“What should ‘care at home until I die’ look like for older people in Australia?-An exploration of services to support long-term community living’.

Australia has an ageing population, and many older people prefer to live in their own homes for as long as possible, rather than move into residential aged care. The recent Royal Commission into Aged Care Quality and Safety identified that our aged care system is difficult to navigate, complex with disjointed service delivery, and sees older people facing lengthy wait times, substandard care, and an under-skilled and underresourced workforce. Specifically, this thesis investigates consumer and provider expectations and perspectives for in-home care services that aim to assist older people in Australia to live safely at home for as long as possible. Furthermore, this thesis presents evidence-based recommendations to assist a Queensland based aged-care service provider and the sector as a whole to provide relevant, coordinated, and continuous care that aligns with consumer priorities and goals for future in-home care.

To explore current in-home care services for older people, a participatory approach was used to engage older people and the service provider and identify factors associated with consumer decision-making for in-home care services that assist older people in Australia to age in place. A socio-ecological model was used to guide research processes, provide a broad insight into factors influencing decisions about in-home care, and report findings. The model included the following factors: individual, interpersonal, organisational, and system. An explanatory sequential mixed methods design was used for the purpose of complementarity and included two distinct phases: (i) a quantitative approach (service provider data and 77 paper-based surveys of consumers) followed by (ii) qualitative methods (two focus groups with consumers and six semi-structured interviews with the service provider). A third (final) phase involved integration of results from the quantitative and qualitative phases to develop evidencebased recommendations for service providers to align their services to meet consumer expectations that will assist older people to age in place.

Analysis identified five key themes across the data: ageing in place; future care needs; social connections; provider practices and services; and aged care systems. At an individual level, the message was clear: older people choose to maintain independence where possible and live in their communities while ageing in place with support. The key xiii theme of social connections at the interpersonal level, showed the importance of family and friends in terms of emotional wellbeing, practical support, and help with decisionmaking for older people. However, some older people identified that their family were not able to help and/or they did not want to be a burden to their family. Organisational factors emerging from the data showed that some older people expressed the staff delivering services were skilled and considerate. However, others were concerned about staff shortages, insufficiently trained staff, and inconsistency of support workers. Furthermore, communication between client-provider was flagged as essential and in need of improvement with some stating concerns about methods of communication (such as newsletters and text messages), call centre wait times, and some staff expressing the need to engage more with clients so older people feel like they have a voice. Other noteworthy findings included widespread concern regarding support accessing aged care systems like My Aged Care, limited access to allied health services (such as occupational therapy [OT]), and concerns about moving into a residential aged care facility.

This thesis contributes to knowledge in relation to in-home services for older people, important service provider attributes, and concerns and preferences for in-home care from the user’s perspective as well as the service provider. Listening to older people has been essential and this thesis has provided valuable insights about current in-home services, suggesting that services should be delivered with the preferences and needs of older people in mind. Findings contribute to how the service provider can apply improvements in person-centred service delivery tailored to the needs of consumers that enable older people to maintain independence and remain connected to their community. The research findings highlight that there are concerns for the future as service providers face pressures with increasing demand, staff shortages, and an under skilled workforce. Considerations for future research may include examination of inhome care recipients across larger populations with a focus on the organisational factors such as staff shortages, skilled staff, access to allied health services, and communication processes to support our ageing population to stay living at home for as long as possible.