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Current home-based long term care models are inadequate to support older people to stay at home and out of hospital.
Most older people want to stay at home for as long as possible and their preferences have become increasingly more respected in recent years. Internationally, there has been a shift from long term care delivered in institutions (ie, residential care, nursing homes) to home-based care. In 2023, for the first time in Australia, more people accessed long term home care (n = 315 000), with Home Care Packages, than in residential aged care facilities (n = 250 300). To achieve the goal of supporting older people to live safely in their own homes as long as possible, it is crucial to optimise long term care to support them.
The current national emphasis on delivering more accessible, timely, person-centered home care can mostly be attributed to the recommendations of the Royal Commission into Aged Care Quality and Safety (2018–21) and the resulting Australian Government Aged Care Reforms (2021–ongoing). The Aged Care Reforms have heavily invested in increased accessibility of long term home care. However, to successfully support individuals to stay at home, additional efforts to improve long term home care are necessary beyond investments aimed at increasing access to a strained sector that is facing workforce shortages. An in-depth understanding of the factors that influence successful and safe ageing in homes, what constitutes high quality home care, and evaluation of individuals’ experiences with care are required to ensure investments and resources are efficiently allocated, and outcomes appropriately and regularly monitored and, where appropriate, refined.
The current state of home-based aged care
Our current understanding of the quality and safety of care delivered at home and its effectiveness in keeping people at home is in its infancy. Public reporting on the program by the Australian Government, available since 2017, has focused on limited information relating to access to home care, which is just one element contributing to the quality of care. Other public reporting on the interface of aged care and health care has briefly reported higher hospital separation rates experienced by those in home care packages, compared to those in residential care, in two states, but does not offer any commentary on the need for further monitoring and evaluation. Similarly, national academic population-based research into aged care has focused largely on residential care recipients. This lack of national long term home care research is potentially the result of inadequate infrastructure to allow for in-depth investigations of the delivery of home care, including an understanding of how individuals interact with the health care sector.
It has been recognised that inadequate aged care provision for residential care recipients invariably leads to greater health care needs and system utilisation. Most quality indicators in aged care settings measure exacerbations of health status due to poor quality care, such as pressure injuries, falls resulting in major injuries, and unplanned hospitalisations. National data infrastructure that allows for the examination and evaluation of those in residential aged care are generally in place at the federal level (eg, National Integrated Health Service Information Analysis Asset, which brings together state/territory hospital data with national health administrative datasets, including residential aged care) and state levels (eg, hospital coding that identifies individuals). Furthermore, the National Aged Care Mandatory Quality Indicator Program monitors the quality and safety of residential aged care, although plans for expansion of the Quality Indicator Program to include home care are currently under consideration.
The lack of data infrastructure, national reporting and population-based research about people receiving home care packages has resulted in a substantial gap in the evidence base to improve care and outcomes for people receiving long term home care compared to residential care. Consequently, a potential misconception or omission from important calls to action within the sector exists, for example, that improving the accessibility to long term home care would address national home care needs, and that residential care recipients and those waiting for home care, but not home care recipients, are the main contributors to increasing national hospital demands.
Increasing home care hospitalisations
Recently the Registry of Senior Australians (ROSA) published a descriptive study on the cumulative incidence of hospitalisations and emergency department (ED) presentations in individuals in long term care at home and residential care. The study identified that in 118 999 people accessing home care and 203 278 people in permanent residential aged care in 2019, people accessing home care experienced more ED presentations (43% v 38%), unplanned hospitalisations (40% v 33%), and potentially preventable hospitalisations (12% v 8%). People receiving home care also spent 2.5 times more days in hospital (7745 v 3049 days/1000 individuals) due to unplanned hospitalisations than those in residential aged care. These differences arise from a greater frequency of hospitalisation combined with longer lengths of stay (per stay median days in acute care was 5 for home care recipients v 3 for residents of permanent care). The numbers in the study were from 2019, and the number of home care recipients have since increased by 81% (from 173 743 to 314 971) between the 2019–20 and 2022–23 financial years. Therefore, without intervention, the total number of days spent in hospital by home care recipients will only increase, and may worsen given the lower number of hours reported per home care package recently (from 17 hours/week in 2010 to 7.7 hours/week in 2022 for people with high care needs).
This also aligns with other recent work from ROSA published for South Australian aged care providers. In reports by ROSA that monitor the quality and safety of care experienced by care recipients within South Australia for the 2021–22 financial year, individuals receiving home care (n = 16 843 from 119 home care services) were found to experience more ED presentations (41% v 36%), delirium and dementia-related hospitalisations (11% v 4.5%), hospitalisations that reported pressure injuries (2.3% v 1.7%), malnutrition (3% v 1.1%), and medication-related adverse events (2.7% v 1.2%) than residents of aged care facilities (n = 11 669, 240 facilities). A comparable, and arguably high, incidence of injurious falls (~11%) and fractures (4.5%) were reported for both cohorts. Importantly, it is evident from these reports that some providers have care recipients that experience these events much less frequently than others (not publicly available) and this information should be the starting point of discussions about how providers can learn from each other to promote better care quality.
Optimal levels of care not yet reached
As we learn about the experiences of long term home care recipients, it is evident that many existing programs fail to deliver optimal levels of care. More support from aged care providers is needed for individual care recipients, but so are improvements in continuity of primary care, accessibility to hospital avoidance programs in the community (eg, urgent care centres, care hubs), and several other potential evidence-informed strategies. However, it is difficult to recommend one element over another, when so little information is available about what contributes to successful long term home-based care. Therefore, we recommend creating infrastructures (nationally and within state health authorities) that allow for a more systematic identification of people in home care, evaluation of the services received, and a monitoring framework that evaluates critical outcomes experienced by care recipients. This will ensure home care program development decisions are informed by evidence and in the context of not just aged care but what else is available within the community. The published studies highlighted in this article are not the first indications of how much more individuals in long term home care need support. We further recommend that these infrastructures are in place before the implementation of further reforms (ie, the Support at Home Program planned for 2025), so the sector can strive to become a learning (health) system and drive reform through the best evidence available. Based on the evidence cited in this short report, and of our collective experience within the aged care sector, sustaining and, where possible, accelerating the trend towards more home care requires collective commitment to urgent change.
Professor Maria C Inacio is the director of the Registry of Senior Australians (ROSA) at the South Australian Health and Medical Research Institute and a deputy medical editor at the Medical Journal of Australia
Dr Stephanie L Harrison is a senior post-doctoral research fellow at ROSA at the South Australian Health and Medical Research Institute
Associate professor Keith Evans is an aged care policy advisor at ROSA at the South Australian Health and Medical Research Institute
Professor Gilian Caughey is the associate director of ROSA at the South Australian Health and Medical Research Institute
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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The need for greater integration between the primary healthcare system and the aged care system to enable high-quality care at home for older Australians is highlighted by this article.
Whilst those on home care packages receive care management as part of their package, without better integration with the primary care system, including GPs and allied health workers their clinical status can be missed or poorly managed. This is not the fault of the aged care providers, they are not set up to manage complex medical conditions. Nor is it the fault of the primary care system which does not have the resources to manage the complex social care requirements.
A collaborative team approach between the two systems focused on the aged individuals, and utilising shared information systems is part of the solution.