Aged Care - Support at Home

Purpose, structure, eligibility, cost to participant, services available, self-management, end-of-life, allied health guidelines, social work role

Three sections follow:

1. Background Material that provides the context for the topic

2. Suggestions for Practice

3. References

Feedback welcome!

Background Material

Introduction

(Department of Health, Disability and Ageing, 2025c, 2025f)

The Support at Home program is designed to help older people live independently at home for longer.  Based on aged care assessment and eligibility, older people will have access to an approved list of services, able to be accessed within the older person’s budget.

The Support at Home program has 8 classifications, each with a quarterly budget to provide ongoing services, linked to different levels of care. The more care an older person needs, the higher their classification will be. Along with the 8 ongoing classifications, there are 3 short-term classifications that help older people maintain independence to avoid unnecessary escalation of care:

1. The Restorative Care Pathway helping older people maintain and improve their independence through primarily allied health services; duration usually 6 weeks.

2. The End-of-Life Pathway providing dedicated funding to access services to support older people to remain at home in their last 3 months of life; duration usually 12 weeks.

3. The Assistive Technology and Home Modifications (AT-HM) Scheme providing separate funding for products, equipment and home modifications.  Participants are given separate funding to access products, equipment and home modifications.

To access the Support at Home program, older people must undergo an aged care needs assessment conducted by an aged care assessor. The following groups are eligible for an aged care assessment:

• people aged 65 years and over,

• Aboriginal and Torres Strait Islander people aged 50 years and over,

• People aged 50 years and over who are homeless or at risk of homelessness.

Eligibility also depends on (i) having care needs, such as physical, cognitive or social difficulties with activities of daily living, quality of life, and/or (ii) requiring assistive technology, equipment or support to stay physically, mentally or socially able to function independently.

People can check their eligibility for Support at Home online at My Aged Care (https://www.myagedcare.gov.au/how-get-assessed) or by calling 1800 200 422.  If their application is successful, they will be referred for an assessment, done in person in their home. 

When assessed as eligible for the Support at Home program, people will receive a Notice of Decision letter and an individual support plan to share with their provider. This will contain:

• a summary of aged care needs and goals

• a classification with an associated ongoing quarterly budget and a list of approved services; and/or

• an approval for short-term supports where necessary: restorative care, assistive technology and home modifications, and end-of-life.

On November 1, 2025, the annual budgets range from $10,731 for classification level 1 to $78,106 for classification level 8.  Funding for the Restorative Care Pathway was between $6000 and $12,000 (6 weeks) and $25,000 for the End-of-Life Pathway (12 weeks).  Funding for the Assistive Technology and Home Modifications scheme varies with a person’s needs.  These amounts are indexed in July annually in line with inflation (Source: https://www.health.gov.au/sites/default/files/2025-11/support-at-home-program-classifications-and-budgets.pdf).

Service categories

(Department of Health, Disability and Ageing, 2025a)

The Support at Home program has 3 service categories for older people:

• Clinical supports – such as nursing care, occupational therapy and physiotherapy.

• Independence – such as help with showering, taking medications, transport or respite care.

• Everyday living – such as cleaning, gardening, shopping or meal preparation.

Based on the aged care assessment, a person will have access to an approved list of services. The person’s care partner (a staff member from your service provider who will work with the person to identify aged care needs, goals, preferences and existing supports) will help choose the mix of services that can be accessed within the budget.  This will be documented in a care plan, which will be reviewed annually and more frequently if required. The care plan is guided by the personal support plan, received on approval for aged care. Requests to change the mix of services from the approved list at any time can be made with your care partner, who will support the person to make sure the services meet a person’s needs.

People cannot access services not on the list.  Contribution arrangements apply for services delivered in the independence and everyday living service categories.  Services in the clinical supports category (for example, nursing), are fully funded by the government.

A single provider will manage and deliver all services and will also assist in arranging and sourcing any required assistive technology and home modifications that have been approved.

Service list  (See Support at home service list at https://www.health.gov.au/sites/default/files/2025-08/support-at-home-service-list.pdf for guidance on what is included and excluded from these services).

Category	Service type	Services
Clinical	Nursing care	Registered nurse Enrolled nurse Nursing assistant Nursing care consumables Providers may apply for the supplementary Oxygen Supplement for Aged Care through Services Australia for eligible participants.
Clinical	Allied health	Aboriginal and Torres Strait Islander health practitioner Aboriginal and Torres Strait Islander health worker Allied health therapy assistant Counsellor or psychotherapist Dietitian or nutritionist Exercise physiologist Music therapist Occupational therapist Physiotherapist Podiatrist Psychologist Social worker Speech pathologist
Clinical	Nutrition	Prescribed nutrition
Clinical	Care Management	Home support care management
Clinical	Restorative care management	Home support restorative care management
Independence	Personal care	Assistance with self-care and activities of daily living Assistance with the self-administration of medication Continence management (non-clinical)
Independence	Social support and community engagement	Group social support Individual social support Accompanied activities Cultural support Digital education and support Assistance to maintain personal affairs Expenses to maintain personal affairs
Independence	Therapeutic services for independent living	Acupuncturist Chiropractor Diversional therapist Remedial masseuse Art therapist Osteopath
Independence	Respite	Respite care
Independence	Transport	Direct transport (driver and car provided) Indirect transport (taxi or rideshare service vouchers)
Independence	Assistive technology and home modifications	Assistive technology Home modifications
Everyday living	Domestic assistance	General house cleaning Laundry services Shopping assistance
Everyday living	Home maintenance and repairs	Gardening Assistance with home maintenance and repairs Expenses for home maintenance and repairs
Everyday living	Meals	Meal preparation Meal delivery

Participant Costs

(Department of Health, Disability and Ageing, 2025b)

Note: Most people will be required to contribute to the costs of care.  However, there is a lifetime cap on contributions. Once people have paid the lifetime cap amount towards your services ($135,318.69 as of 20 September 2025) a person will not be charged any more for the services received. The lifetime cap is indexed on 20 March and 20 September each year.

Standard participant contribution rates  

Age Pension status	Clinical care	Independence	Everyday living
Full pensioner	0%	5%	17.5%
Part pensioner and eligible for a Commonwealth Seniors Health Card	0%	5% - 50% depending on income and assets	Between 17.5% and 80% depending on income and assets
Self-funded retiree	0%	50%	80%

Financial Hardship (Department of Health, Disability and Ageing, 2025c)

People who cannot afford to pay fees or contribute to care costs, can access hardship arrangements by completing  the form at www.servicesaustralia.gov.au/sa462, and sending it and any documentation required to https://www.servicesaustralia.gov.au/financial-hardship-assistance-eligibility-for-aged-care-cost-care?context=23296.

Self-Management

(Department of Health, Disability and Ageing, 2025d)

Self-management is available and can involve:

• coordinating personal services

• scheduling personal services

• choosing personal workers

• managing one’s budget

• paying invoices for services and being reimbursed.

The person and Support at Home provider must agree on the self-management arrangements as part of the care plan.  People organising their own services, you will only be able to spend their budget on services that are part of their support plan and are on the service list. A person can use a third-party worker if their provider agrees, and the provider will engage this person, ensuring the third-party workers meet workforce requirements, for example worker registration.

End-of-Life Pathway

(Department of Health, Disability and Ageing, 2025e)

The End-of-Life Pathway provides funding for additional home care services to help older people remain at home if they are assessed as having 3 months or less to live.  An older person accessing the End-of-Life Pathway will receive funding of around $25,000 for home care services over a 12-week period.  After 12 weeks, and if funds are still left, they can continue using this money for a further 4 weeks.  If services are needed beyond this time, they can request an urgent Support Plan Review so services can continue.

To access the end-of-life pathway a person:

• Must be over 65 (or 50 for an Aboriginal person)

• Have a doctor or nurse complete end-of-life pathway form

• Must request high-priority assessment for the end-of-life pathway, personally or with assistance.

Contributions apply for independence and everyday living services.

The existing provider should be retained to deliver services, if the provider can meet needs under this pathway.  If not, a new provider can be found using the tool on My Aged Care: https://www.myagedcare.gov.au/find-a-provider

Older people can also access palliative care services while accessing the end-of-life support pathway

.

Guidance for Health Practitioners

(Department of Health, Disability and Ageing, 2025f)

Health professionals support older people by:

• recommending home modifications or prescribing assistive technology

• referring patients for aged care assessments

• helping to develop personalised care plans

• working with other health professionals to coordinate care

• supporting the wellness and reablement approach to delivering care.

Under Support at Home health professionals will continue to:

• refer patients for aged care assessments through My Aged Care

• guide patients through care options and pathways

• support access to services that match each person’s health and care needs

• work with care teams to coordinate support and improve health outcomes for patients.

Health professionals role can vary depending on their discipline and scope of practice, but all contribute to helping older people live safely and independently at home.

Making a referral for an aged care assessment

Health professionals have access to several streamlined referral options through My Aged Care.

• Make a Referral online tool available via the My Aged Care website, to determine eligibility for government funded aged care services. The Make a Referral form will take approximately 15-20 minutes to complete and can be found at https://www.myagedcare.gov.au/make-a-referral

• Phone referral by calling the My Aged Care Contact Centre on 1800 200 422.

If the person being referring has registered previously, they can be helped to call My Aged Care on 1800 200 422 to discuss any changes in circumstance/care needs.

Support at Home classification levels and services

Along with the 8 ongoing classifications, there are 3 short-term classifications (restorative care, end-of-lire and assistive technology/home modifications) where health professionals have an important role in delivery.

The Support at Home program has a defined service list which outlines the funded services available to eligible participants and the services that are excluded (https://www.health.gov.au/resources/publications/support-at-home-service-list). The Assistive Technology and Home Modification (AT-HM) list defines the products, equipment and home modifications that are available for Support at Home participants under the AT-HM scheme (https://www.health.gov.au/resources/publications/assistive-technology-and-home-modifications-list-at-hm-list).  Participants can only access government funded services from the Support at Home service list.  

Care plans

Once an older person is approved for the Support at Home program, an aged care provider will allocate a care partner (a care coordinator) to develop the care plan. Health professionals may be involved in care planning if required.  Eligible health professionals can claim a Medicare Benefit Schedule (MBS) item for case conferencing if the participant has a current GP chronic condition management plan (GPCCMP) in place. Fee for service and private health insurance rebates may also be options to discuss with the person.

Restorative care pathway

For existing Support at Home participants, a restorative care pathway can be accessed alongside ongoing services. A Support Plan Review can be completed to request additional funding (evidence will be required). It can also be used to request a reassessment for other aged care services as the episode concludes, if required. This approach to care is particularly useful for older people who are at high risk of injury, illness, or hospitalisation, or who are recovering from these experiences. The Restorative Care Pathway aims to:

• maximise ongoing independence for older people

• prevent, delay and/or reverse physical, functional and cognitive decline through targeted interventions

• enhance quality of life

• support older people to remain living at home.

To access the Restorative Care Pathway, the older person will require an aged care assessment completed by an aged care assessor and meet the suitability and eligibility criteria. Under the Restorative Care Pathway, participants may:

• have access of up to 16 weeks of multidisciplinary restorative care including home based nursing and allied health

• access restorative care services alongside any Support at Home services they already receive

• receive an extra budget of $6,000 (or up to $12,000 if required) for multidisciplinary allied health services

• have access to assistive technology, equipment and home modifications through the Assistive Technology and Home Modifications (AT-HM) scheme.

Health professionals play an important role in supporting participant outcomes within a reablement approach that involves a multidisciplinary team.  The restorative care partner, together with the older person, their registered supporter (if required), and other members from the multidisciplinary team need to develop a goal plan for each episode of restorative care.  This must be in place before or on the day services commence and should be reviewed and updated as the episode progresses.

At the conclusion of the restorative care episode, older people may request a Support Plan Review to assess whether their functional goals have been met or if further support is needed through ongoing services. A Support Plan Review may be requested by:

• the older person or their registered supporter through My Aged Care or through a Services Australia Aged Care Specialist Officer (ACSO)

• a service provider through My Aged Care Service and Support Portal

• GPs, hospital, or community health professional through the My Aged Care contact centre or a My Aged Care web referral.

End-of-life pathway

The End-of-Life Pathway is a short-term pathway to support participants who have been diagnosed with 3 months or less to live and wish to remain at home, by providing more funding to access in-home aged care services. The End-of-Life Pathway is designed to complement services received through states and territories, including palliative care services. In most cases a nurse will refer a patient to the end-of-life pathway by completing an end-or-life pathway application form.  More information about this form is available at https://www.health.gov.au/sites/default/files/2025-10/end-of-life-pathway-fact-sheet-for-doctors-and-nurse-practitioners.pdf 

Under the End-of-Life Pathway, an older person will have access to a budget of $25,000 over 12 weeks. If the older person requires services beyond 12 weeks, an urgent Support Plan Review can be undertaken to transfer the participant to an ongoing Support at Home classification. The End-of-Life Pathway budget can be used up to the 16-week mark to support continuity of care

On the End-of-Life Pathway, older person will have access to:

• a budget of up to $25,000 over a 12-week period, with 16 weeks to use the funds on aged care services if needed, to provide more flexibility as their needs change over time.

• assistive technology and equipment through the Assistive Technology and Home Modifications (AT-HM) Scheme if needed (for example, a height adjustable bed).

Eligibility

An older person is eligible to access the End-of-Life Pathway if they meet the following criteria:

• a doctor or nurse practitioner advises estimated life expectancy of 3 months or less to live

• Australian-modified Karnofsky Performance Status (AKPS) score (mobility/frailty indicator) of 40 or less.

Note that participants will also need to meet general entry criteria for accessing funded aged care services, including being aged 65 or over (or age 50 or over for an Aboriginal or Torres Strait Islander person or homeless or at risk of homelessness).

Health professional’s involvement in the End-of-Life pathway

Health professionals including nurses may be involved in the End-Of-Life Pathway by assisting with:

• mobility

• fatigue management

• nutritional needs

• working closely with the aged care provider’s care team.

Their involvement ensures that the older person receives coordinated, compassionate, and responsive care that aligns with their preferences and supports their dignity and comfort during the final stages of life.

Training and Resources

Learning package 1: The Program Overview training module introduces Support at Home and explains how it will operate. This includes fundamental concepts and processes that underpin Support at Home.  Access at https://rise.articulate.com/share/sMHH0_DQL91fCScANTPUBNB2Asx1wstU#/

Module 3: Short-term pathways provide detail around Assistive Technology and Home Modifications (AT-HM) scheme, Restorative Care Pathway and End-of-Life Pathway, and how they operate.  Access at https://rise.articulate.com/share/Px7p_YkKLSN5iRAmbV1O0GLKiy9Fc8wG#/

There is a comprehensive program manual for registered providers of Support at Home available at https://www.health.gov.au/resources/publications/support-at-home-program-manual-a-guide-for-registered-providers

There is also guidance around prices for services that health professionals can charge at https://www.health.gov.au/sites/default/files/2025-10/support-at-home-prices-for-allied-health-and-nursing-services-fact-sheet-for-providers.pdf .

Suggestions for Practice

(Google, 2025 based on AASW, n.d.; Brightwater Group, 2024; NSW Health, 2023)

In the Australian Support at Home program (transitioning from Home Care Packages), social workers are crucial for holistic, person-centred care, acting as advocates, navigators, and counsellors to help older adults and people with disabilities manage complex needs, access services (like Allied Health, transport, personal care), address psychosocial barriers (ageism, isolation, finances), and develop care plans for independence and wellbeing at home. They bridge gaps between individuals, families, and the vast aged/disability care system, ensuring equitable access and tailored support. 

Social workers offer the following:

• Holistic View: They look beyond just physical needs, considering mental, emotional, and social wellbeing.

• Empowerment: They partner with individuals, fostering self-determination and helping people stay in their homes longer.

• Bridging Gaps: They translate complex bureaucratic processes into understandable steps and actions for clients. 

• Mediating conflicts between family members or with staff to maintain harmonious relationships.

Essentially, a social worker ensures the Support at Home package truly supports the person, not just their tasks, by addressing the complex human elements of aging or living with disability. 

Key Roles of a social worker in Support at Home can include:

• Needs Assessment & Planning: Deeply understanding a client's strengths, history, living situation, mental health, and goals to create truly individualised care plans.

• System Navigation: Helping clients and families understand and access complex services like My Aged Care, Centrelink, NDIS, and other community supports.

• Emotional & Psychosocial Support: Providing counselling for life changes, grief, anxiety, or depression, and addressing issues like ageism and social isolation.

• Advocacy & Rights Protection: Ensuring fair treatment, protecting rights, and giving a voice to clients within the care system.

• Connecting to Services: Linking clients with domestic help, personal care, transport, allied health (physio, OT, etc.), assistive tech, and respite.

• Crisis Intervention: Supporting clients and families during challenging times or transitions, such as hospital discharge or entry to an aged care facility.

• Care Management: Working as a 'care partner' to coordinate services, manage budgets, and support self-management of care. 

• Advanced Care Planning: Helping clients prepare for degenerative illnesses or end-of-life with Advance Health Directives, Enduring Power of Attorney, and Enduring Power of Guardianship.

References

AASW: Australian Association of Social Workers. (n.d.). Older persons credential.  https://www.aasw.asn.au/older-persons/

Brightwater Group. (2024). The cartographers of home care – Brightwater’s social work team.  https://brightwatergroup.com/your-aged-care/the-cartographers-of-home-care-brightwaters-social-work-team

Department of Health, Disability and Ageing.  (2025a). Support at home program – Services.  Australian Government.  https://www.health.gov.au/sites/default/files/2025-12/support-at-home-program-services.pdf

Department of Health, Disability and Ageing. (2025b). Support at home participant contributions. Australian Government.  https://www.health.gov.au/sites/default/files/2025-12/support-at-home-program-participant-contributions.pdf

Department of Health, Disability and Ageing. (2025c). Support at home program: A guide for older people, families and carers (3rd ed.).  https://www.health.gov.au/resources/publications/support-at-home-program-booklet-for-older-people-families-and-carers

Department of Health, Disability and Ageing.  (2025d). Support at home program – Self-management.  Australian Government.  https://www.health.gov.au/sites/default/files/2025-11/support-at-home-program-self-management.pdf

Department of Health, Disability and Ageing.  (2025e).  Support at home program – End-of-life pathway.  Australian Government.  https://www.health.gov.au/sites/default/files/2025-12/support-at-home-program-end-of-life-pathway.pdf

Department of Health, Disability and Ageing.  (2025f). Guidance for health professionals.  Australian Government.  https://www.health.gov.au/sites/default/files/2025-10/support-at-home-guidance-for-health-professionals.pdf

Google. (2025).  Social worker role in Support at Home program.  AI generated response. 

NSW Health. (2023). Social work. New South Wales Government.  https://www.health.nsw.gov.au/workforce/modelling/Pages/social-work.aspx