An Open Letter to the Home Care Community

Dear Home Care Community (older Australians, participants, representatives, carers, family members, advocates, providers, workers, associate providers, peak bodies, Department, Commission, ministers, aged care assessors, consultants, vendors, suppliers, taxpayers and other interested stakeholders),

I’m writing to provide my perspective which is that elements of the home care system and current Support at Home (SaH) program rules have the potential to result in inequitable, and perverse outcomes for different stakeholders including participants and their families, providers and their workers, and the Government and society at large.

I openly acknowledge that I do like a lot of elements of the program and wider system design. I also acknowledge that my perspective is biased towards the medium sized, metro/rural provider viewpoint and then further influenced by my clinical and risk management background. With the deferred start date of the new Aged Care Act we are afforded the gift of time to consider each other’s viewpoint and ideas to see if we can achieve a more equitable and sustainable home care system design for all current and future Australians.

Leaning into my clinical bias, I will present these ideas following the SBAR handover format which stands for Situation (S), Background (B), Assessment (A), and Recommendation (R). The following ideas are presented in no particular order.

Part I of II

1. Commencement of the New Aged Care Act

S: Recently deferred from commencing July 1 2025 to commencing Nov 1 2025.

B: Includes the commencement of the SaH program, statement of rights, strengthened quality standards, provider registration categories, CHSP service alignment, and associated provider registration requirements amongst other things.

A: Nov 1 is a terrible start date for the SAH program as it is a Saturday and does not align with the commencement of an Ongoing classification quarterly cycle.

R: Commence the Aged Care Act 2024 on the currently proposed Nov 1 date but delay the commencement of the SaH program to coincide with the beginning of a quarterly budget cycle. Providers are likely to have significant worker leave to manage on Jan 1 2026 so let’s go for April 1 2026 (or June 1 2026 if taken in combination with idea #3).

2. Additional Home Care Packages

S: 83,000 additional home care packages were scheduled to start being released from July 1 2025 which has now been deferred until Nov 1 2025.

B: There are currently nearly 90,000 older Australians who have been approved as requiring care who are waiting to be assigned a home care package.

A: With the Government's intention to reduce package wait times to 3 months or less the deferral of these additional packages is counter intuitive and will only result in a worsening of the current situation.

R: As part of the required amendment to the Aged Care Act 2024 to revise the commencement date, uncouple the 83,000 additional home care packages and prioritise their expedited release from July 1.

3. SaH Service Pricing

S: Following the announcement in Dec 2024, providers were to set service pricing for the first year of the SaH program before capped pricing was to be introduced from July 1 2026.

B: With the deferred SaH start date, there has been no announcement of whether capped service pricing would still be introduced from July 1 2026 or would be deferred until the second year of the program from Nov 1 2026.

A: Having spent considerable time pondering and discussing the current service pricing information that is available with many providers, associated providers, peaks, and Government representatives it is clear that the sector was not ready for SaH pricing from July 1 2025. In my opinion the disparity in how providers were interpreting the existing rules was only going to result in increased confusion for participants.

R: When viewed in combination with issue #1, I would consider that a better outcome may be to move to a capped service price model from the commencement of the SaH program from July 1 2026 (assuming this is enough time for IHACPA to crunch the numbers).

4. SaH Participant Contributions

S: Of all of the SaH program rules I consider the participant contributions to be one of the most vital elements in order to strike the balance between equity and sustainability (which I feel is not achieved with the current design).

B: I can understand the Government (and taxpayer) perspective behind the current contributions design. With the vast numbers of older Australians that will be entering the 65+ aged bracket over the coming decades, the age dependency ratio (older dependents to working-age population) escalates to an eye watering 38.2% in the early 2060’s up from the current levels of around 27%. This presents all sorts of challenges for the government to fund social security, healthcare, and other services.

A: What I think needs to be reconsidered is the blanket 0% contribution that is applied to 'Clinical Supports' regardless of the participants pension and CSHC status (I will be kicked out of the clinical club for suggesting this).

R: Option a) Introduce a sliding scale contribution rate for the ‘Clinical Supports’ category (ie. Self-funded retirees and part pensioners can afford to contribute to Clinical services also). This resulting reduction in the amount of Government subsidy that is payable could then be used to further offset the costs for our most vulnerable (eg. As an illustrative example, the ‘Everyday Living’ contribution rate for a full pensioner may be able to be reduced to 10% from the current 17.5%).

Option b) Revisit the financial hardship eligibility criteria to make it applicable based on the result of the initial means assessment (not a separate application) and reduce the threshold for when it applies.

Option c) Scrap the whole confusing contributions framework and revisit the levy-based funding mechanism that was initially recommended.

5. SaH Defined Service List

S: The current SaH program rules rely on the Single Assessment System (SAS) in order to both assess and review a participants care needs in order to prescribe funding classifications and services.

B: The reality is that waiting times for both assessment and review are too long and are also impacted by where the participant happens to reside (aka. the location lottery).

A: Even if the SAS hits and maintains its prescribed assessment and review KPIs we are going to end up in situations where a participant is unable to access required care in a timely manner. The perverse outcome will be that in order to meet duty of care requirements under the quality standards, providers will be forced to escalate the care of participants to the primary and hospital health care systems (the very thing the program is trying to avoid).

R: Option a) The Department is already gaining increased control over participant expenditure by introducing the defined services list. Why not allow all SaH participants the ability to access any and all of the services on the defined list in accordance with their agreed care plan with a provider which will enable flexible and responsive changes in care and reduce the support plan review (SPR) burden within the SAS (NB. This is currently what is being afforded to Grandfathered participants until such time as they are reassessed).

Option b) If providing access to the full defined service list is not a viable option then at minimum every notice of decision needs to include Registered Nursing regardless of the participants assessed need at the time.

6. Ongoing Classification Rollover

S: The current SaH rules specify that a participant with an ongoing classification may only rollover the greater of $1000 or $10% of their quarterly budget from one quarter to the next.

B: The current HCP program has resulted in some participants amassing large sums of unspent funding. A lot of people I speak to have not fully grasped that the ongoing classification rollover does not snowball from one quarter to the next (ie. the higher of the 10% or $1000 is not calculated upon any amount of unspent funds you have rolled over from the previous quarter, only your base quarterly budget once the 10% care management has been deducted).

A: Whilst I agree to this shift in approach to ensure that taxpayer funds are being used as intended I would suggest some tweaking of the upper rollover % to allow for some of life’s lumpiness. Consider an example whereby a participant has been in respite or hospital and has additional unspent quarterly funds. It would be ideal to have a buffer of rollover funds available in the next quarter to assist with the higher care needs that is often associated with these transitions in care.

R: Increase the maximum rollover amount to 20% between quarterly budgets.

7. Care Management

S: Under SaH rules Care Management shifts from being a fee (as under HCP) to a service budget. This care management service budget equates to 10% of a participants ongoing quarterly classification.

B: The 10% of each participant’s quarterly budget is grouped together with the other participants within the providers service delivery branch to form a ‘care management pool’ (aka. The pool). The pool is available for the provider to claim against for delivery of the care management service type delivered in connection with an ongoing classification for any participant in the pool (ie. The pool belongs to everyone in the service branch to use if and as they need it if funding is available).

A: I can understand what the Department is trying to achieve with this model but I think the reality will look completely different. Providers will rapidly drain the available pool each quarter in order to deliver the required support levels leaving them to either provide unfunded care management, deliver suboptimal care management levels in order to try and make it last, or even worse, stop delivering care management during a quarter once the pool is exhausted.

R: This idea will be unpopular, but I think Care Management should be treated like any other service for all classifications. The funding remains as part of the participants budget and is claimed against the quarterly budget in line with how much care management the participant requires and agrees to as part of their care plan (which is exactly how it operates under the RCP and EOLP). No more pool. No more 10% cap. Just a budget that is 100% available to fund care based on the participants current need and preferences.

8. Restorative Care Pathway (RCP)

S: Full transparency. The RCP is one of my favourite SAH elements. I do however think the funding needs to be revised in order to achieve the pathways intended purpose and potential.

B: The current Short Term Restorative Care (STRC) program has been delivering some transformative results for our clients for years. This is largely due to the intensive nature of the clinical multidisciplinary team (MDT) that can intervene due to the generous funding. Both STRC and RCP allow a participant to access 2 care episodes per 12-month period.

A: An episode of STRC provides approx. $14k and covers 8 weeks which equates to just over $250 of funding available per day. An RCP episode is $6k and can be used over up to 16 weeks equating to just over $53 per day (a 79 % decrease). Now the caveat being that under the SaH rules a participant can also be potentially accessing assistive technology (AT), home modification (HM), and ongoing classification funding simultaneously making direct comparisons very challenging.

R: a) I would like to see RCP move to the same model as the EOLP whereby a participant cannot access the Ongoing classification simultaneously. Instead, increase the single episode of RCP funding to $12k and drop the time frame to 12 weeks to align with the quarterly ongoing cycles (also see recommendation c).

b) To offset some of this increased cost I believe that participants should have a SPR at the conclusion on an RCP episode and move down classifications levels if their assessed needs have been reduced (which is the goal of the RCP).

c) I would also like to see the 5000 RCP episodes be offered in alignment with the ongoing classification quarterly cycles (eg. There are 5000 RCP episodes that are available to commence July 1, Sept 1, Jan 1, and Apr 1 each year).

9. End of Life Pathway (EOLP)

S: Like the RCP, the addition of the EOLP is a hugely positive step forward for home care to help support the goal of helping older Australians to live within the community setting during end of life whenever possible if that is their choice.

B: The EOLP episode equates to $25k that can be used for up to 16 weeks. Eligibility links to a medical or nurse practitioner confirming an estimated life expectancy of 3 months or less and a score of 40 or less on the Australian-modified Karnofsky Performance Status (AKPS) tool.

A: Like many commentators have already pointed out, end of life assessment is not an exact science and there will be participants who will heroically outlive their 16 week funding allocation. The result? We potentially disrupt the funding continuity of care during this most vulnerable period for the participant and their loved ones.

R: EOLP funding should be converted into a daily subsidy that is payable in addition to a participants ongoing classification. Access to this daily subsidy continues while ever a participant scores 40 or less within the Australian-modified Karnofsky Performance tool.

10. Personal Care

S: The Personal Care service type is essential in helping a participant to complete daily tasks like self-administering medications, changing incontinence aids, having a shower, drying, getting dressed, and grooming. This service type currently sits within the ‘Independence’ contribution category which attracts a contribution of up to 5% for full pensioners and 50% for part pensioners and self-funded retirees.

B: Personal care is one of the foundations of home care and is critical to maintaining the health and wellbeing and dignity of a participant. Current HCP funding does not support daily personal care for most care recipients (which is a sad reality).

A: There is the real possibility that some participants may reduce, or even forgo personal care entirely for periods at a time relating to inability to afford out of pocket contributions. The knock on potential implications of missed medications and medication errors, and increased risk of skin deterioration and pressure injury risk will result in primary care and hospital admissions that will far outweigh the cost of this service being fully subsidised.

R: I would strongly encourage reconsideration of the ‘Personal Care’ service type to be included within the ‘Clinical Supports’ category and therefor attract no client contribution for full pensioners in particular (part pensioners and self-funded retirees could contribute on a sliding scale as per idea #4). The reality of how the 'Personal Care' service type should be operating in best practice is via an assessment and direction from a Registered Nurse or Occupational Therapist. (ie. The clinician completes an assessment of the participant within their home and develops the reablement based personal care plan which is then delivered by community support workers).

Alright, I’ll stop there for now but I do have another 10 ideas semi drafted for another day.

Congratulations (and apologies) if you made it this far. I encourage anyone to add your own comments and challenge, amend, and add to these ideas from your own perspective (but please acknowledge your own biases in the comment so we can learn from each other).

Part II is available here