Navigating the No-Man’s Land: The Gap in Support for Older People and Their Caregivers Before Aged Care
by: Tanya Connor, Insider Information

Navigating the No-Man’s Land: The Gap in Support for Older People and Their Caregivers Before Aged Care

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The Australian aged care system is undergoing critical transformation as it grapples with the increasing demands of an ageing population. However, significant gaps remain, particularly in the phase of accessing formal aged care services where general practice and other primary care professionals are the substantive connection to the health system yet have little knowledge of the intricacies of navigating access to home or residential aged care or the many other programs and supports available. This whitepaper delves into the systemic issues that create barriers to accessing aged care, highlighting the profound impact on older adults and their caregivers. It also underscores the urgent need for policy reform and practical solutions. By examining real case studies, drawing on extensive research, and offering expert insights, we propose a roadmap for closing the support gap to ensure that older Australians receive the care they need before reaching a crisis point. The recommendations include policy changes, creating Medicare items for aged care journey support, improved education for primary care providers, and leveraging aged care expertise to support individuals and their families during the pre-approval phase of accessing aged care services. Additionally, it explores the potential benefits and risks of the forthcoming Support at Home Program, which, while promising to reduce wait times, presents challenges related to the single assessment system that could exacerbate disparities in care outcomes.


Introduction

Australia's ageing population is growing at an unprecedented rate. By 2026, more than 22 percent of Australians will be over 65—up from 16 percent in 2020, which was already double the 8.3 percent at the start of the 1970s (University of Sydney, 2023). This demographic shift results in an increasing demand for aged care services and an increase in the percentage of the population required to support them as family caregivers. Before engaging with aged care providers to deliver formal home or residential care, primary care—general practitioners, allied health professionals, and pharmacists—is the primary connection to the health system and the need for ageing support. However, there is a stark disconnect when transitioning through the ageing journey into receiving formal aged care services. This disconnect leaves many older Australians and their caregivers in a vulnerable position, often without the information, support, or guidance they need during critical times.

This whitepaper seeks to explore the challenges faced by older Australians, their caregivers, and healthcare professionals during this transitional phase—from identifying that formal aged care services are required to receiving them—a period that typically spans a year or more. The frustration, stress, and unavailability of useful information exacerbate the already fragile condition of the older person and their caregivers. It also proposes practical solutions that could be implemented at a systemic level to bridge the gap while navigating access to aged care service approval while still under the care of their primary care providers and family caregivers and not yet supported by aged care providers. The ultimate aim is to ensure that individuals receive timely and appropriate support, reducing the burden on families and the healthcare system. With the implementation of the Support at Home Program in 2025, these issues may become more pronounced due to the single assessment system, emphasising the need for comprehensive information, knowledge, and advocacy during the assessment process.


The Current Landscape

A System at Odds: Diagnosis vs. Impact

General practice, allied health professionals, and pharmacists are essential for supporting older Australians throughout their ageing journey before, during, and after implementing formal home care and residential care delivered by aged care providers. However, the intersection between primary care and the aged care access system presents significant challenges due to the differing foundational principles of these systems. While primary care is inherently medical and diagnosis-based, aged care is impact-based, focusing on individuals' functional capacities and needs to maintain daily activities and social connections as they age. This fundamental difference creates a complex landscape for older adults attempting to navigate the processes to access aged care services through My Aged Care, armed with information from their primary care history based on a medical model and diagnosis, leaving them ill-prepared for the functional, impact-based questions of the aged care screening and assessment process. Further, the nuances of effective caregiving are different from the forte of primary care, and the vast experience contained within the professionals of the aged care sector is inaccessible to those navigating the role of primary caregiver.

The forthcoming Support at Home Program, set to commence in 2025, aims to streamline access to home care services by unifying existing programs like the Commonwealth Home Support Programme (CHSP), Home Care Packages (HCP) and the Short Term Restorative Care Programme (STRC). While this reform proposes to reduce wait times, the single assessment system it introduces may pose additional challenges. This system centralises service eligibility determination, with a return to assessment required for changes to the developed support plan. Research into similar systems, like the NDIS, has shown that outcomes can vary significantly based on a participant's knowledge and ability to advocate effectively during the assessment process (Mavromaras et al., 2018). Implementing reforms reliant on this centralised single point of failure requires that older Australians and those supporting them be provided with information and advocacy to prevent disadvantage.

My Aged Care: Gateway or Gatekeeper?

The Australian Government's My Aged Care system, established as the gateway to accessing aged care services, is intended to streamline access to aged care services. Although anyone can refer to My Aged Care, the system's complexity and the gatekeeping role of My Aged Care and assessment teams create barriers to accessing necessary services. Only some outside these entities understand the intricacies of navigating a successful outcome to obtaining the support required for an older person, making it time-consuming and challenging for older people, caregivers, and primary care professionals to navigate the system to access aged care services effectively.

The Role of General Practitioners

General Practitioners (GPs) are often the first point of contact for older adults experiencing health declines or loss of independence, frequently making or proposing the initial referral to My Aged Care. However, the medical model's focus on diagnosis and treatment may not align with the functional information about daily living activities assessed for aged care service approval. Moreover, the constraints of the Medicare system exacerbate these challenges, as current funding does not support the extensive discussions and guidance required to navigate the aged care system effectively. GPs spend up to 20% of their working hours on non-billable tasks, a figure expected to rise with the ageing population (Brown et al., 2021). The lack of reimbursement for these activities challenges the economic viability of GP practices in supporting patients to access aged care services. This limitation in billable time, combined with the unavailability of streamlined information and resources for navigating aged care and caregiving, leaves older adults without the necessary knowledge, skills, and support. As a result, many are deemed ineligible for services, exacerbating their health issues and placing additional strain on caregivers.

The Support at Home Program may help alleviate some of these pressures by creating a more streamlined and transparent system. However, the success of this program will depend largely on the ability of GPs and other primary care providers to adapt to the new assessment processes and effectively guide or support their patients in articulating their needs during the single assessment process. Without proper preparation and support, the risk remains that older Australians will continue to fall through the cracks, unable to access the services they need promptly.


The Human Impact of the Support Gap

Systemic Delays and Their Impact

The design of the current system often results in older adults being deemed ineligible for services due to their inability to articulate their needs in a manner that aligns with the binary screening questions or aged care assessment methods. Further compounding this is the nature of the initial call to or from My Aged Care, which functions as a screening tool. Most older adults and caregivers are unaware that their responses during this call will determine their eligibility for further assessments and services. This natural reluctance to present themselves or their older loved one as incapable, combined with the structured nature of the screening process, often results in older adults being classified as ineligible for services despite their actual need for support. The situation has changed little since the Royal Commission into Aged Care Quality and Safety highlighted these challenges for those who need aged care services. Even after successfully passing the initial screening, older adults can face further delays or removal from the assessment list due to a poorly timed follow-up call from the assessor, often weeks or months later. Consider a family caregiver who manages all daily care tasks—meals, cleaning, appointments, laundry—for their loved one, who may not fully grasp the extent of support they receive. The caregiver is nominated as the My Aged Care Representative, and the older person is deemed eligible for further assessment. However, when the assessor calls the older person directly, they may downplay their needs out of stoicism, saying, "I'm doing okay," or "I don't need help because my daughter helps me." This response can lead to an immediate removal or delay of the assessment, leaving the caregiver unaware and the older person at significant risk if the caregiver becomes unavailable.

Moreover, inefficiencies and delays within the system have serious implications for older adults and their caregivers. Delays in accessing Home Care Packages (HCPs) can significantly affect health outcomes, including increased mortality rates (Edney et al., 2023). The complexities and inefficiencies of the system in accessing aged care also place a considerable burden on caregivers, who often need more formal services to provide adequate support.

The introduction of the Support at Home Program is anticipated to streamline access to services, potentially reducing some of these delays. However, the reliance on a single assessment system also introduces risks, particularly for those who are not fully informed or aware of how to advocate effectively during the assessment process. The apparent absence of consumer satisfaction data from the Integrated Assessment Tool (IAT) live trial further complicates our understanding of how well this new system will serve older Australians. Previous research on consumer-directed care highlights that outcomes can vary significantly based on socioeconomic status, health literacy, and the ability to advocate for oneself (Dow et al., 2013). Without adequate support and information, the benefits of reduced wait times could be undermined by disparities in care outcomes.

The Consequences of Delayed Care

The process to obtain government-subsidised aged care services is lengthy. Access is through an initial phone screening interview with My Aged Care, which, if eligible, initiates a referral to a needs assessment process conducted by the Regional Assessment Services (RAS) for CHSP or the Aged Care Assessment Teams (ACAT) for HCP and residential care.

Delays in accessing aged care services are well known and result from government caps on supply, increasing demand, and prioritisation processes. According to Australia’s Aged Care Sector: Mid-Year Report 2023-24, in December 2023, more than 50,000 people were waiting for a home care package at their approved level. This does not account for those approved but unable to access entry-level assistance under the Commonwealth Home Support Programme (CHSP), which services more than 800,000 older people. The time taken to assess and approve individuals for aged care services contributes to additional delays, which can extend to many months and are not counted in these wait times. With most people approved initially for the CHSP, their hope is short-lived when they face the reality that the services they have been approved for are inadequate to meet their needs and virtually impossible to secure due to funding to providers being exhausted or workforce shortages resulting in CHSP providers being unable to deliver services effectively even when funding is available.

Even when individuals manage to access the aged care system, the journey often begins with multiple calls that result in people being told they are ineligible before successfully making it through the My Aged Care screening process. This is followed by delays extending up to 18 months before they can obtain services. This leaves older people and their caregivers feeling unvalued, ill-informed, frustrated, disillusioned, and desperate with the crisis point that enabled them to articulate their needs and gain access through My Aged Care further exacerbated. This time and lack of support it takes to reach aged care providers damages those future care relationships with the aged care provider before they have begun, leaving aged care providers to rebuild trust that has been eroded by delays and complexity unrelated to them. This erosion of trust in the aged care system can have long-lasting effects on the care recipient and caregiver's experience of the aged care services they ultimately obtain and their overall well-being.

Impact on Older Adults

The unavailability of support to access the aged care system and the wait for aged care services have a profound emotional, physical, and psychological toll on older adults and their caregivers, who find themselves in a "no man's land" with little knowledge and support to navigate this complex path. Delayed access to necessary care can exacerbate existing health conditions, leading to a decline in physical health, increased frailty, and a higher risk of adverse outcomes, such as falls and hospital admissions.

Research highlights that delayed access to Home Care Packages (HCP) is associated with poorer health outcomes, including increased mortality rates among older adults awaiting care (Edney et al., 2023). The psychological impact is also significant, as older adults may experience anxiety, stress, and a sense of hopelessness as they struggle to navigate a system that seems to work against them rather than for them. The cumulative effect of these challenges can lead to a rapid decline in overall health and quality of life.

The Support at Home Program may offer some relief by unifying services under a single framework, potentially reducing the time it takes to receive care. However, the centralised nature of the assessment process could also mean that older adults who cannot identify and communicate their needs effectively might still face barriers to accessing appropriate care. This underscores the importance of ensuring that the assessment process is both accessible and supportive, with adequate provisions for advocacy and information dissemination to those who need it most.

Impact on Family Caregivers

Family caregivers, who often step in to fill the gaps in support, face immense stress and financial strain. The demands of caregiving can lead to personal, annual, or even leave without pay as they take time off work to care for their loved ones. In more severe cases, which happen more frequently than expected, caregivers may feel compelled to resign from their jobs, further exacerbating financial strain and contributing to long-term economic instability.

Older caregivers, particularly spouses, often suffer worse health outcomes than the person they are caring for, as the physical and emotional toll of caregiving can lead to significant health issues (Gaugler et al., 2010). The impact of being an informal carer extends beyond just the caregiver, affecting broader family dynamics and the well-being of the caregiver's children and partners due to the time, physical and emotional demands of caregiving. The lack of knowledge on how to provide proper care and the stress of managing incidents such as falls or medical emergencies can lead to a deterioration in the caregiver's health, both mentally and physically (Sarris, 2020).

The introduction of the Support at Home Program is proposed to mitigate some of these issues by streamlining the process and reducing delays. However, without addressing the underlying need for better information and advocacy support during the navigation assessment and planning phases, caregivers may continue to struggle. The risk of varying outcomes based on a caregiver's ability to navigate the system remains a significant concern.


Economic and Social Implications

The economic and social implications of the support gap leading up to aged care services extend beyond individual families to the broader society. As caregivers are forced to reduce their workforce participation or leave their jobs entirely, there is a significant loss of productivity and skills within the workforce. This loss not only impacts the immediate family but also has long-term consequences for businesses and the economy.

A report by the Productivity Commission of Australia (2011) found that early intervention in aged care services is cost-effective, helping prevent or delay the need for more intensive and expensive care, such as residential aged care, by addressing issues before they escalate. The Australian Institute of Health and Welfare (AIHW) reported that early provision of community-based aged care services leads to lower overall health system costs by reducing reliance on hospital services and delaying the transition to residential care (AIHW, 2018).

Moreover, the lack of adequate support systems and resources can lead to increased demand for emergency services, as older adults and their caregivers turn to hospitals as a last resort when other avenues of care are inaccessible.


Case Studies

Dennis' Story: Falling Through the Cracks

Dennis, an 85-year-old man living alone with no family support, suffers from Chronic Obstructive Pulmonary Disease (COPD) and severe arthritis. Despite his deteriorating health, Dennis has been denied support from My Aged Care on three occasions. The screening questions used during his assessments did not capture the reality of his situation—Dennis can technically shower and eat on his own. However, the physical toll of these activities has left him barely functioning. His home has become cluttered because he can no longer reach to put things away, and with necessary items required within arm's reach of his bed and chair and his diet consists of premade sandwiches brought by a neighbour if he isn't up to his twice-weekly walk to the nearby shops. Dennis is a classic example of someone who falls through the cracks in a system designed to intervene only when a crisis occurs.

John and Mary's Journey: The Cost of Delayed Support

John, a 78-year-old man, began experiencing significant mobility issues and cognitive decline, which led his wife, Mary, to seek help through the My Aged Care system. Despite John's deteriorating condition, the initial assessment labelled him as "not yet eligible" for a Home Care Package (HCP), primarily because the needs weren't articulated in a way that matched the criteria. Over the next year, John's health declined further, leading to frequent falls and increased dependency on Mary, who was struggling to manage her own health issues. It wasn't until John had a severe fall that instigated by the hospital they were reassessed and finally approved for a HCP. However, by this time, John's condition had worsened significantly, and the delay had caused immense physical and emotional strain on Mary, leading to her own hospitalisation and subsequently John’s admission to residential care.

Evelyn's Experience: Navigating the System Alone

Evelyn, an 82-year-old woman living alone, was advised by her GP to apply for aged care support as her ability to care for herself had diminished. Her daughter, Sarah, took on the role of navigating the My Aged Care system. The process was overwhelming. Sarah struggled to balance her full-time job, her own family, and the demands of coordinating care for her mother. Despite being placed on a waiting list, it took over ten months for Evelyn to receive any support, during which time her health deteriorated. Sarah eventually had to take unpaid leave from work to provide the necessary care, causing financial strain on her family. The prolonged waiting period and lack of immediate support led to significant stress and guilt, impacting the entire family dynamic.

Frank and His Daughter: The Toll of Private Care

In his late 80s, Frank lived with his daughter, Amanda, his primary caregiver. As Frank's health needs increased, Amanda sought assistance through the aged care system. However, the complexity of the system and the significant delays in receiving an HCP meant that Amanda had to cover the gap with private services, which quickly depleted their savings. Frank's physical and mental health declined as they waited for formal support, placing immense pressure on Amanda, who eventually had to quit her job to care for her father full-time. This financial strain and the emotional toll led to a breakdown in their relationship, as both struggled with feelings of frustration and helplessness.


Analysis of Case Studies

These case studies reveal common themes and challenges that highlight the deficiencies in access of the current system. Stories remain unchanged since the revelations of the Royal Commission into Aged Care Quality and Safety despite prioritising navigation and caregiver support within the recommendations. The difficulties in identifying and articulating needs, the complexity and fragmentation of the system, gatekeeping, and delayed support all continue to contribute to the adverse outcomes experienced by older adults and their caregivers.

The binary nature of the assessment questions used by My Aged Care fails to capture the needs of older people, leading to delays in accessing necessary services and disillusionment with the aged care system. This is compounded by the lack of early intervention and guidance, which could prevent many of the issues highlighted in these case studies.

The introduction of the Support at Home Program offers a potential solution to some of these issues by unifying services under a single framework and potentially reducing wait times. However, the reliance on a single assessment system also introduces new risks, particularly for those who may not be fully informed or capable of advocating effectively during the assessment process. The absence of consumer satisfaction data from the IAT live trial further complicates our understanding of how well this new system will serve older Australians, highlighting the need for careful monitoring and ongoing support to ensure equitable outcomes.


Policy and Systemic Recommendations

The Importance of Early Intervention

Research consistently supports the notion that early intervention with aged care services can significantly improve outcomes for older people, their caregivers, and the economy. However, the current system continues to deny access to services until a crisis point is reached, which exacerbates the issues rather than addressing them early on.

Improved Health Outcomes for Older People

Early intervention with aged care services can delay the progression of chronic diseases and reduce the need for emergency hospital admissions. A study published in the Journal of Aging & Health found that timely access to home care services was associated with better health outcomes and reduced hospitalisation rates among older adults (Arber & Ginn, 2015). Another study in BMC Geriatrics highlighted that early engagement with aged care services, such as home modifications and community support, significantly improved the quality of life and physical health of older adults by enabling them to maintain independence longer (Keefe et al., 2016).

The Support at Home Program, by centralising services and potentially reducing wait times, could enhance the timeliness of care. However, without addressing the need for better information and advocacy during the assessment and planning phases, the benefits of early intervention may not be fully realised. While designed to streamline processes, the single assessment system must be carefully managed to ensure that it does not inadvertently widen the gap in care outcomes based on socioeconomic status, health literacy, and advocacy capabilities.

Benefits to Caregivers

Research in the Journal of Gerontological Social Work shows that early access to respite care and support services for caregivers can reduce caregiver burden, prevent burnout, and improve mental health (Gaugler et al., 2010). The efficiencies and caregiving confidence that comes from early access to information and guidance allow caregivers to continue in their role without experiencing severe stress and reduce the likelihood of premature entry to residential care of the older adult. Early intervention also allows caregivers to maintain their employment and financial stability, as they are less likely to have to leave work or reduce their hours to provide care, which has significant economic implications (Navaie-Waliser et al., 2002).

The streamlined services under the Support at Home Program are proposed to provide quicker access to aged care services. However, the variability in outcomes based on a caregiver's ability to navigate the system remains a significant concern, particularly given the risks associated with the single assessment system. Ensuring that caregivers have access to adequate information, training, and advocacy support will be critical to achieving equitable outcomes under the new program as it has been in the past and current systems.

Economic Benefits

A report by the Productivity Commission of Australia (2011) found that early intervention in aged care services is cost-effective. Addressing issues before they escalate helps prevent or delay the need for more intensive and expensive care, such as residential aged care. This saves public funds and reduces the economic burden on families. The Australian Institute of Health and Welfare (AIHW) has reported that early provision of community-based aged care services leads to lower overall health system costs by reducing the reliance on hospital services and delaying the transition to residential care (AIHW, 2018). This is reinforced in the AIHW report on Older Australians which highlights that early provision of community-based aged care services continues to play a critical role in reducing overall health system costs by decreasing reliance on hospital services and delaying the transition to more intensive forms of care, such as residential aged care.(AIHW, 2024)

The potential for the Support at Home Program to reduce wait times and streamline access to services presents an opportunity for significant economic benefits. However, these benefits will only be fully realised if the system is designed and implemented to ensure equitable access to care. The risks associated with the single assessment system, including the potential for disparities in outcomes based on socioeconomic status and advocacy capabilities, must be carefully managed to ensure the program achieves its intended goals.


The Role of the Care Finder Program

In response to the widespread challenges faced by older Australians and their families in navigating the My Aged Care system, which was identified during the Royal Commission into Aged Care Quality and Safety, the Australian government has introduced the Care Finder program. This initiative is specifically designed to assist older people in navigating to access aged care services. However, it is limited to those who do not have any support person in addition to other communication barriers.

Policy Gaps and Opportunities

While the Care Finder program is a significant step forward for a small, defined cohort of older people, it also underscores the need for more comprehensive and systemic reforms. The existence of such a program suggests that the current structure of My Aged Care is too complex for many Australians to navigate independently. This raises important questions about how the system could be simplified or supported by additional resources to ensure that all older Australians can access the care they need without requiring specialised assistance.

The Care Finder program should be seen as a temporary solution to a much larger problem. Policy efforts should focus on simplifying the My Aged Care process, enhancing the accessibility of information, and providing better education and resources for both consumers and primary care providers. In doing so, we can create a system where programs like Care Finder are less necessary as the pathways to aged care become more straightforward and accessible.

A major oversight is the significant gap in supporting primary care providers with the knowledge, efficient processes, resources, and funding needed to assist older people and caregivers during the journey to accessing aged care services. Primary care professionals, already under pressure from the demands of an ageing population, are well-positioned to guide patients through this complex system. However, their ability to provide the necessary information and guidance is severely limited without adequate support. Leveraging primary care providers' skills and existing relationships efficiently requires providing simple, efficient tools and resources that enable them to assist patients more effectively without adding to their already substantial workload.


Proposed Solutions

  1. Medicare Items for Aged Care Journey Support: Introduce Medicare item numbers that allow primary care professionals to bill for consultations specifically focused on aged care navigation. This would include time spent on detailed consultations, coordination with My Aged Care, and developing comprehensive care plans that address medical and non-medical needs.
  2. Education for Primary Care Providers: Implement training programs for GPs and other primary care professionals focused on the aged care system. This training should include practical guidance on effective referrals and clarity on responding to patient challenges with the aged care access system and caregiving.
  3. Aged Care Expertise for Pre-Aged Care Support: Establish a network of aged care advisors who can provide independent, unbiased guidance to older Australians and their families during the pre-approval phase. These advisors would help individuals understand the processes and their options, guide the identification of their needs, and troubleshoot caregiving challenges while they wait for formal aged care services.
  4. Aged Care Toolkit for Primary Care Providers: Develop a comprehensive aged care toolkit for primary care providers and individuals based on the ageing journey, which includes information about relevant programs, supports, eligibility, and referral pathways for all stages of the journey. The toolkit would include fact sheets created with expertise from the aged care sector, designed for consumers at each stage, providing practical guidance, resources, and links to relevant organisations. Topics covered could include managing long-distance caregiving, home safety, nutrition challenges, mobility and transfer techniques, managing personal care, continence, challenging behaviours, preparing for My Aged Care screening and aged care assessments, and more.
  5. Group Coaching Sessions: Offer group coaching sessions hosted by aged care experts, accessible live or on-demand, to provide caregivers and older adults expert guidance on caregiving and system navigation. These sessions would cover key topics such as preparing for assessments, understanding My Aged Care, selecting providers, and the many aspects of the caregiving journey.?


The Role of Stakeholders in the Solutions

Primary Care

Primary care providers, as the cornerstone of healthcare, are crucial in guiding and assisting older Australians as they navigate the complex landscape of aged care services.

Primary care providers must be educated on how to effectively guide individuals through the aged care system. By equipping GPs and other primary care providers with the necessary knowledge and tools, they can better support their patients in articulating their needs and ensuring they receive the appropriate care services in a timely manner. This will likely reduce the unbillable time they currently spend supporting older people.

One proposed solution is to integrate training programs that focus on aged care navigation into the ongoing education of primary care providers. Additionally, as previously described, an aged care toolkit for primary care professionals would assist in streamlining the time required by primary care and give consistent, accurate information to consumers who currently rely largely on peer discussion groups.


Aged Care Providers

Aged care providers also have a pivotal role in supporting individuals before they officially enter the aged care system. The journey to aged care begins long before services are formally in place, with many individuals and their families struggling to navigate the process independently. Unfortunately, the complexities and delays often experienced during this period can result in frustration and anger at the aged care system and damage the relationships and trust between the care recipient, their families, and aged care providers before the relationship begins.

To mitigate this, aged care providers should focus on improving their understanding of, acknowledgement of, respect for, and response to the consumer journey to aged care. This could involve developing more consumer-centric entry processes designed to rebuild trust and ensure a smoother transition into aged care service delivery. By proactively engaging with potential clients and offering guidance and support before they enter formal aged care services, providers can help alleviate some of the stress and uncertainty that often accompanies this process.

Moreover, aged care providers could develop partnerships with primary care providers to create a more integrated support network for individuals navigating the aged care system. Such collaborations would ensure that both medical and non-medical aspects of ageing are adequately addressed, leading to better outcomes for older people and their caregivers.


Government and NGOs

Government and non-governmental organisations (NGOs) are critical in bridging the gaps within the aged care system, particularly in supporting individuals and their caregivers before they enter formal care. One of the significant policy gaps identified is the lack of a coordinated system to provide early and ongoing support to people as they age before they are eligible for aged care services.

Governments could address this by funding or subsidising programs that leverage aged care expertise to support people throughout their caregiving journey. Such programs would ensure that individuals receive the necessary guidance and support early on, which could prevent crises and reduce the overall strain on the aged care system. Additionally, there should be a focus on educating both consumers and health professionals about navigating the aged care system, including the many fragmented supports currently available.

NGOs can play a complementary role by offering independent advocacy and support services that help individuals and their families navigate the complexities of aged care. By providing unbiased information and assistance, NGOs can help to ensure that people are making informed decisions and are accessing the appropriate services at the right time.


Community and Family Engagement

Lastly, community support networks and family caregivers are essential for the aged care landscape. However, they are often under-resourced and under-prepared for the challenges they face. To better equip and support these groups, there needs to be a greater emphasis on community and family engagement initiatives, greater media representation of practical strategies and positive impacts of early acknowledgement of independence, choice and control of the ageing journey.?

One effective approach could be the provision of media columns, webinars, educational programs, and group coaching sessions that address the specific challenges of caregiving and system navigation and where stories and practical strategies shared provide family caregivers with the knowledge and tools they need to feel more informed and confident in caregiving and reduce the isolation and stress they often experience.

By empowering communities and families with the right information and support, we can create a more resilient and responsive ageing journey that truly meets the needs of older Australians and their caregivers. This holistic approach, which involves primary care, aged care providers, government bodies, NGOs, and the community, is essential in closing the current gaps and ensuring everyone fortunate to live a long life has access to the care and support they need.


Conclusion

The journey to aged care in Australia is fraught with challenges, leaving many older Australians and their caregivers struggling to navigate a complex and fragmented system. The frustration, anxiety, and fear generated by this difficult process often result in care relationships with aged care providers starting from a negative position, where individuals feel they have had little informed choice or control. The lack of information, resources, and funding to support primary care professionals in effectively guiding and assisting patients through aged care assessments is a missed opportunity. This gap delays access to necessary care, exacerbates health issues, places undue strain on caregivers, and intensifies the demands on primary care providers as they contend with escalating well-being concerns. This whitepaper highlights the critical need for early intervention, better integration of services, and increased support for individuals and their families throughout the journey to accessing aged care services.

The Support at Home Program presents an opportunity to address some of these issues by unifying services and potentially reducing wait times. However, the risks associated with the single assessment system and the lack of consumer satisfaction data from the IAT live trial underscore the importance of careful monitoring and ongoing support. It is crucial that the system be designed and implemented to ensure equitable access to care, with adequate provisions for information, knowledge, and advocacy to support older Australians and their caregivers throughout the assessment and planning phases.

By addressing the systemic issues outlined in this paper and implementing the recommended policy changes, Australia can create a more compassionate and efficient ageing journey ensuring they receive the care they need before reaching a crisis point. The solutions proposed here are not just about improving the system for the future but are urgently needed today to support the growing number of older Australians who deserve a dignified and well-supported ageing experience.


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Tanya has over 20 years of experience in senior and executive roles within the aged care sector. She founded Insider Information to provide on-demand access aged care experts to enhance the internal capabilities of aged care organisations. Committed to improving the aged care journey for both providers and consumers, Tanya has expanded the reach of Insider Information to support individuals and families, offering unbiased guidance from seasoned experts to navigate the complexities of ageing, caregiving, and aged care. Tanya is spearheading the Aged Care Unveiled Summit in Melbourne, bringing together primary and acute healthcare professionals, older people and caregivers to enhance their understanding of the aged care system and the outcomes they receive.

To register for the summit go to https://pages.insiderinformation.com.au/aged-care-unveiled-1-day-event


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