needs to determine their eligibility to receive government‐funded aged care services in Australia. Individual proposed PC‐QIs amenability for change within current organizational structures were explored. Barriers and opportunities to adapt service elements of the aged care assessment service to better align with the intent of the proposed PC‐QIs were identified. Methods A mixed methods study was conducted over five phases. A scoping review identified domains of quality for aged care services as perceived by older adults. Service elements of an aged care assessment service were mapped alongside quality domains informing key attributes of each quality domain. Self‐determination theory was used to formulate each proposed PC‐QI to align with key attributes and quality domains. Consultation with a consumer group enabled revision of the proposed PC‐QIs. A focus group with clinicians evaluated the amenability of each proposed PC‐QI for change and identified barriers and opportunities to better align service elements with older adults' perceptions of quality. Results were informed by qualitative and quantitative data from a structured focus group. Focus group discussions were audio recorded and subsequently transcribed verbatim. Qualitative data were analyzed using a deductive thematic approach by two independent researchers. Results Twenty‐four proposed PC‐QIs were developed. Refinement to descriptors of the proposed PC‐QIs were made by the consumer group (n = 18) and all were affirmed as being amenable to change by aged care assessors. Barriers in meeting the intent of the proposed PC‐QIs were identified across five domains including: health care staff knowledge (18.7%; n = 3); clear communication (31%; n = 5); person‐centred approach (18.7%; n = 3); respect for client (18.7%; n = 3); and collaborative partnership with client (12%; n = 2). Participants made 21 recommendations. Of the five service elements in delivering an aged care assessment service, barriers in meeting the intent of the proposed PC‐QIs were identified at the intake and booking of an assessment and during the assessment. Conclusions Recommendations identified provide assessment services guidance on ways to adapt service elements to better align with older adults' perceptions of quality. Patient and Public Contribution Patients and carers were involved as collaborators in this project at the protocol stage which included participating in discussions regarding the refining and modification of the protocol, refinement of the proposed PC‐QIs, data collection forms and supplementary information for participants.

Significant reforms have occurred in the provision of aged care services in Australia over the last decade, [7][8][9][10][11][12][13] incorporating models from international systems to improve the system's sustainability while ensuring appropriate care to older adults. 8The Royal Commission into Aged Care Quality and Safety made five significant quality improvement recommendations relevant to regulation and legislation, and are summarized in Box 1. 13  Quality management tools, including a client satisfaction survey (10 questions) are used to measure the quality of the service provided. 14ements of aged care assessment services in Australia are broadly categorized into five areas including the intake and booking of the assessment, conducting the assessment, follow-up after the assessment has been completed, formulation of the support plan summary and a final letter summarizing the outcome of the assessment and approval for government-funded services.Each service element has several components which are described in Table 1.
Home care QIs (HC-QIs) such as the second-generation HC-QIs developed by an international research network (interRAI) are currently used by organizations who deliver home care services.These indicators, derived from the Community Health Assessment and the Home Care Assessment, 16 measure the functional (e.g., Cognition, Activity of Daily Living), Clinical (e.g., falls, pain), social (e.g., Caregiver distress) and utilization (e.g., hospital use) aspects of care. 16While these QIs can be used to measure the delivery of home care services, the domains measured do not align with the elements of an assessment service that determines an older adult's eligibility for access to home care services.For service elements such as assessment of eligibility, the perspectives of what older adults perceive to be quality service is very limited. 17e lack of quality domains that align with elements of assessment services that determine eligibility has been identified in an international scoping review. 17This international scoping review explored elements older adults considered to be important in the provision of community aged care services given the dearth of literature on assessment for eligibility.This research identified five client-perceived quality domains for community aged care services, including (i) staff knowledge; (ii) respect for clients; (iii) a person-centred approach; (iv) a collaborative partnership with a client; and (v) clear communication. 17ditionally, this scoping review identified the key attributes that defined each of the quality domains.
These findings highlight the need for person-centred QIs (PC-QIs) for assessment services that assess an older adult's eligibility for aged care programmes, to enable measurement of the provision of service elements to ensure that they not only meet legislation, policy and practice (inclusive of an organization's structure) but align with the perceptions of older adults who are receiving these services.

| OBJECTIVE
The objectives of this study were to: 1. Develop a set of proposed PC-QIs that measure the quality of the aged care assessment service from a client's perspective.T A B L E 1 Service elements of an aged care assessment service.

Service element Description
Intake/booking of assessment Web and phone-based referrals are received via the My Aged Care Portal.Referrals are prioritized using a priority matrix (low, medium, or high) which provides a timeframe in which an assessment is expected to be completed.Assessments are allocated to an assessor, and an administrator arranges the booking of an assessment, which can occur over the telephone or via a letter in the mail.
This study is an analysis of qualitative and quantitative findings that aimed to answer the following research question: Aged Care for all aged care assessors.

| Development of proposed PC-QIs
The set of proposed PC-QIs were developed across four phases and are outlined below.
Phase 1: Five quality domains and their corresponding key attributes identified by clients 17 were used as the foundation for developing the proposed PC-QIs (Table 2).This aimed to ensure the client's perspective of what a quality service looked like, was the key domain* in each proposed PC-QI.
Phase 2: The service elements of an aged care assessment service were mapped alongside the five quality domains identified in phase one.This informed the development of the key attributes (title) of each proposed PC-QI (Table 2; ACAT service element^).
There are five distinct service elements that older adults experience when they interact with aged care assessment services (Table 1).
Phase 3: Self-determination theory (SDT) was used as a framework to guide the development of the proposed PC-QIs (Table 2; SDT # ).
This was done by ensuring the definitions of the three constructs of SDT, autonomy (sense of choice), competence (feeling good about what you can do) and relatedness (feeling connected to other people) were reflected in the proposed PC-QIs.Replacement of the current aged care assessment programme with a single comprehensive assessment service that promotes self-determination and autonomy of the older person was recommended (recommendation 28) by the Royal Commission into Aged Care Quality and Safety. 13To align with future directions of the aged care assessment programme, the use of SDT was seen as an integral aspect in the development of the proposed PC-QIs.SDT defines three basic psychological needs of autonomy, competence and relatedness and argues that a person's satisfaction of these psychological needs promotes wellbeing and strengthens their inner resources which in turn strengthens their resilience. 18SDT is considered a general theory of human motivation and has been used in survey research, clinical trials and experimental studies in health. 19Kofi Osei-Frimong 20   3. What changes could be implemented within the current organizational context of the aged care assessment service, to address these barriers?(n = 24) (Table 2; proposed PC-QIs).
A total of 73 focus questions including one introductory question, 24 questions requiring a yes/no response, and 48 openended questions were developed (Table 2).Two members of the eQC Patient and Carer Advisory Board self-nominated to participate in separate telephone interviews with the focus group facilitator, to trial the focus group questions.Feedback was invited regarding the facilitator's ability to conduct the group impartially and borne in mind when conducting the actual focus group.Clients not consistently advised they can have a support person present at the assessment if preferred.b Cultural background and religious preferences, including the client's preference of using an interpreter service versus family member should be discussed.

| Face-to-face focus group discussion
Clear understanding of and communication between intake and administration staff, of a client's cultural and religious preferences.
Clear and accurate documentation of a client's cultural and religious preferences and preference for support person.
Suitability of assessment time confirmed with client (option to offer appointments outside of scheduled times).
Clients contacted by telephone to book assessment time.

Information on waiting times provided
Client's offered choice of mode of delivery of assessment, and choice documented once confirmed.
Clients advised they can have a support person present at the assessment.Provide information that is easy to read and limit the use of acronyms.Describe aged care services in accordance with Commonwealth government colour coded information booklets.For example, purple book = home care package.Develop easy read handout sheets that take into consideration clients with a cognitive impairment, those who have a decision maker and those from different cultural backgrounds.
Easy read handout sheets could be used by assessors as a visual aid when explaining the aged care assessment process to the client/family.Assessors should be appropriately skilled and trained at providing a more flexible approach to the assessment process, to accommodate different cultural backgrounds and clients who have communication and/or cognitive difficulties.
Time allocated to assessors to complete the assessment should reflect the complexity of the client's situation.The use of allocating clients a 'window of time' for the assessment could be used to accommodate for assessor delays in assessments.and feasibility of implementing a person-centred care framework at a health care system level, to inform the development of PC-QIs. 22This study used structure, process and outcome components of a personcentred care conceptual framework that was previously developed using a narrative review of the literature on PC-QIs. 23The improving systems for their clients and recognized there was a need to improve communication processes and data systems.The latter, however, related to sharing data and improving communication processes between service providers only. 24 comparison, the findings of our study were obtained through focus group questions based on a set of proposed PC-QIs reflecting what older people have described as being important qualities of a service experience and presenting them to clinicians to facilitate discussion.This methodology provided for a robust exploration that included the perspectives of not only clinicians, but also of older service recipients.
Recommendations for improving communication between the client/family receiving the service and providers of the service were a key finding of our study.How care decisions of people living with dementia are made and experienced was explored in a systematic review.The findings of this study concluded decisions were made in three overarching ways, including, being excluded, prior preferences taken into account, and current preferences respected.This study, however, did not provide any recommendations on how to include the preferences of people with dementia in care decisions, but rather concluded that informal decision-making was complex. 25e development of basic resources and easy read printed handouts was one recommendation to facilitate improved communication with clients with a cognitive impairment and in situations where a substitute decision maker is involved.The intention of this recommendation was to better facilitate a shared decision-making approach between the assessment service, client, and the shared or substitute decision maker at the time of the assessment.The use of decision aids has been shown to be effective for older adults by increasing their knowledge and risk perception, decreasing conflict and enhancing participation in the decision-making process. 26The use of TalkingMats (low technology communication framework that uses simple pictures on a textured mat) as a decision aid for older adults with mild to moderate dementia has also been shown to help people with dementia clarify their thoughts and express their views as well as helping them to come to a decision about how they felt they were managing with daily tasks. 27other key finding of our study was the significance of incorporating strategies to ensure a client is treated with dignity and respect when receiving aged care assessment services.Recommendations included the importance of understanding a person's cultural background and religious preferences, including whether the client was comfortable using an interpreter service, or preferred family members to be present at the time of assessment.Freeman et al. 28 outlined barriers that reduce cultural respect when providing primary health care services to Aboriginal and Torres Strait Islander Australians, including the inability to provide flexible and timely interpreter services, complex language used by staff, and racism and discrimination displayed by staff.The study also found the use of external programmes that were developed in research projects that existed outside the population group for which they were intended were a significant barrier to reducing the gap in cultural respect.The findings of our study also identified complex language used by staff as a barrier, however, this was viewed by participants as being applicable to all client groups regardless of their culture or religious background.A study using semi-structured interviews to T A B L E 4 (Continued) Aged care assessment service element Participant quotes think that the services they are receiving are their package (services provided as a home care package for clients with medium to high care needs) and this is so confusing for them to understand'.Participant 'Sometimes, with some clients, you need to go slowly.Really slowly to help them understand they can trust you.That they can trust the service.Some clients don't understand what you tell them in that one assessment, so you need to have a follow-up hone call or visit.This is something that we used to do, but we can't do this anymore' (Participant) 'yeah … okay … the communication style of the assessment, you know, asking them (clients) have you had information, for example, on the assessment process itself?"And it could be easy to read handout sheets that the assessor can give to the client.Maybe we could have a number of resources and tools to use'.
Follow-up (Participant) 'I think they (clients) think we are case managers, and that we then manage their care package or their aged care services.They really don't understand that we only do the assessment, and that is where we fit into the whole aged care system'.(Participant) 'I haven't looked at one of the approval letters in a long time, but does it say something down the bottom about who you can contact for assistance?I don't know how much control we have because its, you know, it's a Commonwealth template that is used … right?' (Participant) 'You know, we could actually have a flow chart or something we could give them (clients) to make it easier'.(Participant) 'We are told not to give out our phone number to clients.They are just given the call centre number, so if they want to talk to us directly, they can't'.

BOX 1 .
Relevant recommendations from the Royal Commission into Aged Care Quality and Safety (2018) Recommendation 1 included establishing a new Aged Care Act to provide an aged care system that is based on an older person's universal right to high quality and timely support and one which enables older people to exercise choice and control over the planning and delivery of the care they receive.Recommendation 2 specified the new Aged Care Act should list the rights of older people seeking and accessing care including their right to equal access and choice between services available.Recommendation 22 included the expansion of quality indicators in residential aged care, the development of quality indicators in home care (home care services are services provided to community-dwelling people) and the development of a quality-of-life assessment for consumers in both residential aged care and home care.Recommendation 23 specified that the Australian Government should use the quality indicators for ongoing continuous improvement by implementing reporting and benchmarking of individual service provider performance.Recommendation 28 replacing the current Aged Care Assessment Program, which includes Aged Care Assessment Teams and Regional Assessment Services, with a single comprehensive assessment process, and that this new assessment process should promote selfdetermination and autonomy of the older person.While the development, implementation, and reporting of quality indicators (QIs) in aged care services in Australia was a positive step by the Royal Commission to ensure that quality services are provided, there was no specific recommendation for the development, implementation or reporting of QIs for the Aged Care Assessment Programme.Currently, the quality of aged care assessment services in Australia is measured by a set of key performance indicators directed by the Australian Government, Department of Health and Aged Care.

2 . 3 .
Identify the amenability for change of each proposed PC-QIs in the current organizational structures of the aged care assessment service.Explore barriers and opportunities for change to incorporating the proposed PC-QIs into aged care assessment services from the perspective of aged care assessors.

Phase 4 : 1 .
I was given at my assessment interview was easy to understand.Conducting the assessment Competency Three subquestions asked in relation to each proposed PC-QI (a) Is the proposed PC-QI amenable to change?(Yes/No) (b) What are the barriers to incorporating the proposed PC-QIs into local aged care assessment services?; and (c) What changes could be implemented within the current organizational context of the aged care assessment service, to address these barriers?Abbreviation: PC-QI, person-centred quality indicators.influence the nature of their participation, which in turn could improve the value and outcome of services delivered.Patient and public involvement.The 24 proposed PC-QIs were presented to the evaluating quality of care (eQC) Patient and Carer Advisory Board.This group provided feedback on readability and amendments were made accordingly (Table2; Advisory board review € ).The eQC Patient and Carer Advisory Board is a collaboration of patients and carers established to inform the embedding of partnerships between lived experience experts and researchers.Its aim is to ensure a consistent focus on participant collaboration across all stages of quality-of-care research including the planning, delivery, monitoring and evaluation phases of research.The eQC Patient and Carer Advisory Board is led by researchers based at the Centre for Health Services Research at The University of Queensland and is located at the Princess Alexandra Hospital in Brisbane, Australia.The Board has eight members of the public and includes persons living with dementia, carers or former carers of people living with dementia and, people with an interest in dementia/ dementia services.The board was involved as collaborators in this project at the protocol stage which included participating in discussions regarding the refining and modification of the protocol and the proposed PC-QIs, data collection forms, and supplementary information for participants.Development of structured focus group questions (questions asked of ACAT assessors to [a] determine if each proposed PC-QI is amenable to change within the current organizational context [b] identify barriers and [c] generate recommendations to address barriers).The semi-structured questions for the focus group were developed using the proposed set of PC-QIs and aligned with objectives two and three of the study.Each proposed PC-QI developed in Phases 1-4 had three subquestions: Do you think the proposed PC-QI is 'amenable to change'? (Yes/ No response) (n = 24).2. What are the barriers to incorporating the proposed PC-QI into local aged care assessment services?(n = 24).

A
face-to-face focus group was facilitated by the first author who is an occupational therapist who specializes in aged care.She worked as an aged care assessor in the Metro North ACAT from 2019 to 2020, has a sound understanding of the aged care assessment service elements and has completed training in qualitative methods.Five of the six participants were known to the facilitator through her previous work; however, participants were independently recruited by the service manager and the facilitator had no knowledge of their participation before the commencement of the focus group.The facilitator's previous roles most likely contributed to her having a greater awareness of the barriers and recommendations that may have been raised and discussed by participants.Accordingly, the facilitator briefly introduced the study and clearly explained that her role was to facilitate (and not influence) discussion before the formal process began.The group comprised six participants and the discussion took approximately 90 min.At the focus group meeting each participant was provided with two paper-based data collection sheets, one for demographic information and one to record their response (yes/no) to the amenability for change of each proposed PC-QI.Information in the participant information sheet was presented verbally, including the recording and transcription of the focus group discussion, and anonymity of responses.Participants were advised that they could choose to cease participating in the focus group at any time.Before commencing the focus group discussion, the facilitator provided background information about the research project informing the development of the focus group questions.Instructions were verbally provided to the group, including an opportunity for questions before the process formally began.Working definitions were agreed upon for the focus group discussion.The definition 'Amenable to change', was defined as: the outcome of the proposed PC-QI measuring a client's 'quality experience' can be influenced and/or changed by modification of an ACAT service element that can be changed at the local level.The ACAT service element identified requiring change does not rely on systems and/or processes that are governed by controls that exist outside the influence of the local service itself.Before proceeding to identifying influencing factors (i.e., barriers and potential strategies), assessors were asked to identify examples of legislation, policy and processes that could not be changed at the local service level, promoting a robust discussion between participants and further clarification of things that were outside the influence of the local ACAT Service.All participants acknowledged they were familiar with the aged care assessment quality framework which was designed to assist organizations to deliver a consistent approach of high-quality My Aged Care assessments.14Participants were presented with each proposed PC-QI and their associated subquestions.Participants were first asked to vote (yes/no) as to whether the proposed PC-QI was amenable to change and record their vote on a fit-for-purpose record form.They were asked not to discuss their votes with the group.As a group, participants were asked to discuss barriers in meeting the proposed PC-QI (client's perception of service quality), and recommendations that could be implemented at a local level to address these barriers.The focus group was audiotaped and transcribed verbatim.Participant voting T A B L E 3 Barriers and recommendations in meeting quality domains aged care clients perceive as important across aged care assessment processes.Aged care assessment service elements Proposed quality domains Barriers identified against quality domains Recommendations to address barriers Corresponding proposed PC-QI Intake/booking of assessment Respect for clients.a Person-centred approach.b Clear communication.c Client's cultural and/or religious preferences not always considered. a Communication between intake and administration staff not always consistent.a,c Clients not always provided a choice of the time of assessment or the mode of delivery of assessment.b Appointment times often mailed out to clientslimiting direct communication with clients.b Provide information to client's that reflects their individual situation.Develop a one-page simple flow chart providing information to clients on what to expect during the assessment, and what happens next.Assessors to show clients video resources available on the My Aged Care Website that describe a service experience from a client's perspective.

6 |
Follow-upParticipants reinforced during the discussion that an aged care assessor does not take on the role of 'case manager' for individual clients.The group discussed their limitations in providing extensive follow-up after completing the assessment and providing the client with the relevant information about what services they had been approved to receive.The current follow-up process was discussed and collectively they agreed the approval letter mailed to clients could be reviewed to improve its readability for clients.4| DISCUSSIONTo the best of our knowledge, this is the first study that has developed a set of proposed PC-QIs for services that assess an older adults' eligibility for government-funded aged care services, affirmed their amenability for change in accordance with legislation, policy and organizational structures, and explored the barriers in meeting their intent when delivering aged care assessment services.This mixed methods study presents clinician identified strategies for local service delivery levels.The ability to address 24 evidence-based proposed PC-QIs were quantitatively described.While barriers were identified in meeting the intent of the proposed PC-QIs across three of the five aged care assessment service elements, participants discussed modifications that could be made at a local level to address these barriers and to facilitate a change in practice to improve the quality of the aged care assessment service, as perceived by clients.Investigation of clinician perspectives on the implementation of quality domains has been used in other studies.The views of clinicians and quality improvement experts were explored in one study with the aim of understanding the measurement, acceptability Abbreviation: PC-QI, person-centred quality indicators a Respect for clients.b Person-centred approach.