Why we’re struggling to meet demand for subsidised home care

The Royal Commission into Aged Care Quality and Safety focuses on aged care in the home.

aged care at home wheelchair

Michael Woods, University of Technology Sydney and Sarah Wise, University of Technology Sydney

The Royal Commission into Aged Care Quality and Safety is this week turning its focus to aged care in the home.

So far it has heard evidence of long waiting times to access home care services and a complicated system of fees. It’s only a matter of time before it questions the reasons behind those wait lists and fees.

Unlike aged care, access to many health care services is unlimited. Anyone can seek an appointment with their GP or turn up to a hospital emergency department, in most cases for free.

But the number of home care packages available to older Australians is capped, and the frail elderly are asked to foot some of the bill.

While some may argue to uncap the number of home care places, and replicate parts of the health system by providing free care for all, it’s not that simple. Governments will keep increasing the number of subsidised home care services in response to needs, but costs will also keep rising.

The challenge is to find the right funding balance between individuals and taxpayers, and for the system as a whole to remain sustainable.


Read more: Aged care failures show how little we value older people – and those who care for them


Why are many health services free?
Australia has a high standard of health care, which supports people to live to a longer, and generally healthier, old age.

Our Medicare system of funding is based on the principle of universal public health insurance which is paid for by the government (that is, the taxpayers). Public patients receive free care in public hospitals. Medical services by GPs and specialists are subsidised, as are many blood tests, X-rays and other imaging, allied health services (such as optometry), and most medicines.

In the year to September 2018, 86 per cent of all GP attendances were “bulk billed” (provided at no cost to the patient).

These benefits, however, come at a cost. About 10 per cent of Australia’s economic output (gross domestic product) is spent on health care and two-thirds of this is funded by governments.

And, of course, not all health services are free for most people. Visits to dentists, physiotherapists and others are regular reminders of this. A more equitable way of funding dental care is one of the emerging issues for the upcoming federal election.


Read more: Two million Aussies delay or don't go to the dentist – here's how we can fix that


What is home care?
Aged care plays a different role to health care in supporting people to stay at home. There are two forms of home care.

First, the Commonwealth Home Support Program assists with daily activities such as meals, transport and personal care (showering, dressing, and so on) and some allied health services such as physiotherapy and podiatry (foot care).

In 2016-17, around 723,000 people received one or more of these services.

Second, Home Care Packages provide expanded support, with daily activities as well as more complex health care from nurses and allied health workers.

At September 2018, there were over 90,000 people receiving one of the government’s subsidised Home Care Packages.

Why are many elderly asked to help pay for home care?
Australia’s population is ageing. In 2017 3.8 million Australians were aged 65 and over. In the next 40 years this will probably grow to 8.8 million. The costs of funding aged care will continue to increase.

In 2011, when one of us (Michael Woods) was the presiding commissioner on the Productivity Commission’s inquiry into aged care, we put forward three principles to help governments create a sustainable funding models for aged care:

- accommodation and everyday living expenses should be the responsibility of individuals, with a safety net for those of limited means

- health care services provided through aged care (such as nursing and allied health care) should be subject to charging arrangements consistent with those in the health care system

- individuals should contribute to the cost of their personal care according to their capacity to pay, but should not be exposed to catastrophic costs of care.

The current fee arrangements broadly reflect the intent of these principles.

The government aims to keep fees for the basic Commonwealth Home Support Program at very affordable levels and has produced fee guidelines for providers. There are no formal income tests and while some providers do no more than seek a voluntary contribution for some services, others may recover around 10% of the cost of some services as direct fees or membership subscriptions.

For the more complex and higher cost home care packages, providers can charge consumers a basic daily fee of 17.5 per cent of the basic rate of the single age pension.

There is also an income-tested care fee, which recognises many older people have a greater capacity to contribute to the costs of their everyday living expenses. As a safety net for all, however, there are annual and lifetime caps on these fees.


Read more: Explainer: what is a home care package and who is eligible?


The home care system has many issues to address, but it is not in crisis
Despite the growing number of government-subsidised home care packages, the latest aged care statistics show that at December 2018 there were over 127,000 people on a national priority list for services that met their needs.

The wait time for some, sadly, is too long. However, some subsidised help is available for nearly all people on the list. Over 96 per cent of people on the list had been offered, and were generally accepting, a lower level of subsidised support while they waited for a higher level of service.

There are also questions about how this queue is created and the assessment process itself that the royal commission may want to follow up.

For example, not all assessments and referrals to services are necessarily based on current needs. At December 2018, 96,000 people who were waiting for their approved level of home care package also had an approval for a permanent place in residential aged care. This suggests the assessment process may contain an element of anticipating future needs, rather than reflecting current needs.

Another concern with the current assessment process is a lack of focus by some assessors on helping older people to regain a level of independence through short-term “reablement” programs rather than adding them to the queue for ongoing services. As the Department of Health notes, a wellness and reablement approach in assessment and service delivery is not being consistently and effectively applied across the regions.


Read more: There is extra funding for aged care in the budget, but not enough to meet demand


For the foreseeable future we can expect the government to keep increasing the number of subsidised home care services, but it will also keep a careful eye on the balance between public and private funding, and seek to keep the overall cost to the elderly and to the budget within sustainable limits.The Conversation

Michael Woods, Professor of Health Economics, University of Technology Sydney and Sarah Wise, Senior Research Fellow in Health Policy, University of Technology Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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    COMMENTS

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    Ted Wards
    21st Mar 2019
    10:07am
    When you look at the figures of who receives what, less than 5% of the total population of older people end up in residential care, so should it not follow that 5% of the funding goes to residential care and 95% of funding goes to CHSP & Home Care Packages? It doesn't happen though. As all residential care facilities are privately owned, why do they get such a big slice of the pie?
    MICK
    21st Mar 2019
    5:06pm
    Not all older Australians require Aged Care. Only those who cannot manage do.
    The issue with these packages is I believe a 2 year delay. So if your mother is at the stage of having to be cared for and needs a package she'll have to wait for 2 years to get it? Kidding?

    The reason for home care is the cost of care in a Nursing Home is huge. Unless the elderly are paupers they'll be expected to fund a part of this but readers need to realise the government component can be $250 a day if high care is required and on top of that the facility will ask the retiree to contribute around $100 a day on top of that depending on the level of care sought. The private rooms are expensive.
    tams
    22nd Mar 2019
    7:43am
    Sorry to amend your statistics

    Aged Care facilities
    10% owned by Governments
    36% owned by For profits
    54% owned by Charities/ not for profit
    tams
    22nd Mar 2019
    7:43am
    Sorry to amend your statistics

    Aged Care facilities
    10% owned by Governments
    36% owned by For profits
    54% owned by Charities/ not for profit

    21st Mar 2019
    10:17am
    The future looks very gloomy. The government is blaming the large amount of baby boomers causing funding issues. Due to the large influx of immigrants the future is not looking good as the numbers requiring aged care will increase dramatically. God help Australia.
    sunnyOz
    21st Mar 2019
    10:46am
    Jannie - I am fully with you on your opinion. I have just spent months going through the home care debacle with my elderly aunt that I assisted caring for, and that was a frightening eye opener. First sorting out the home care package, then the actual care. Carers turning up late or not at all, plus a continual rotation of different carers, many with limited English. Jobs - like house cleaning - done so poorly, I usually did a clean after they had left. They would quickly run the vacuum around - but then not empty it, which my aunt could not do. Certain things the home care package did not cover - like cleaning windows.
    In the end, as reluctant as she was, my aunt made the decision to move in to an Aged Care facility. It scares the S..T out of me, and the country cannot and will not be able to cope with the number of seniors. Only yesterday the PM was boasting he had 'slashed immigration figures'. What a joke! Wasn't a slash - was a trickle! I am just grateful that I won't live long enough to be around in 30 years time to see the mess this country is heading into.
    Tom Tank
    21st Mar 2019
    11:21am
    Residential aged care facilities rely very heavily on migrant labout to do most of the tasks. The wages are low but the vast majority of employees are both very caring and good workers.
    An issue with aged care is that most are run by companies for profit and maximisation of profit, in the main, can be the name of the game.
    Staffing levels are not mandated and there is always a drive to dispense with the need to have a Registered Nurse on duty.
    Tom Tank
    21st Mar 2019
    11:21am
    Residential aged care facilities rely very heavily on migrant labout to do most of the tasks. The wages are low but the vast majority of employees are both very caring and good workers.
    An issue with aged care is that most are run by companies for profit and maximisation of profit, in the main, can be the name of the game.
    Staffing levels are not mandated and there is always a drive to dispense with the need to have a Registered Nurse on duty.
    Anonymous
    21st Mar 2019
    4:51pm
    Tom Tank what you say is true the facilities use migrants with limited English. Can you imagine how frustrating this must be for the elderly. I do not agree that they are caring and good workers as my mother in law is in a facility and I have observed what goes on. One day the do gooders and politicians will be in need of care as they will get old also. They will then get some of their medicine back. The future is not good for the elderly and sick.
    MICK
    21st Mar 2019
    5:10pm
    Jannie - they come after you by denying you a pension. They come after you with their capital gains tax even if you make a below CPI profit (that's a loss in real terms. They come after the assets of your estate with the same.
    The bastards do not even have the decency of providing aged care support unless you are destitute. Seems like the bloody minded casino always wins and wastes everybody's hard earned money whilst pushing those who need help onto the streets to fend for themselves.
    Anonymous
    24th Mar 2019
    11:35am
    I fully expect to have to pay for any aged care I will require in the future. I am under no illusions at all that I will get anything from government. We need more taxpayers to pay for all that is required and if we dont taxes will have to be increased. people will love that I am sure!
    Buggsie
    21st Mar 2019
    11:23am
    The aged care system may not be in crisis but is certainly approaching crisis point. Chronic underfunding by successive mainly coalition governments has resulted in a partially broken system, often open to profiteering by private providers who are only in there to make a dollar for shareholders. My wife has a degenerative neurological illness and needs daily support. Despite this, support through the Commonwealth Home Care Program has been withdrawn by her provider because she is now classed as high care - despite taking our money for years! She is approved for a level 4 package- waiting time up to 15 months - but our contribution will be about $22,000 per year, despite holding a pensioner concession card. Placement in a nursing home may be our only option as continuing with home care is becoming very difficult for both of us. Roll on the Royal Commission, hopefully it will provide some equity and justice for all aged people.
    MICK
    21st Mar 2019
    5:12pm
    LNP government always fund their own PRIVATE institutions and strip the public ones. Schools - swimming pools laid on whilst public schools are bled dry.
    Hospitals - private hospitals where you can get in with a couple of days notice whilst you have to wait for months in the public system.
    I sort of give up and we just make our own way as best we can.
    Charlie
    21st Mar 2019
    12:15pm
    I am looking at privately run village rental accommodation at the moment, that provide services to over 55's only.

    They seem to fill the gap (ignored by the Dept of housing) by providing modern and safe accommodation to aged couples and singles, who are presently tossed in among the desperadoes.

    A disadvantage for some like myself, is that a large portion of the pension is taken for food prepared on the premises, but not a greater amount than one would normally spend. Its just that its a more eat-in environment. I am one who likes to graze and drink random cappuchino down town. I could spend off any reserves.

    They are not really an aged care facility, but provide a place where a greater number of customers are within reach of the mobile health services.
    MICK
    21st Mar 2019
    5:13pm
    A retirement village is different to a Nursing Home. You look after yourself for the former and you are looked after (intensely) for the latter.
    Charlie
    21st Mar 2019
    5:55pm
    That's the word they use. Retirement Village

    21st Mar 2019
    1:05pm
    I am on a home-care package funded by the NDIS. The problem with the sector is the poor quality of helpers it attracts. Many cannot speak or understand even basic English, are lazy, do a sloppy job, lack initiative, and often do not engage their brains at a rudimentary level. Until this issue is addressed, the industry will remain in crisis.
    MICK
    21st Mar 2019
    5:14pm
    You may be in the wrong place Knows-a-lot.
    Buggsie
    21st Mar 2019
    1:54pm
    A further comment re aged care workers. My wife recently spent a week's residential respite care in a local nursing home. She found the quality of the carers and nursing staff to be quite good but as shifts changed so did the staff and relating to them was difficult. As we live in a small regional coastal area the issue of migrant workers doesn't arise, but levels of training and commitment vary. Also, this is the most expensive aged care facility in our area, so expectations of clients are high! All in all my wife gave a rating of 7/10 for her week's experience.
    GeorgeM
    21st Mar 2019
    11:43pm
    They (the bureaucrats who make these Reports to satisfy their political masters) seem almost proud to say "The home care system has many issues to address, but it is not in crisis"!
    The fact is there are thousands who don't get the level of care they need, and tens of thousands who don't get any support at all - including the unknown thousands who are not even put on Waiting Lists by the CHSP as the lists are either too long or because many service providers don't even create waiting lists. It's not a crisis indeed! When will these lies stop?
    Anonymous
    26th Mar 2019
    4:49pm
    The lies will never stop. Our corrupt politicians are a disgrace. They do not know what goes on in the real world, all wear blinkers. They are ok because they get early pensions and $$ way in excess of what we pensioners get. They also live in wealthy suburbs where there are no gangs or live next door to a refugee or immigrant that cannot speak English. Australia is stuffed good and proper, perhaps I should say real Aussies are stuffed and the politicians dont give a stuff about us.
    Florgan
    2nd Apr 2019
    10:20pm
    Where do the service providers get off charging $125 per hr to come in and clean and I use that term loosely.
    How can the govt say you are eligible for a home care package, no matter which level, and then not provide the carers to supply the home care.
    What a pathetic system