The home care path: from siloed support to true collaboration

As Australia’s population grows, more and more people are living with multiple chronic health conditions. And with a whole generation of Baby Boomers set to enter their 80s over the next decade, we can expect the demand for chronic, age-related health care to rise dramatically. Amid these conditions and in the context of Support at Home, LYNDA CHALMERS, CEO of Care Connect, makes the case for coordinated, multidisciplinary health care.

The health challenges faced by older Australians are often complex, interwoven and shaped by factors including a person’s age, physical and mental health, family history, and cultural background. Many older Australians also live alone, rely on family and friends for transport or meals, and juggle multiple medical appointments each month. These matters shouldn’t be considered in isolation. Rather, they should be seen as interconnected needs requiring coordinated solutions.

Complexity requires tailored care

People with complex health needs are often required to interact with a web of service providers and systems — these might include primary care, hospitals, aged care, housing, mental health or community services. Each service will have its own offering, processes and priorities. Therefore, without deliberate integration, the person in need of care risks being ceaselessly shuttled between services — left potentially vulnerable without any oversight of their case.

A tailored care plan, co-created with the patient, can work to improve cohesiveness and coordination across a care team. Its existence ensures that the GP knows what the physiotherapist is working on, that the home care manager understands the medication regime, and that the family is aware of any early warning signs to look out for. This interconnectedness of the people and services responsible for someone’s care not only improves health outcomes but also leaves a patient confident that someone is keeping an eye on the big picture for them.

The real cost of siloed care

Siloed care isn’t just costly and inefficient — it can be dangerous. Consider cases in which multiple providers carry out the same assessments within weeks of each other, while urgent needs potentially go unnoticed. Or cases where gradual declines in mobility or cognition are missed because providers assume others are monitoring for them.

These cases are extremely common. And the consequences could be a sudden fall, an infection left untreated, a rushed trip to the ED, or worse. These emergencies can often be traced back to missed opportunities for early intervention — opportunities that likely would have been caught and acted upon under a coordinated, multidisciplinary care model.

The power of multidisciplinary teamwork

The reality is that no single professional can address the full spectrum of someone’s health needs. A GP might prescribe a patient medication for heart failure, while a dietitian ensures all meals are appropriate, a physiotherapist helps maintain mobility, a social worker connects a patient to community support, and a home care manager ensures the patient’s home environment is safe and accessible.

When these professionals — and informal carers, like adult children or grandchildren — combine to form a multidisciplinary team, they can create a complete picture of the person and their needs. Working from a shared care plan reduces duplication, creates efficiencies, closes gaps and ensures everyone is aligned on the same goals. This isn’t just a ‘nice to have’ — it’s the foundation for better outcomes.

Home-based supports: essential, not optional

For many older people, home is not only where they want to be — it’s where they thrive and recover best. But in order for this to occur, the right supports must be in place. A home care worker who spots a new bruise can prevent a small fall from becoming a major fracture. A nurse who picks up on changes in breathing can trigger a GP review before pneumonia develops.

Early intervention at home prevents deterioration, supports timely hospital discharges and avoids premature admissions to residential care. It’s also significantly more cost-effective than acute care. With Australia’s largest generation reaching 80 in the next few years, home-based care should be treated as essential infrastructure in our health system, not optional.

Helping patients navigate the aged care system

According to GPs and health professionals, it’s crucial for people to start the conversation about aging and care early — before a crisis forces them to rush decisions. It’s important to encourage older people to register with My Aged Care and help them prepare for their assessment by pulling together a clear medical summary and a list of their needs and questions.

If needs are urgent, there are local providers who can guide people through the system and advocate for priority placement. However, informal carers shouldn’t step away once services are in place — it’s important they remain in contact with the provider so that together, they can adapt the care plan as needs change.

The path forward

Meeting the needs of an aging population requires moving from siloed support to true collaboration. Multidisciplinary health care, delivered in the home wherever possible, is one of the most powerful levers we can pull to improve longevity, wellbeing and dignity in later life.

As a sector, we need to invest in the systems, training and relationships that make this possible. That means better information-sharing between providers, more flexible funding models and recognition of the critical role home-based supports play in keeping people healthy and independent.

Importantly, this approach isn’t just better for people — it’s essential for the sustainability of our healthcare system. Without a coordinated, multidisciplinary model, the scale of care required to meet the needs of Baby Boomers risks overwhelming our already stretched hospitals, GPs and aged care facilities. Integrated care is a strategic necessity if we’re to prevent the coming wave of demand from becoming an unmanageable burden on the system.

We’re standing on the precipice of one of Australia’s greatest demographic shifts — and only by taking a coordinated, multidisciplinary approach will we be able to ensure that older Australians don’t just live longer but live better.

Lynda Chalmers is CEO of Care Connect, a provider of in-home care services across New South Wales, Queensland and Victoria. Having been in the health and aged care sector for more than 30 years, Lynda’s expertise spans both for-profit and not-for-profit organisations, with experience in health, community, disability and aged care sectors. Prior to joining Care Connect in 2024, Lynda held key leadership roles at Mercy Health and Royal Freemasons. As CEO, Lynda is dedicated to fostering a values-driven and client-centred culture. Lynda’s vision is to ensure that people remain at the heart of everything Care Connect does, helping them live independently with confidence and dignity.

Top image credit: iStock.com/Ridofranz