Support at Home was meant to transform aged care, but its assessment and funding model has left older Australians waiting too long, paying too much and receiving services shaped by budgets rather than need.

After being announced as a ‘once in a generation reform’, the government’s much-vaunted Support at Home (SAH) program went live on 1 November 2025. It aimed to replace the Home Care Package program which had been providing services to assist older people to stay at home since 2013. Eligibility, level of care and service recommendations for that previous program were determined by a clinical assessor as part of an aged care eligibility assessment. The new SAH program landed with a thud and almost no older person has had a good word to say about it ever since.

At the operational and personal level, the teething problem period is now over and the jury is in. In the eyes of older people, their families and most aged care providers, SAH is inefficient, too expensive and is failing to meet the needs of older people. People are waiting too long for assessment and, once assessed and approved, are waiting too long for service. Almost all these problems had been anticipated but were ignored at the design phase.

But SAH is not just flawed at the operational level. The experience of the last six months confirms that it is questionable public policy and based on poor program logic, especially in the design of the assessment and funding allocation system.

Until SAH, aged care assessment and care planning in Australia (and internationally) had the same goal and followed the same process as other health, disability and other human services that are substantially funded by taxpayers. SAH has turned this process on its head.

Best practice needs assessment and care planning processes typically involve three steps:

Assess/identify/diagnose the person’s problems and issues

This step involves a clinician or a specialist assessor or a service provider talking with the older person and assessing them to identify their problems and issues. In health care, the end result is a diagnosis or diagnoses. In aged care, the end result is the identification of functional limitations including physical abilities to manage activities of daily living, cognitive limitations (including dementia), mental health issues and social issues including loneliness.

Service and care planning

This step first involves identifying the goals of the care that needs to be provided. With those goals in mind, the outcome of service and care planning is the identification of the range and quantum of services required to meet the person’s goals and meet their needs, treat their condition, and support them to live as independently as possible.

In the case of community aged care, step two has traditionally involved assessors and aged care providers in identifying the most efficient and effective service or range of services required to both keep the older person safe and delay or prevent admission to hospital or residential care. This step has necessarily involved taking account of the person’s strengths, preferences, appetite for risk, the place the person lives, the availability and capacity of family carers and the resources available in the community they live in.

Determine the resources (human, financial, physical) required

This step involves a realistic assessment of what resources will be required to meet the person’s needs, treat their condition, and support them and a realistic assessment of whether these resources are currently available or will be so in the short-term. If the necessary resources are not available, it involves exploring alternatives. These might include being placed on a waiting list or receiving different or less services or treatments.

In the case of older people living at home, step three typically involves working with the older person and their family to identifying the most cost-efficient and effective service or range of services required to keep them safe and delay or prevent admission to hospital or residential care taking into account their strengths, preferences, community resources and appetite for risk.

The three steps above are not how Support at Home assessment and funding allocation works. This is because the government has reversed steps two and three.

Support at Home practice step one: Assess/identify/diagnose the person’s problems and issues

This step is essentially the same except that it is completely centrally controlled and micromanaged by public servants through the My Aged Care portal and undertaken by assessment agencies under contract. All assessments are undertaken using a new ‘Integrated Assessment Tool’, which expert clinicians say needs urgent refinement. While the advisers who worked on the development of the tool were told that assessors would all be clinicians and that all assessments would be face to face, this is not what the government specified when it went to tender for assessment agencies or how it has been implemented in practice.

Support at Home practice step two: Determine the funding level that the person is eligible for

This step involves feeding the information from step one into a computer algorithm that determines the funding to which the person is entitled. Assessors cannot override the results, even if the algorithm results in demonstrably incorrect outcomes. The perspective of the growing list of critics is that this is yet another version of #Robodebt. The government refutes this, arguing that humans are involved every step of the way because a human assessor completes step one. There are growing calls for the government to allow expert clinical assessors to override the algorithm, all of which have been ignored so far.

Step three: Service and care planning

This step involves identifying the range and quantum of services that the person can afford out of the individual budget that was determined in step two. SAH was introduced with a significant increase in consumer fees, and many older people are reported as turning down required services because the fees are too high.

What is the role of the aged care system and how do we meet the growing demand?

The re-engineering of this three-step process raises critical issues. The first is that the government is now redefining the role of aged care. It is not clear whether this is intentional or not. Either way, it is a bad idea.

Aged care in the community should be a care and support scheme that aims to keep people safe at home and out of institutional care. But it is being turned into a hybrid financial entitlement / insurance scheme. The NDIS is, as its name suggests, an insurance scheme. The aged care system is not an insurance scheme. It is a care and support scheme. Yet it seems that this critical distinction has been lost in the design of SAH, especially in how SAH assessment and funding allocation now works.

The second policy failure is the biggest of all. Australia now has no coherent aged care demand management strategy. The Commonwealth Home Support Program (CHSP) has been left to wither on the vine rather than being the tier of care that prevents or delays people needing more expensive SAH or residential care. SAH is designed to allocate everyone a financial entitlement with no consideration of what funding is realistically required to cover the cost of the services required to prevent or to delay admission to residential care.  This is simply penny wise pound stupid.

It goes without saying that, without significant redesign, Australia can expect demand for residential care to increase at even a faster rate than it is now. Yet decision-makers seem not to be aware of, or concerned by, this unmanaged risk. This is especially concerning because Australia has a significant shortage of aged care beds. The only options to manage the shortage of aged care beds is to decrease demand, increase supply or both. Realistically, doing both is essential.

The last three decades has seen a long list of aged care policy and implementation failures interspersed by a seemingly unending number of reviews, most recently the Aged Care Royal Commission. SAH is the exact opposite of the joined-up, affordable and effective aged care system that the Royal Commission envisaged and recommended.

At this stage, SAH seems destined to join the long list of previous failures. This is because SAH is betwixt and between. It is neither an effective care system nor an efficient insurance scheme. And this leads to the biggest failure of all: aged care in Australia now has no coherent demand management strategy. Taxpayers, older people and their families will ultimately pay the price.

The views expressed in this article may or may not reflect those of Pearls and Irritations.