For too many older people, the supports they need don’t arrive early enough, or in a way that keeps them safe and well at home
Most of us want the same thing for our later years: to enjoy the lives we’ve worked so hard to create.
We want to spend our days doing the things we love, to stay close and connected to our family and friends, and, importantly, to remain in the comfort of our own homes.
Yet, fewer than 15 per cent of older Australians remain living at home as they age, a statistic that should give us all pause.
For too many older people, the supports they need don’t arrive early enough, or in a way that keeps them safe and well at home. Avoidable hospitalisations continue to place enormous pressure on older people, families and the health system. Too often these hospital visits aren’t due to sudden illness, but to missed opportunities for early intervention.
And behind every number is a person – a neighbour, a parent, a grandparent– whose wellbeing relies on a system that works together, not in silos.
If we’re to prevent unnecessary hospitalisations and help people avoid residential aged care before they’re ready, we must rethink how services are coordinated, communicated, and delivered.
When we look closely at why older Australians end up in hospital unnecessarily, several underlying causes consistently emerge.
- Slow deterioration can go unnoticed
Many hospitalisations stem not from dramatic events, but from the slow unnoticed decline that occurs when no one is actively monitoring changes in a person’s condition. A urinary tract infection that goes unrecognised can lead to a fall. Missed medications can trigger a medical crisis. Subtle mobility changes, nutritional issues or cognitive decline can escalate quickly when there isn’t someone checking in regularly.
Older people don’t always recognise these changes in themselves – and understandably so. Self-monitoring is subjective and many often don’t know what to look out for. Without proactive oversight, risk accumulates quietly.
- Resistance to services and insufficient low-level support
Another major factor is resistance to support. Many older Australians decline services because they fear losing independence or don’t feel their needs justify help.
When people only receive low-level support – a cleaner, a gardener, the occasional check-in – or no support at all, no one is close enough to spot emerging issues or intervene early. This means risks that are otherwise preventable often go unidentified until they become crises.
- Lack of integration and oversight
One of the biggest contributors to preventable hospitalisations is a lack of integration and communication between service providers. A client may see their GP, have their medications changed, or report a new health concern, but in many cases, this information rarely makes its way to the organisations providing day-to-day support.
Similarly, hospitals often discharge patients without notifying the provider responsible for coordinating their care, leading to potential health risks once they return home.
Support and oversight from family can go some way in plugging these gaps and keeping relevant providers informed, but when loved ones live further away or even interstate, we’re forced to rely on an often-vulnerable older person to manage things. When no one has full visibility, information can quickly fall through the cracks.
- Funding stream silos
At the heart of the problem is fragmentation. Health is state funded, aged care is federally funded, and GPs are funded through Medicare. Primary Health Networks and hospital systems operate in parallel.
Each program works within its own rules, budgets and deliverables, and none are designed to look at the one person who is simultaneously drawing on all these services.
The result? Duplication, inefficiency, wasted resources and, most importantly, older people missing out on the coordinated support they need.
Why coordinated, multidisciplinary care works
Coordinated care works because it aligns all the moving parts of a person’s support network.
When a central team has visibility across all services, duplication drops away and risks are identified earlier. Instead of five separate providers working in isolation – and sometimes delivering the same interventions without realising it – one coordinated model ensures the right supports are delivered at the right time by the right people.
Pooling information and aligning services around the person, rather than the funding stream, means case managers, nurses, allied health professionals, GPs and hospitals all operate from the same understanding of the client’s needs, goals and current risks.
This makes hospital discharges smoother, ensures that services are reinstated quickly after an acute episode, and supports a genuine shift from reactive responses to proactive prevention.
A coordinated model strengthens the crucial feedback loops that prevent older people from falling through the cracks. For instance, if medications change, if a GP has concerns, if a client has a fall, or if a hospital discharges someone home, the team coordinating their care knows immediately and can adjust supports without delay.
This is what effective multidisciplinary care looks like in practice: clear oversight, consistent communication and a shared responsibility for keeping people well and at home.
If we are to keep older Australians out of hospital and in their own homes for longer, we need a system that puts them at the centre. Integrated, multidisciplinary services are the solution.
Centralised intake, triage, navigation and coordination ensure that someone is always watching for change, and is able to respond. This is the shift from reactive care to proactive prevention.
It’s what stops deterioration from becoming hospitalisation. It’s what helps people return home safely after a hospital stay, with the right mix of supports immediately in place. It’s what gives families peace of mind that someone is truly looking out for their loved one. When care is coordinated, person-centred and multidisciplinary, older Australians can stay where they most want to be: at home, and out of hospital.
Lynda Chalmers is the CEO of Care Connect, a provider of in-home care services across New South Wales, Queensland, and Victoria. Picture: Supplied.Original Source: Preventing hospitalisations using a multidisciplinary care model – Aged Care Insite
Source: aged care insite
Published: 4th December 2025
Here is a link to the original article: Preventing hospitalisations using a multidisciplinary care model – Aged Care Insite