With the election of a new government and appointment of a new aged care minister, there is an opportunity to pause to consider whether the directions the Department of Health is heading with the proposed Support at Home program are the most appropriate ones for older Australians wishing to remain living at home, writes Adrian Morgan.

Adrian Morgan

The new minister Anika Wells has a very large agenda of issues to manage in residential care, but it is important that changes to home care do not slip past under the radar.

The aged care royal commission provided only general guidance as to the directions home support should proceed, so it has fallen to the Department of Health to complete the detailed work in formulating arrangements.  But the final decisions on the shape and rules of the program rest with the government, not the department.

The department issued a document outlining its initial proposals in January this year proposing a start date of 1 July 2023.   Although the new scheme will amalgamate three previous programs, it fails to adopt the best of each of its predecessors.

Significant concerns

Many people with a detailed understanding of the challenges of delivering quality care and support in people’s homes have raised significant concerns about Support at Home.  A key conclusion is that the program will be inappropriate to assist people who have significant cognitive challenges, multiple health conditions and rapidly changing needs.  Its strength is that it should work reasonably well for older people with good cognition, limited and stable support needs, good computer skills and/or strong family support.

Some of the specific concerns about the program are:

  1. The program at its core is very rigid and prescriptive.  Not only will ‘independent’ assessments determine a person’s eligibility for specific services, but they will also determine the duration of these services.  This rigidity stands in stark contrast to the volatile needs of many older people and is a significant step backwards from the flexibility of home care packages. 
  2. Older people will need to be independently reassessed whenever they need more than a minor change in their services.  This means the consumers will need to wait to receive the services they require until the assessments have been completed.  With the probable high volume of assessment requests, there is every chance the waiting time for assessments will blow out as they did with Aged Care Assessment Teams (ACATs) in many parts of the country.  And if the NDIS experience is a guide, people wanting to appeal decisions on their service allocations to the AAT will typically have a six-month wait to resolve their issues.
  3. The assessment tools for the scheme are being validated against the services available to consumers under the current programs.  But it is recognised that the current programs are often inadequate to enable people to live well in their own homes, with some individuals still being effectively forced unnecessarily into residential care because they cannot access the services they require.  The limitations of the current arrangements are being permanently incorporated into Support at Home by way of the assessment tools.
  4. The new program appears to overlook the insights from the Aged Care Royal Commission relating to the importance of building services around people, rather than shoe-horning them into bureaucratic categories and systems. 
  5. Service types are restrictive and regimented, and largely reflect the historical categories originally devised for the defunct Home and Community Care (HACC) program.  The service types may be appropriate for people with simple needs, but they are problematic for people with complex needs requiring a mix of services during a single visit.
  6. Service provision will tend to become more fragmented and un-coordinated as consumers are encouraged to make their own arrangements with individual workers.  This approach is inappropriate for people who have multiple or complex health and personal issues, where effective service coordination becomes crucial to achieving good outcomes.

The Department indicates that it has held consultations with a variety of stakeholder groups about the Support at Home proposals, but these discussions have been conducted without much transparency, so it is not possible to know what is likely to emerge from them.

Given that more than one million people are going to be affected by the changes, it is crucial we have a system that will provide appropriate levels of support and care.  Failure will lead to increased pressure to transfer people to residential care or hospital which would be a very unwelcome outcome for the individuals who are affected, for our over-burdened hospitals and for the community at large.

Support at Home is very reminiscent of the discredited proposed changes to the NDIS which were rejected in July 2021 after a widespread backlash from all sectors of the disability support community.  If they were inappropriate for consumers with disability, they are also likely to be even more inappropriate for older Australians.

I do not know of anyone arguing for the status quo, but the proposed model has fundamental weaknesses that put the quality of support for older people at home, especially the most vulnerable individuals, in significant jeopardy. 

I hope that Minister Anika Wells can take the opportunity to apply fresh eyes to these issues, and not be hurried into signing off on a less than adequate program.

*Adrian Morgan is General Manager of Brisbane-based not-for-profit home care provider Flexi Care.

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  1. One of the fundamental issues with providing safe and effective support for older people living at home is the lack of quality training given to support workers. The role of the community support worker is dynamic and requires a level of skill and knowledge beyond those who work in residential care. I have over 20 years of experience supporting older people and people with disabilities in the community as a support worker, a Care Co-ordinator and the last 14 years teaching Aged and Community Care in Vocational Education. The trend we see now is that people are being supported in the home for a much longer duration before entering residential care. Care needs are more complex now and require a trained response specifically in the areas of dementia care, medication assistance, palliative care, First Aid to name a few. Carers need to be adaptable, flexible, they need to know how to respond in emergency situations, identify and manage risk such as WHS in the home, identifying and reporting suspected abuse and neglect and possess good literacy skills to be able to report and document incidents, hazards etc appropriately. Organisations need to support ALL their care workers to achieve a minimum Certificate 3 qualification which enables care workers to be armed with knowledge and skills that enable them to provide safe, respectful and ethical support and they need to be paid for it!!! I have heard many negative accounts from families about the quality of support they receive for their family members and organisations not supporting their untrained carers to gain a qualification, eg, paying them for the time they need to get training. If we make no significant changes with issue, then nothing will change.

  2. Here, here. All the webinars I have attended discussing the proposed Support at Home Program, never once have I heard a presenter say the words dementia, cognitive decline, forgetfulness, confusion, etc yet at least 30% of Daughterly Care’s clients live with dementia and many more live with cognitive decline, forgetfulness, and confusion, and yet the new Support at Home Program proposes that the organisation providing the care won’t manage the care they are delivering and that clients only get Case Management of a MEASLY 1 hour a month by a DIFFERENT COMPANY, if they were fortunate enough to be granted it in the Assessment process.

    The idea that such a fractured system could deliver quality care is INSANE because it doesn’t take into consideration how it makes the whole in-home care system less productive, less efficient, and more costly as the Nursing Homes and Hospitals pick up the pieces/cost of a badly designed in-home care service failing to work.

    Yet the evidence is in-home care done well prevents hospitalisations and premature placement in a Nursing Home, saving the Govt money.

    Care Managers working closely with clients, care workers & family members and GPs and Specialist Drs is what delivers quality care WITH DIGNITY for Older Australians living with cognitive impairment.

    That flawed structure has to be re-thought, sanity needs to prevail.

    Also, can the Health Department please understand that in-home care businesses have a higher workload now since January 2022 since we started “living with Covid”. There are weeks when 25% of our workforce is sick with Covid, mostly thanks to their children picking up Covid at school and coming home and infecting their family. It’s damn hard work to still deliver essential services, my point being we DON’T HAVE TIME to lobby for commonsense to prevail when we are busy caring in very trying times. It’s harder now for in-home care than it was in 2020 or 2021. It is FUNDAMENTALLY UNFAIR to expect the in-home care industry to cope with major changes that fracture the care when we are busy “living with a pandemic”.

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