Substitute Care

This policy applies to transport accidents on or after 28 November 2007.

Policy

The TAC can pay the reasonable costs of substitute care during the first 12 weeks after the injury or death of a person who was the primary carer for a disabled member of their immediate family at the time of the transport accident.

Substitute care must be provided by an authorised provider.

All substitute care services require prior approval from a TAC officer (where possible) and will require approval before accounts can be paid.

Transport Accident Act 1986 reference: s.3 'primary care-giver', s.3 'member ot the immediate family' and s.60(2)(ca)

Background

There are significant stresses placed on families where a person who is injured or dies as a result of a transport accident is also the primary caregiver for an elderly or disabled member of his/her immediate family.

The TAC can pay the reasonable costs of substitute care during the first 12 weeks after the injury or death of a person who was the primary caregiver to an elderly or disabled member of their immediate family member at the time of the transport accident and the accident occurred on or after 28 November 2007.

Substitute care can be funded to assist a client's immediate family during the client's recovery phase or, in the case of more serious injuries or death, to allow time for longer term care arrangements to be put in place.

The TAC's liability to reimburse substitute care services is set out in section 60(2)(ca) of the Transport Accident Act 1986. This section applies where a person is injured or dies as the result of a transport accident that occurred on or after 28 November 2007.

Definitions

In this policy:

• Substitute Care refers to the provision of care and attention services for a disabled or elderly immediate family member of a client who is injured or dies as a result of a transport accident.
  
  A substitute care program may consist of the following service types:
  • Personal care support: assistance with personal activities of daily living (ADL's), eg. showering, bathing, dressing, toileting, assistance with eating and drinking, mobility and transfers, and supervision at home due to safety issues
  • Community access support: assistance with community ADL's, eg. shopping, banking and recreational activities
  • Therapy support: assistance to participate in rehabilitation programs, which are developed and monitored by an allied health professional, eg. performing a home exercise program or an 'independent' gym/swim program
  • Supported residential care services: for detailed definitions of the applicable service types refer to the TAC Residential Care policy.
• Primary caregiver refers to a person who provides care and attention to an elderly or disabled member of their immediate family on a daily basis, and for at least 20 hours per week.
• Care and attention refers to the provision of assistance to an elderly or disabled member of their immediate family which is required due to the immediate family member's physical, sensory and/or cognitive disabilities or deficiencies and where this is the most age appropriate and least restrictive response to the immediate family member's needs. Care and attention can be provided in a range of settings, including the immediate family member's home and other community venues or facilities.
• Elderly or disabled immediate family member refers to the partner, parent, child or sibling of the TAC client who is injured or dies as a result of a transport accident.
• Substitute care personnel refers to a person who is employed by a TAC authorised provider and is appropriately trained and/or qualified to provide the required care and attention service(s). Refer to the TAC Appendix - Service Provider Eligibility Criteria.
• Authorised provider of substitute care refers to members of the TAC's Care and Support Services Panel or another provider authorised by the TAC.

Guidelines

Who is eligible to receive substitute care services?

For the TAC to fund substitute care the client must:

• have been the primary care-giver
• have been providing care and attention to an elderly or disabled member of their immediate family at the time of the transport accident
• be unable to perform care and attention duties due to his/her transport accident injuries
• not have been receiving a salary or wages for that care prior to his/her transport accident. The Commonwealth Governments 'Carer Allowance' and 'Carer Payment' benefits are not considered to be salary or wages for the purposes of this policy
• have an accepted TAC claim
• have sustained injury or dies as a result of a transport accident that occurred on or after 28 November 2007.

Eligibility for substitute care begins from the date of a client's injury or death.

What does the TAC consider when determining a client's eligibility for substitute care services for an immediate family member?

The following factors will also be considered when determining a client's eligibility for substitute care:

• Supports and services used pre-accident by the client's immediate family member
• The age and needs of the immediate family member
• The reasonable capacity of other members of the household and/or the immediate family to perform substitute care tasks.

In regard to substitute care services what conditions apply?

The following conditions apply:

• A maximum of 12 weeks substitute care can be funded during the first 12 weeks after the death or injury of the TAC client
• Substitute care services must be provided by an authorised provider
• Substitute care payments can be made by the TAC to cover the reasonable costs of funding an authorised provider
• Substitute care payments will be paid under the TAC client's claim
• Substitute care services must be provided and received within Australia.

Who can recommend or request substitute care services?

Substitute care services can be recommended by the client's hospital treating team, community-based therapy team or TAC Support Coordinator.

Substitute care services can be requested by the client's legal representative, family members or the TAC client. The General Practitioner (GP) of the disabled or elderly immediate family member can also request substitute care services.

What documentation does the TAC require to fund a request for substitute care services?

Medical Documentation 
In order to consider paying for substitute care services a request needs to be made on the client's behalf by a medical practitioner to the TAC. The TAC may consider alternative information such as an Aged Care Assessment Service (ACAS) report or information from a hospital or rehabilitation service advising that a TAC client is an in-patient and is unable to perform his/her care duties.

The request must document the:

• nature and extent of the client's transport accident injuries and functional status
• relationship between the client and the person requiring care
• impact of the client's transport accident injuries on his/her ability to perform the requested substitute care tasks
• expected duration of the client's incapacity to perform substitute care tasks as a result of his/her transport accident
• number of hours per week/fortnight/month that substitute care services are required
• tasks required to be undertaken within substitute care for the immediate family member.

The TAC may contact the provider that has recommended the substitute care service prior to approving the services to ensure that it is reasonably required is the most appropriate response to the needs of the immediate family member. Refer to the TAC's Privacy policies.

Other Documentation If applicable, the TAC requires evidence of the TAC client receiving the Commonwealth Governments 'Carer Allowance' and/or 'Carer Payment' benefits prior to his/her transport accident.

Family members (or other appropriate sources) may provide additional information to assist the TAC in determining eligibility for substitute care services.

Does the receipt of a 'Carer Allowance' and/or 'Carer Payment' effect a TAC client's eligibility to substitute care services?

If a client has provided written documentation to the TAC demonstrating he/she was in receipt of the Commonwealth Governments 'Carer Allowance' and/or 'Carer Payment' benefits prior to his/her transport accident, he/she may be eligible for substitute care.

The TAC understands in accordance with the "Taking a break from caring" section of the Eligibility for Carer Payment information located on Centrelink's website, a primary carer can take a break from caring for up to 63 days (equivalent to 9 weeks) per calendar year (1 January until 31 December) and still qualify for the 'Carer Payment' and/or the Carer Allowance'. Centrelink advises a primary carer may also use these 63 days if they are sick and can not provide care for his/her immediate family member.

As a result, a TAC client is able to receive the 'Carer Allowance' and/or 'Carer Payment' from Centrelink for up to 63 days while he/she is in hospital and also be eligible for Substitute Care benefits from the TAC.

Does a client's level of employment impact on his/her entitlement to receive substitute care services?

TAC clients may be eligible to receive substitute care services irrespective of whether they were in paid employment provided they were the 'primary caregiver' to the immediate family member for at least a total of 20 hours per week at the time of his/her transport accident.

Will the funding of substitute care services be reviewed?

During the 12-week period that an eligible immediate family member may receive substitute care, the TAC may review the amount of care approved to ensure that the services are still reasonably required and are the most appropriate response to the needs of the client's immediate family member.

How may substitute care services be funded?

Substitute care may be funded:

• by direct payment from the TAC to the TAC's Care and Support Services Panel member (or another provider authorised by the TAC), or
• as a reimbursement where a client or his/her representative has forwarded original receipts of payment to the TAC.

Is an injured parent eligible for substitute care services to care for his/her child?

The TAC can fund the reasonable cost of child care services for a client who before the transport accident, was engaged in the care of a child and has sustained an injury in a transport accident which impacts on his/her ability to provide child care services. Eligibility will be considered under the Child Care Services for accidents on or after 1 January 2005 policy.

Can the TAC fund services to assist with domestic activities of daily living/home services?

Domestic activities of daily living (ADL) assistance is not payable under substitute care services. Domestic ADL assistance may be funded as 'Home Services' by the TAC.

If the TAC client was living with his/her elderly or disabled immediate family member before the transport accident, the reasonable costs of home services may be funded by the TAC. Eligibility will be considered under the Home Services for accidents on or after 1 January 2005 policy.

Will the TAC fund services as substitute care if the services can be funded under another provision of the Transport Accident Act 1986?

As services funded under substitute care are limited to the first 12 weeks after the death or injury of the TAC client, the TAC will always assess a TAC client's entitlement to services under other provisions of the Transport Accident Act 1986.

Who can provide substitute care services?

Substitute care services can be provided by:

• a TAC authorised care agency. Refer to the TAC's Care and Support Services Panel.
• another provider authorised by the TAC. This would only occur or be considered if the eligible immediate family member resides in a rural or remote area where the services can not be provided by an authorised care agency.

In all circumstances, prior approval must be obtained from the TAC before engaging a provider to perform substitute care services.

If another family member takes leave from work to care for the disabled or elderly immediate family member while the TAC client/primary carer is in hospital can the TAC reimburse their wages?

Substitute care services must be provided by an authorised provider. Substitute care payments can only be made to cover the cost of funding an authorised provider.

Can a substitute care worker claim travel?

The TAC cannot fund the cost of transport for substitute care services.

What fees are payable?

Fees for substitute care services will be paid in accordance with the TAC fee schedule.

What if the client continues to be unable to provide care to his/her disabled or elderly immediate family member after the first 12 weeks following the transport accident?

The TAC is only able to fund substitute care during the first 12 weeks following the client's transport accident.

If further support is required by an elderly or disabled immediate family member beyond the first 12 weeks following the client's transport accident, refer to the Department of Health and Ageing - Home and Community Care (HACC) Program and the Commonwealth Carelink Centres for information regarding government programs and community support services.

In relation to substitute care services what will the TAC not fund?

The TAC will not fund:

• services that were not provided by the TAC client as the primary carer prior to the transport accident
• services where prior approval has not been provided by the TAC
• services beyond the first 12 weeks after the death or injury of a TAC client
• services provided by a person not authorised by the TAC
• fees associated with non-attendance
• the cost of telephone calls and telephone consultations between providers and eligible immediate family members/clients and between other providers, including hospitals
• any costs of travel for the client's eligible immediate family member or their substitute care personnel
• the entry or participation costs for a client's eligible immediate family member and their substitute care personnel to recreational or leisure activities
• services that replace parental responsibilities, e.g. supervision of a child. Refer to the Child Care Services for accidents on or after 1 January 2005 policy.
• services received by the injured person's eligible immediate family member outside the Commonwealth of Australia
• services provided more than 2 years prior to the request for funding except where the request for funding is made within 3 years of the transport accident. Refer to the Time Limit to Apply for the Payment of Medical and Like Expenses policy.