Need to know
- Home care businesses that draw on government funds can put the quest for profits ahead of meeting the highly personal needs of their clients
- The private businesses that provide the services are overcharging, carers are underpaid, and recipients are being shortchanged as a result
- Home Care Packages will be replaced by the Support at Home Program starting in July 2025, and advocates are hoping a fee-for-service model will reduce exploitation
It's not an unusual predicament for older Australians to find themselves in.
Ross's wife of 47 years, Margaret, who was diagnosed with dementia in 2016, needed help to continue living at home. They couldn't afford an aged care facility and Ross didn't want to send her to one anyway. He'd heard the horror stories, and visited some grim-looking institutions himself.
But navigating the aged-care bureaucracy, filling out countless forms and finally getting his wife onto a Level 4 home care package, was no small undertaking. It's the highest level of home care available, meant for people with complex care needs, and includes a range of hands-on services.
The annual home care government subsidy, about $66,000, and the helpers it made possible certainly eased the burden. But it's just Ross now. His wife recently passed away.
There have been reported cases where providers have cherry picked home care recipients with the least complex care needs because more difficult cases cut into their bottom line
The support was critical, but Ross has serious issues with the way the money was handled by the home care provider. Now that his wife is gone, he's found the time to speak out.
And he's far from alone in feeling that home care businesses that draw on government funds can and will put the quest for profits ahead of meeting the highly personal needs of their clients.
Some say the home care system is broken. The private businesses that provide the services are overcharging, carers are underpaid, and recipients are being shortchanged as a result.
Money seems to be the driving force. There have been reported cases, for instance, where providers have cherry-picked home care recipients with the least complex care needs because more difficult cases cut into their bottom line.
Difficult choice, no guidance
Once the package was finally approved, Ross was left on his own to go through a list of home care businesses provided by the government's My Aged Care agency. There were several in the area. He ended up picking a business with an office on Sydney's North Shore – a private, for-profit operation that's among the largest home care providers in Australia. He had no way of knowing whether it was the right choice.
The subsidy went directly to the home care provider to be managed. Though Ross had the right to approve which services he wanted, other charges against his subsidy came out automatically.
Rates and fees vary widely from provider to provider, making it that much harder for people to know who to trust their subsidy with
These included a $19.50 per day care-management fee plus a $18.50 per day package-management fee. The services rendered for these payments were never made clear.
Aged care experts say this is a systemic issue. Rates and fees vary widely from provider to provider, making it that much harder for people to know who to trust their subsidy with.
Home care workers are poorly paid and under-valued by their employers and rarely receive enough supervision or support.
Pressure to add services
But what rankled Ross the most – and convinced him the business was chasing profits – was that it was constantly pushing him to spend more.
"The management was always pressuring me to have additional helpers or other services, such as cleaners, gardeners or tradespeople to do house maintenance, because they said I had some unspent money," says Ross.
Ross didn't see the point of using the funds for extras that he didn't need, and their apartment complex already had a gardener.
They never went over the cap, but they sure tried to
Ross, husband of home care recipient Margaret
When he finally relented at one point and accepted a cleaning service, a woman showed up without cleaning supplies or equipment. Ross felt sorry for her. She stayed for less than an hour, using what was available, and Ross's subsidy was charged $110 – much more, Ross believes, than the cleaner was paid.
In case its costs went over the subsidy amount, the home care provider also asked for Ross's credit card details. Ross made sure that didn't happen. Before long, his level of trust for the business he selected to help look after his wife began to decline.
"They never went over the cap, but they sure tried to," he says.
Concern for overstretched workers
Ross was also bothered by the disparity between how much the workers who visited his home were apparently paid per hour and how much the home care provider charged against his subsidy. The provider's normal hourly rate was $84.19.
According to a home care worker who discreetly disclosed the information to Ross, the workers were paid less than half that. When asked, the worker also informed Ross that she and her colleagues received no benefits such as sick leave or paid holidays. (The work week award rate for full-time aged care workers is around $25 to $30 per hour. Casual employees earn around $31 to $37 per hour.)
"They stood outside my door with their phones and clocked on, because they only get paid for the time they're here," Ross says. "They rushed from one job to another. They really get screwed."
One day, a harried young, home-care worker who he'd never seen before showed up at their house. Ross was due to go to an appointment, but there was a problem – the carer would have had no way of knowing how to look after his wife, or even be familiar with the layout of the house. He assumed the regular carer was sick.
He cancelled his appointment so he could be there to help, spending the allotted hours showing the helper what his wife needed. They never saw the woman again after that. Ross says other clients of the business reported similar experiences.
The current design of the home care system creates incentives for providers to 'drive costs up to the cap', especially through administration fees.
Problems across the sector
Home care recipients have made the failures of the home care system known to advocacy groups.
Anna Willis, the CEO of Aged Care Justice, says the issues Ross outlines are affecting many.
"We have had cases of providers charging for services but carers not turning up. Or they turn up and stay for a limited time without providing quality service."
There are ongoing problems with the delivery of care in a consistent fashion, due to workforce shortages and a lack of trained staff
National Seniors CEO Chris Grice
National Seniors CEO Chris Grice points out the issue of extra services going to existing recipients while others wait. "Providers shouldn't be delivering and charging for services that are not required or requested by the recipient, especially when there are around 68,000 people waiting for their services to start."
"There are ongoing problems with the delivery of care in a consistent fashion, due to workforce shortages and a lack of trained staff," he says.
'The price for everything goes up'
Ross's concern that their home care provider was focused on maximising revenue reached a high point when a nurse not affiliated with the business recommended that he get a hospital bed with a special mattress for his wife.
"I arranged this through a hospital equipment hiring company and the charge was to be $395, which included rental, delivery and pickup and assembly," Ross says.
"The home care provider management heard what I was doing through their home helpers and contacted me to say that this would be covered by my subsidy and they would arrange payment. I did all the organising, all they had to do was the payment."
Once you go through the home care provider, the price for everything goes up
The final charge for the bed against Ross's subsidy account was $1254.
"Their markup was not a bad fee for just writing out a cheque with my subsidy money," Ross says. "Once you go through the home care provider, the price for everything goes up."
Poor pay, patchy training
A 2021 Grattan Institute report on the government's home care program suggests that such outcomes should not come as a surprise.
"Older people get little advice and support to find services," the authors write, adding that the number of private services "has grown dramatically, with little oversight of quality and value for money". There are currently around 1000 home care providers in operation across Australia.
The report also paints a troubling picture of how the people showing up at your home are treated by the businesses they work for.
"Home care workers remain poorly paid and under-valued. Training is patchy, work is often insecure, and there's insufficient supervision, support and staff development," the Grattan researchers say. "Not surprisingly, it is increasingly difficult to recruit and retain aged-care workers."
One of the authors of the Grattan Institute report, Hal Swerissen, an emeritus professor of public health at La Trobe University, tells CHOICE that the current design of the home care system creates incentives for providers to "drive costs up to the cap", especially through administration fees.
Administration fees are charged whether or not services are delivered. (In Ross's case, the $38 daily administration fee was charged whether or not any workers came over.)
New government program coming in 2025
The federal government is aware that the home care system has too many problems to continue as is. Based on the findings of the 2021 royal commission on aged care and safety, it announced that Home Care Packages will be replaced by the Support at Home Program starting in July 2025.
Home-care workers remain poorly paid and under-valued. Training is patchy, work is often insecure, and there's insufficient supervision, support and staff development
The Grattan Institute
Support at Home providers will primarily be paid on a fee-for-service basis, rather than receiving the full subsidy upfront.
The new model is expected to increase transparency, mandating quarterly reports showing exactly where the money is going, Swerissen says.
"This would mean there would be less incentive to upsell," he says.
And the actual home care component – the money that pays for workers to visit homes – is expected to be funded separately to other costs for the provider. "This will make it much harder for providers to game the system and gouge clients," Swerissen says.
Step in the right direction
Anna Willis of Aged Care Justice says the government's new plan addresses the core problem in that it gives more control to home care recipients, but the support options also need to be more flexible.
A major shortcoming of the current system is that it often doesn't allow recipients to spend the funds on things they really need. Willis tells the story of a home care recipient in poor health whose hot water system failed. She couldn't afford another one, and it wasn't included in her home care package.
"How can that person stay at home comfortably without hot water, which is excluded from home care package expenditure?"
In another case, a recipient was in desperate need of a new mattress – also excluded.
Recipients who have been diagnosed with cognitive decline or physical impairment need support to understand and administer the home care package
Aged Care Justice CEO Anna Willis
"People receiving home care want to make their own decisions about care and pay only for the care they receive," Willis says.
Like Swissersen, Willis sees the lack of effective oversight as a fundamental flaw, leaving home care recipients at the mercy of the private market. Navigating the system would be tough for anyone. For aged people with medical conditions, it's that much tougher.
"Recipients who have been diagnosed with cognitive decline or physical impairment need support to understand and administer the home care package," Willis says.
Chris Grice of National Seniors supports the fee-for-service component of the upcoming Support at Home Program as it will "restrict the capacity of providers to charge variable rates for identical services".
"The old system was open to exploitation. It is far better to allocate people with a package based on the amount of service provided rather than giving people a budget and asking them to find the best deal."
'No one on their side'
The government's new plan has some improvements, but in Swerissen's view, tighter government regulation of providers only goes so far. What's missing is an intermediary between home care recipients and providers that acts in the best interest of recipients.
The 2021 Grattan Institute report recommends well-resourced regional home care offices run by the government. So far it has committed to a limited version of this, but the aged care experts say it won't be enough.
Effectively, older people will have no one on their side that they can talk to to help them manage the system
Professor Hal Swerissen, La Trobe University
"People will struggle to get the information they need, it will be challenging for them to stay on top of the administrative arrangements and the providers will continue to manage them, although within tighter rules," Swerissen says. "Effectively, older people will have no one on their side that they can talk to to help them manage the system."
Toward the end of Ross's wife's life, the home care provider had a gala awards event for its staff at an upscale venue nearby. One of the homecare workers Ross knew was picked up in a limousine, as he assumed the rest were. He thought the workers deserved it, but he also wondered how much of his subsidy money was paying for the night.
Complaints about home care providers can be lodged with the Aged Care Quality and Safety Commission, or call 1800 951 822.
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