Risk of system failure if in-home care program adopts wrong model: report

The repurposed Support at Home aged care program needs to have the right design from the beginning, according to a new report.

Adopting a flawed model would endanger the welfare of the one million senior Australians who depend on its services, and it could jeopardise the entire system itself, said Dr Rachael Lewis of the UTS Ageing Research Collaborative and lead author of a review of the initial proposal for the program.

“Getting the design wrong, risks the wellbeing of these elderly clients, the viability of the providers and the sustainability of the aged care system overall,” said Dr Lewis.

In 2021, and after years of recommendations from industry stakeholders, as well as the royal commission, the then Coalition government agreed to consolidate the three existing home care programs – the Commonwealth Home Support Program, the Home Care Packages Program and the Short-Term Restorative Care Program – into one entity, the Support at Home Program, due to launch July 2023.

But when the Support at Home Program Overview paper was released in January, many stakeholders complained the scheme ignored recommendations made by the royal commission and advice of providers, and that the program’s implementation was being rushed. This led the new Minister for Aged Care Anika Wells to defer the program’s commencement by 12 months to enable further consultation.

“We will use the extra time wisely to work with older Australians, their families and carers, workers, advocates and providers to do everything we can to achieve a better in-home aged care system,” said Ms Wells in July.

Dr Lewis and a team of UARC researchers have released a report of their analysis of the Overview paper. Called Support at Home – A commentary on the design of the proposed unified program, it identifies a number of strengths and weaknesses of the model.

Strengths

Speaking to Australian Ageing Agenda, and starting with the strengths, Dr Lewis said: “Many elements in the proposed design of the program have merit, and potential to improve the current experience of a fragmented and often frustrating system for accessing care and support at home.”

One of those merits is the development of an integrated assessment process, “which is intended to provide a single access pathway and a more seamless transition for older Australians as their needs change over time,” said Dr Lewis.

“We also strongly support the incorporation of restorative care as a dedicated category within an integrated assessment process, if not as a standard point of entry for all older Australians to the aged care system,” she added. “The provision of restorative care to all older Australians who would benefit from it would have the effect of slowing or reversing age-related decline and reduce overall demand on the system as a whole.”

The development of a service catalogue also has the benefit of improving the transparency and consistency of in-home aged care services across different providers, Dr Lewis told AAA.

“A comprehensive list of services will also provide for periodic analysis and review of the outcomes of different types of support provided to older Australians, and better targeting of public subsidies.”

Weaknesses

As for the researchers’ concerns, Dr Lewis points to the individualised support plans that allow older Australians to engage with multiple providers in the delivery of assessed services.

“It will be important to clearly define the roles and responsibilities of each party in the allocation, management, delivery and outcomes of subsidised services,” said Dr Lewis. “Support at Home must avoid a scenario in which the various parties – assessors, care managers, and providers – become responsible for outcomes which they cannot meaningfully control.”

Support at Home should also avoid over-burdening either older Australians or providers with compliance activities, Dr Lewis told AAA. “Especially in cases where well-established providers are efficiently meeting the entry-level needs of older Australians. Assessment processes should be proportionate to the needs of clients, while regulatory requirements of providers must reflect the nature and risk of the services being provided.”

The design of the Support at Home program also needs to be sensitive to the different business models and cost structures of provider organisations, especially those which service rural, regional and remote communities, she said.

“A one-size-fits-all approach to pricing and funding – while potentially improving transparency and consistency – also risks forcing these providers out of the market and reducing access to services for cohorts of older Australians.”

“In-home care could be more equitably shared.”

Perhaps the biggest concern is the program’s financial sustainability. As Dr Lewis notes: “The annual public cost of subsidised in-home care is $6.9 billion, which represents around 90 per cent of program costs. The proportion of costs currently borne by taxpayers is not sustainable.”

Sustainable and equitable funding of the Support at Home program must be a guiding principle in its design, she said.

“Our paper proposes a series of options for how the cost of in-home care could be more equitably shared between taxpayers and those older Australians who have the financial capacity to make a reasonable contribution.”

These options include:

• the use of a means-tested, variable client contribution and a balancing public subsidy
• a fixed public subsidy supplemented by a Medicare-style client contribution charged at the discretion of the provider.

“Getting the design of the Support at Home program right in the first instance will be crucial for the independence and wellbeing of senior Australians, for clear accountability between the various roles in the system and for the long-term sustainability of aged care,” said Dr Lewis.

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