The value of providing home care outside the home – opinion

Over the past ten years the range of care and support that can be easily accessed by elders who depend on care at home in this country has become increasingly narrow. Despite the rhetoric of increasing consumer choice and of expanding numbers of packages being available, it’s become difficult and often impossible to afford access to services offered outside the home. 

Day care services, for example, once the backbone of community care support, have become increasingly unaffordable for those who rely on Home Care Packages. It appears that help with shopping and various forms of day trips for elders who are otherwise homebound are also increasingly out of reach.

As a result, receipt of a Home Care package has in many instances come to resemble a sentence to social isolation. Exacerbated by the Covid induced lockdowns of the past three years, more and more service users are stuck at home when there are no family members or close contacts to take on trips. For those living alone, in particular, this can have very significant negative long-term effects.

Taking action to remedy this needs to be central to the development of the new program for in-home care. Yet in the most recent discussion paper, A New Program for In-Home Aged Care, released in October 2022, no mention was made of the issue. Nor were any of the new directions in service provision proposed in the paper likely to remedy the loss. The first call for responses to the document closed at the end of November, so it is to be hoped that, like my own brief submission, many of those who provided comments will have pointed out the need for a more fundamental rethink of the plans outlined in the discussion paper.

Recent research on shrinking out-of-home care options.

According to a new research paper by Myra Hamilton and others published this year in the Australasian Journal of Ageing, the shrinking menu of out-of-home care options is one of the consequences of the funding changes and program regulations introduced by the Australian government over recent years. The researchers, from the University of Sydney and UNSW, focus on the availability of dementia day care, carefully document the declining availability of centre-based support. Such changes, arising from funding shifts and rigid program boundaries, make block funded CHSP services unavailable to recipients of Home Care packages for all aged care consumers, not just those with dementia.

In the 1980s and 90s, it was common for HACC funded programs to provide day care, shopping support, home visiting services and a range of other options that sustained community participation and helped homebound elders maintain and even develop social contacts, at low cost to both government funders and service users.

But programs that provide care at home in recent years have moved away from the funding approach adopted by this pioneering community development-based initiative. In place of services provided by local, democratically operated non-profit community groups that combined paid work with volunteers, there has been a shift towards a more commercially oriented approach. 

As reliance on fee-for-service type payments increased with the expansion of the HCP over the past decade, there has been a decline in the support provided outside the home. In place of day care services staffed by a mix of volunteers and paid staff, now high hourly individualised service charges are imposed. As one of the centre based service directors interviewed by the researchers in the AJA article noted, this has excluded many previous clients:

‘People who receive a home care package now are deemed that they're no longer eligible to attend the centre. Where people need in reality both those things to remain at home, they need a home care package, and they need the social support, but what the government has done is they're saying that you can have one.’

The researchers also documented the devastating impact of social isolation that the loss of social connection outside the home has on those unable to leave the home due to Covid lockdowns. One of those interviewed in the study summed it up simply.

‘A lot of people noticed a decline in some of their loved ones, like cognition, because they wouldn't be interacting with people as often as they were. And also, our people's physical mobility and balance declined because they weren't doing regular activity and physical work with us.’

We can do better as we develop the new program of home-based care for Australia. Because centre-based support and services funded by grant funding methods are typically more cost-effective than the alternative, they are a very good investment. 

We know we can do it because we’ve done it before. Responding to the shortage of GPs and the almost complete absence of home visits by doctors these days, let’s also think of how we can develop the approach. Many other countries have long experience here, clearly demonstrating the value of access to centre based primary health care support resources for community care clients.

As we think about the design of the new home care program we need to remember what has been proven to work well. Let’s not neglect and destroy social contact for those elders who choose to remain at home. We need to renovate and rehabilitate what we have before it is destroyed.

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