Is the household model of care truly the future of aged care?

Aged care is evolving from an institutionalised model of care into a person-centred one. At the heart of this growth is the environment where people live.

As part of its Final Report, the Royal Commission into Aged Care Quality and Safety called for consistent standards to outline accessible and dementia-friendly design. It wanted a safe and comfortable environment that nurtured independence, function and enjoyment.

It also strongly supported the small household model of care. Small-scale household environments are popular because they promote a home-like feeling and staff can provide more personalised care. 

These ideas and initiatives have been reinforced by the National Aged Care Design Principles and Guidelines, which while they’re not mandatory, will guide refurbishments and new residential aged care builds. 

Nick Seemann, Co-author, Dementia Training Australia Environments Specialist and MD of Constructive Dialogue Architects, previously spoke to Hello Leaders about the Principles and Guidelines. 

More recently, he appeared at the International Dementia Conference in the panel ‘Future fit – a household model of residential care for tomorrow’. 

“This is a conversation we’ve been having for over 20 years. We’ve seen different endeavours on how we can go from traditional institutional nursing homes to different things that bring life into a building,” Mr Seemann explained. 

“The building can either support the model of care or create barriers. The message [to change] has been consistent, I think the implementation is often slow because it takes time.”

But change is occurring, both in Australia and overseas. Providers are looking at how they can put the person first and develop home-like environments in existing buildings, or if they’re truly not fit for purpose, new builds. 

One local provider that’s embraced the household, person-centred care brief and pushed the boundaries is Community Home Australia (CHA). Anyone on LinkedIn would see their leaders, including Rodney Jilek and Nicole Smith, making positive contributions.

Ms Smith, the Chief Operating Officer for CHA, highlighted that they have found success through NDIS and private funding, meaning they can be incredibly versatile with just how small-scale their households are. 

They’re not just providing the bricks and mortar. Guests are included in key decisions. 

“We can build household models and we can make nursing homes look amazing, but no one’s ever actually picked the design. It’s nobody’s home. Every single place that someone with dementia goes is never going to be their home,” Ms Smith said. 

“Unless you have people with dementia more involved in picking the colour of the curtains and having some actual choice it’s just not their home.”

Ms Smith recognised that many providers would not adopt a household model because financial viability isn’t easy to achieve with 12-16 residents, she said sometimes it’s just a way of thinking that needs to change. 

“We need to step away from the design, it is not the be-all and end-all. It is a great starting point but we need to realise that if Jim likes lunch on the grass, let’s do that. If three people get along now we have another private dining area. We keep trying to force people to all do the same thing at the same time. That’s just not person-centred,” she added.

The view from across the pond

In the United Kingdom, not-for-profit provider Belong has operated with a household model for 16 years. CEO Martin Rix explained that developing a unique model of care hasn’t been easy in the UK. However, for them, 12 residents in each household provide the best balance between commercial viability and quality care delivery. 

“It’s not perfect. There are lots of things we learned along the way. One thing that hasn’t been easy but we’re still convinced it’s the right thing, is that we form our households based on what we believe is social cohesion,” he explained.

“Somebody might live with dementia, somebody might live without dementia, and they’re next to each other. It’s about what people we think work together. That has some challenges and disadvantages.”

Mr Rix also backed up the view that even though the building and physical environment are important, the philosophy of care and how that care is delivered matter the most. 

“We see the environment as the foundation for fantastic outcomes for people. But you have to provide the other things on top of that otherwise it’s meaningless.”

Financial constraints can be a distracting factor as there is an additional cost in delivering this model of care. Less tangible benefits include a decreased reliance on the healthcare system and better health and social outcomes for residents and communities. 

“Care providers don’t have the financial and head space to think about doing things differently. You have to be brave enough to do it but you also need the time to come to conferences to talk to people and share ideas and that’s not easy to come by.”

What does the future look like?

In Australia, the Design Guidelines and Principles are a blueprint for change in aged care design. But they’re by no means a stock-standard template as Mr Seemann said they’re a step in the right direction. 

They will help to enhance existing buildings through simple changes, rather than decreeing that every provider needs to build from the ground up. 

“Change is hard. There’s been positive change in Australia over the last 20 or 30 years and it’s come from organisations focused on making the person the centre of the model of care,” he explained. 

“But we can do that in small steps. We can look at the household of the whole organism, its movements of people, staff workflows, routines and rhythms that make something home, not an institution. The big challenge is how do we fix 3,000 buildings rather than think they’re all gonna be replaced because they’re not.”

Additional support for providers interested in change is available through organisations such as Dementia Training Australia, Dementia Australia, Dementia Support Australia or the Government’s Aged Care Capital Assistance Program (ACCAP). 

CHA’s person-centred approach also inspires. Ms Smith has personally taken guests to select their new home, sharing that the process gave her goosebumps. It’s a simple step towards continued inclusion and supported decision-making. 

Then there’s the staff. Both Belong and CHA have had their challenges recruiting staff who are confident working under a unique model of care. Plenty of staff thrive, especially when they’re supported by management. 

“We really build the resilience of the team. They are absorbed like a village and a lot of the things we do are community based. We invite the whole community into all of our programs. From that day they feel like they have a family,” Ms Smith said.

Does this mean the future of aged care is only the small household model? Maybe, maybe not. Ms Smith believes the model is scalable and she would like to see providers “embracing our elders as part of the community, more respect for people with dementia being in the community and more risk-taking.”

Mr Rix wants variety and choice; “I’d like people to have options through services based on the idea that the people who live within can use their vast life experiences to create opportunities for joy for both themselves and others who live with them.”

Similarly, Mr Seemann said there would be something special gained by variety; “I hope that there’s a very eclectic range of different buildings so I can look at a wintering home and get excited about that. Or I can look at smaller community-based care opportunities; a range of things that are much more what we think of when we say household.”