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REVIEW OF INNOVATIVE MODELS OF
AGED CARE
APPENDIX 3
RESEARCH PAPER 3
JANUARY 2020
The Royal Commission into Aged Care Quality and Safety was established by
Letters Patent on 8 October 2018. Replacement Letters Patent were issued on
6 December 2018, and amended on 13 September 2019.
The Honourable Tony Pagone QC and Ms Lynelle Briggs AO have been appointed
as Royal Commissioners. They are required to provide a final report by
12 November 2020.
The Royal Commission intends to release consultation, research and background

papers. This research paper has been prepared by the Flinders University, Bolton
Clarke Research Institute, SAHMRI and Stand Out Report for the information of
Commissioners and the public. The views expressed in this paper are not
necessarily the views of the Commissioners.
This paper was published on 24 January 2020 in three parts:

the main report; appendix 3 (this part); and a technical report
© Commonwealth of Australia 2020
ISBN 978-1-921730-02-3 (online)
With the exception of the Coat of Arms and where otherwise

stated, all material presented in this publication is provided
under a Creative Commons Attribution 4.0 International licence.
For the avoidance of doubt, this means this licence only applies
to material as set out in this document.
The details of the relevant licence conditions are available on

the Creative Commons website as is the full legal code for the
CC BY 4.0 licence <www.creativecommons.org/licenses>.
The terms under which the Coat of Arms can be used are detailed
on the Department of the Prime Minister and Cabinet website
<www.dpmc.gov.au/government/commonwealth-coat-arms>.
REVIEW OF INNOVATIVE MODELS OF
AGED CARE
Appendix 3
November 2019
Innovative models of aged care Appendix 3

Contents
Table 1 Innovative models of care for residential care ....................................................................... 1
Small-scale, domestic living ............................................................................................... 1
Dementia villages ............................................................................................................. 4
Community-based shared housing arrangements................................................................. 6
Multisensory care for advanced dementia ........................................................................... 8
Care Coordination for advanced dementia .......................................................................... 9
Community of practice for advanced dementia .................................................................... 9
Intergenerational communities ........................................................................................ 10
Teaching nursing homes .................................................................................................. 12
Table 2 Innovative community models of care................................................................................ 13
Respite care....................................................................................................................................... 13
Community-engaged scholarship ..................................................................................... 13
Social and/or community integration ................................................................................ 14
Social and care farming ................................................................................................... 17
Cottage and homelike respite .......................................................................................... 17
Adult placement ............................................................................................................. 18
Day centre ..................................................................................................................... 20
Support worker ................................................................................................................................. 20
Integrated care .............................................................................................................. 20
Care coordination ........................................................................................................... 22
Case management .......................................................................................................... 24
Collaborative care .......................................................................................................... 25
Coordinator and navigator............................................................................................... 25
Workforce optimisation .................................................................................................. 27
Dyadic caregiver interventions for people with dementia ............................................................... 29
Other community care models ......................................................................................................... 32
Age-friendly cities and communities ................................................................................. 32
Senior-friendly community living ...................................................................................... 33
Asset-based approaches.................................................................................................. 38
Autonomous team working ............................................................................................. 43
Table 3 Innovative models of care for rural/remote living populations .............................................. 44
Outreach ....................................................................................................................... 44
Community engaged scholarship ...................................................................................... 45
Friendly communities ..................................................................................................... 45

Coordinator and navigator............................................................................................... 46
Table 4 Innovative models of care for Aboriginal and Torres Strait Islander populations ..................... 47
Culturally specific aged care............................................................................................. 47
Remote dementia support program ................................................................................. 48
Collaborative community service model............................................................................ 48
Table 5 Models of care and supports for CALD groups..................................................................... 50
Table 6 Innovative models of care for younger people (under 65 years) ............................................ 51
Integrated/co-located housing ......................................................................................... 51
Individual units with shared supporting services ................................................................ 52
Shared housing with supporting services ........................................................................... 52
Combined aged and disability service for families .............................................................. 53
Table 7 Innovative models of care for LGBTI populations ................................................................. 54
LGBTI affirmative assisted living ....................................................................................... 54
Naturally occurring retirement community........................................................................ 54
Multiagency collaboration ............................................................................................... 55
Table 8 Innovative models of care for homeless populations ........................................................... 56
Residential/supported accommodation for aged homeless ................................................. 56
Permanent Housing and Support Services ......................................................................... 58
Table 9 Selected examples of innovative technologies to support LTC for older people ...................... 60
References ................................................................................................................................. 62

Table 1 Innovative models of care for residential care
Key Countries Settings, Key features Extent Delivery Strengths Challenges / Resources Impact on Consumer
examples available population implemented weaknesses inequity views
Small-scale, domestic living Key features

• Homes with limited number of residents
• Person and relationship-centred care, flexible routines
• Homelike design, hidden medical/staffing equipment, no staff uniforms
• Involve ‘culture change’
• Preferred by consumers [1-4]
• Resident autonomy and independence promoted and fostered
• Improved resident outcomes from a limited number of studies with methodological limitations: improved social engagement, improved quality of care
indicators, reduced restraint and psychotropic drug use [5-8], reduced decline in caregiver relation [9]
• Possible increased activity levels [10]
• Possible increased staff emotional strain [11]
• Very low level of certainty of evidence of impact on resident outcomes
Eden US Dementia- Homelike design and Introduced 10 Culture change Systematic review: One Systematic Staff turnover Information Scoping
Alternative specific or social programming. years ago in a model. controlled before-after review: Lack found to be not available. review:
* [1, 12-16] general Connects residents to nursing Focus on study with single site (N = of rigorous higher in Eden Person- Residents
aged care. outside world, through facility in New engagement and 80) may indicate reduced evidence for Alternative centred (non-
pets, plants and children. Berlin, New empowerment of helplessness and effect on facility than in approach dementia-
Existing facility undergoes York. staff in effecting boredom. resident traditional theoretically specific)
limited environmental Registered at this change. outcomes. nursing homes. enables more satisfied
changes to make more 190 facilities Three studies tailored care with care
‘homelike’. (2016). found no to residents compared
significant with differing with
effects on needs. traditional
resident nursing
physical homes.
functioning
compared
with
traditional
homes.
Innovative models of aged care Appendix 3 1

Green US 7–12 Residents have control Commenced Staff are universal Systematic review: Require Higher capital Information Systematic
House (GH) residents over daily life. in 2003. workers known as Improvements in bedfast complex cost, greater not available. review (single
model * [2, per house. Residents encouraged to ‘Shahbazim’: care residents, catheter use, human space site studies):
3, 6, 8, 14, Dementia- engage in meaningful 230 houses in partners with low-risk pressure ulcers, resources requirement per Person- Greater
15, 17-27] specific or activities. operation multiple roles. physical restraint use, management. resident. centred satisfaction
general Homes are free-standing, across 54 “Advanced staff hospital readmissions approach with care and
aged care. semi-attached facilities and training”. and avoidable hospital Staffing Lower enables engagement
bungalows, with private 63 houses in readmissions. model hospitalisation tailored care in meaningful
bedrooms and bathrooms development ‘Guide’ supervises Studies of single site: challenging; rates and costs to residents activities.
and shared common across 13 all non-clinical Better quality of life, often multiple to Medicare. with differing
areas. facilities Shahbazim work better function. tasks for staff needs. Greater family
Medical infrastructure (2019). and oversees Other: to complete Similar cost to satisfaction.
hidden. house. Lower direct care simultaneousl residents as
Staff care for up to 10 staff turnover. y. traditional care.
residents. Medications
Staff empowered to dispensed by Systematic
prioritise tasks. licensed nurses, review: More
Staff accepted as doctors and direct care time
members of household. therapists who to residents.
only visit
household when
needed.
Clustered Australia Dementia- Promotion of resident Several in Higher staff Selected studies: Systematic 20% greater Accommodati Better
domestic # specific autonomy and self- various training, PCA: Cross-sectional study review: Lack capital cost, on cost consumer-
[4, 28-34] care. esteem. suburbs in nurse ratio, & demonstrated of rigorous greater space partially rated quality
Domestic cottages, each NSW. direct care hours. associations with better evidence for requirement per subsidised by of care vs
housing small number of quality of life, lower effect on resident. government standard care.
residents, domestic hospitalisations and resident based on
kitchen and living area. potentially inappropriate outcomes. Cross-sectional asset
Meals prepared in unit by medication use. retrospective assessment.
staff and residents. study: same Government
Allocation of staff to running costs as provides care
specific units. standard care, subsidy.
Independent access to higher staff
outdoors. training costs.

The UK, Dementia- Applied within small Model 12-month 12 Butterfly homes rated Systematic Care homes Information English Care
Butterfly Canada, specific household living in a applied in program within as ‘outstanding’ by the review: Lack supported by not available. Quality
Household Ireland, care – family-like environment. more than existing small- English Care Quality of rigorous ‘Dementia Care Commission
model of Australia, culture No institutional features 100 homes in scale living care Commission. evidence for Matters’ during Inspection
care # [35- US, the change such as staff uniforms, UK, Ireland, homes. effect on 12-month reports on
39] Netherland organisatio medicine trolleys, and Canada, resident implementation Butterfly
s n. rigid routines. Australia and Staff focus on the outcomes. period. homes found
Belief that people living the US (2018). development of residents and
with dementia can thrive Recently attached family were
in nurturing environment. adopted in leadership, nurse highly satisfied
Leadership, staff, families the modelling and with quality of
and care partners taught Netherlands. emotional care and
to be person-centred and intelligence. safety, and
relationship-focused. daily running
of homes.
Green care Norway, 24-hour Small-scale living Emerged in Nursing staff Systematic review: One Minimal Some May be Information
farms * [40- the nursing Agricultural activities. Europe in require explicit longitudinal study (N = evidence of agricultural particularly not available.
44] Netherland care in a Maximise participation in early 1990s. competencies 115): residents of green benefit. production. For suited to older
s, France, small- daily outdoor, domestic More than because of the care farms are more Implementati others, care is people from
US scale, and work-related 1000 in the integrated task. often engaged in on barriers main income rural/remote
rural, activities. Netherlands domestic or outdoor are physical source. areas with
farm-like Presence of animals, 2017); activities, less often environment agricultural/
setting. plants and other natural approx. 200 engaged in passive (e.g. degree farming
Also aspects. provide care activities than those in of backgrounds.
provides for people traditional homes. They urbanisation),
specialised with are significantly more characteristic
day respite dementia physically active than s and
for people (including those in regular small- competences
with those used for scale homes. of staff and
dementia respite only). managers,
Expanded to and political
Norway, UK, context.
France, Japan,
China and US.

Evermore # UK General Older people live in a First Staff are ‘universal Relationship-based, Paucity of Information not Information Information
[45, 46] aged care. family home setting with Evermore workers’ or domestic homelike robust available. not available. not available.
up to 12 people. Have community Mulinellos who approach. evidence.
their own kitchenette, will be built in operate in
bedroom and bathroom, Manchester, teams in one
and shared communal UK and household to
spaces. Specialist opened in establish
dementia households also 2019. relationships.
provided. Residents take The work with
part in daily household residents to run
life. the
Motto is ‘live happy’. household in a
Staff facilitate resident way that best
access to services and the meets
community. their needs.
Martha The Dementia- Group of 12 residents. At least 11 Person-centred Relationship-based No eligible Information not Residents Information
Flora # [47- Netherland specific Residents have own facilities approach to approach. Residents can studies available. required to not available.
49] s, UK care. apartments consisting of currently dementia care. live with partner. identified on pay personal
bedroom/s, bathroom operate Focus on contact systematic contribution
and pantry, plus access to across the with family and No eligible studies review. to living
shared communal space Netherlands. staff forming identified on systematic cost; however
and garden. Personalised Model also personal review. part is
care. Residents design being relationships with reimbursed
rooms. implemented residents. through
Residents can live with across chronic care
partner and have access multiple sites act according
to society (including in the UK. to personal
nearby shops, etc). finance check.
Dementia villages Key features
• Community living for people with dementia
• 6–7 residents per house, plus communal shops and gardens
• 24-hour nursing care
• Safe environment where residents can participate in everyday activities within a ‘village’ setting
• Lack of robust evidence for impact on resident outcomes
Hogewey The Dementia- Residents choose which Located in Approx. 250 staff. Care is person-centred No eligible Building costs Residents Information
(De Netherland friendly lifestyle will suit them and town of Dementia care Encourages community studies estimated at enabled to not available.
Hogeweyk) s communit bring their own Weesp, training. involvement, with good identified on €19.3 m continue the
# [17, 50- y with 23 belongings and pets. Amsterdam. Overnight, use of assistive systematic (£15.1 m). State lifestyle they
53] homes, Relieves resident anxiety, residents left technology and review. funded €17.8 m had before
each confusion and anger by alone, monitored minimisation of with the rest living in the
accommod providing a safe, familiar via assistive medication. Some from sponsors village.
ating 6–7 and human environment. technology. criticism that and fundraising. Consideration
residents. Focus on ‘maximising the 120 community Dementia-specific care in model Care costs same of varying

Residences quality of people's lives, volunteers. homes suited to misleads as standard. resident
enclose keeping everyone active, 4.89 direct care individual lifestyle. residents into Facilities rented backgrounds.
central focusing on everything hours per day per Residents engage in believing they out. Care funded
communal they can still do, rather client. village activities beyond are living in a Costs reduced via long-ter-
village than everything they the residential care ‘real’ by limited care insurance
area with can't’. home (e.g. shopping). community. managerial with out-of-
hairdresse Medication is minimised. team and pocket
r, cinema, Use of reminiscence multitasking contributions.
supermark therapy. staff.
et, Overnight, residents left
restaurant, alone and monitored via Investment per
café, pub, assistive technology. resident:
doctor and €126,768
physiother (US$183,110).
apist, run
by carers.
Bryghuset Denmark Dementia- Linked to global Located in Nurses present in Residents with Information Relatives felt it
Dementia friendly movement of dementia- Svendborg. normal working advanced not available. important for
Village # communit friendly communities that Opened in hours. During dementia may residents to
[54, 55] y with 125 originated in Japan. 2016. other hours, not be able to maintain
residences Svendborg City benefit from connection to
(56 residential care activities life outside
dementia nurses are on call. provided by the dementia
residences village, since village and
). this requires prioritised this
Modelled resources to be enabled.
on De beyond what is
Hogeweyk. provided.
Korongee Australia Dementia- In development. Australia’s Information not Collaboration Information Information
Dementia specific Plans for 90 residents, 15 first dementia available. between not available. not available.
Village # care tailored houses, village Glenview
[56, 57] (including supermarket, cinema, currently Community
early café, beauty salon, being Services and
onset). gardens. developed in HESTA
Residents choose which Glenorchy, superannuation
lifestyle will suit them. Tasmania. fund to provide
Residents can walk As of Feb A$19 m, plus
around village and 2019, site Australian
participate in everyday work started, Government
life decisions. with expected funding.
completion
late 2019.

Community-based shared Key features

• Apartment-style or single-family home, small-scale living with 6–10 residents per home
housing arrangements
• Urban setting, emphasis on connection to neighbourhood, resident autonomy
• Care provided by care workers and family members
• Suited to Culturally and linguistically diverse (CALD) populations and people with dementia
Group Australia General Small-scale living (6–10 Commenced Carers are Holistic approach to care. No eligible Residents Provider and Well received
homes aged care, residents). in 2012. universal workers Homelike model located studies receive home privately by relatives of
Australia # including Each resident has private Nine sites in or homemakers. and integrated into identified on care packages owned residents.
[58, 59] dementia bedroom. suburban Two to three staff community. systematic plus out-of- homes. May
and Allocation of staff to living Sydney, eight per home with no Person- and relationship- review. pocket costs be limitations
younger units. Non-identified under agency staff. centred care. while living in for those of
people. homes (no signage, etc). development. Carer:resident Meaningful activities and community low
24-hour support ratio 1:4; one staff involvement of residents homes run by socioeconomi
delivered by universal member at night. in daily activities. community care c background.
staff (‘homemakers’). Specific staff High staff ratio with staff provider.
Dementia-friendly design: training in culture consistency.
‘homelike’ with safety, and philosophy. Alleviates aged
home furnishings, large Training care budget
gardens, smart assistive disseminated through user
technology. online and in paid model.
Focus on engagement in person,
routine activities (e.g. fortnightly.
cooking, gardening,
shopping).
Shared Germany Small-scale Separate from traditional 3121 Care providers Can be successfully Lack of Providers Low income Information
housing living nursing homes. residences and landlords are established in rural as systematically emphasise that crucial factor not available.
arrangemen facilities Often large apartments in estimated to bound by contract well as urban areas. identified nursing staff in reducing
ts (SHAs) * for older urban settings. Typical be operating to each tenant Concept of care can be evidence for work more access to
[60, 61] care- structure is a flat with across individually and adapted to include more positive efficiently and SHAs, but
dependent kitchen, living room and Germany (in not to a group of people from low impact on have greater social
persons, private bedrooms. 2015) with residents as a socioeconomic resident flexibility of assistance can
predomina Main aims are family approx. 594 in whole. backgrounds, as well as outcomes. personnel provide
ntly structure, connection to Berlin. Focus on family to suit the strong family planning than in support.
suffering neighbourhood and involvement in ties of ethnic groups. Social support traditional Most
from autonomy. care. may apply nursing homes. residents are
dementia Nursing staff are 'guests'. standards and middle class
(6–8 restrictions to and approx.
residents). access. 80 years old,
with
dementia.

Charles US Neighbour Each house has 6 Currently two Household Residents may benefit Ageism and Start-up funded Annual fee Information
House hood- bedrooms and 3.5 homes in NC, staffing model, from living in small generational by parent may preclude not available.
Eldercare based bathrooms. US, one in following a holistic homelike setting. differences organisation, people on low
Homes [19, residential Engages in surrounding Yorktown care philosophy may pose Charles House incomes.
62, 63] home who neighbourhood activities. (2011) and and team Continued involvement challenges for Association
may or Resident and family one in approach to in the community. long-term (not-for-profit).
may not participate in decision- Winmore caregiving. care models Program is self-
be living making. (2014). 24-hour care by that aim to sustaining
with Person-centred care. staff and involve the through
dementia. Residents encouraged to volunteers, who wider collection of
be active and contributing work with community. participant fees.
members of household. residents and
families to Annual fee to
incorporate them residents is
into household US$69,600
life. (2014), not
Staff:resident including
ratio 1:3 during physician/health
day and 1:6 at care or
night. medications
Winmore house
built at cost of
US$425,000
(2014).

Group Sweden Blocks of 8-10 residents per unit. Pilot in Staff are Systematic review: A Systematic Pre-Post Apartments Information
Living (GL) * (Malmo) * flats in the 2 units located in ordinary Sweden responsible not before-after study review: Lack longitudinal make it not available.
[64-67] suburbs, blocks of flats, each unit (1985). only for patient reported positive effects of rigorous study: Cheaper difficult to
adapted consists of 4 flats. care but also for on residents' emotional evidence for (than residential care for
for people Flats have private areas cooking, cleaning, symptoms compared effect on care due to residents who
living with with 1 or 2 rooms with washing, with traditional care, but resident lower have a serious
dementia. toilet and shower, as well transportation results were unadjusted outcomes. institutional physical
as a kitchen, living room, and activating for baseline differences, care and small- disability.
dining room and laundry therapies. and there is low certainty scale
room available to staff in this evidence. housekeeping).
and residents. Units are staffed Estimated cost
Care adapted to 24 hours, with Cost analysis study: per day
residents' needs. three staff during Patients used institutional
Focused on day and one at significantly less care £68 vs £42
normalisation: no hospital night. Staff are institutional care after group living.
routines and lessened paid by and admission to GL.
resident anxiety. recruited from Low certainty in
Private living county council this evidence.
arrangement (own room and municipality.
in a flat, own furniture), Staff undergo a
and resident pays rent. 3.5-week training
Flats staffed around the program on caring
clock. for patients with
No administrative dementia.
procedures.
The Dementia- Maximum of six units (6
Netherland specific residents) located near to
s [5] care. a traditional nursing
home but situated more
than 200 metres away.
Residents prepare own
meals.
Advanced dementia care models
Key features
Multisensory care for advanced • Multisensory program for late-stage dementia
dementia • Focus on environment and loving touch
• Providing care for people living with dementia or at end of life
Namaste Many, Advanced Group or individual Available in By existing staff to Applicable to anyone at Lack of robust Not expensive. Unclear. Well received
Care including dementia multisensory program of 10 countries. groups or end of life regardless of evidence. Uses existing by family
program* UK, US, at end of care. Australian individuals. age, culture or diagnosis. Studies resources members.
[68-76] Australia life Focus on environment availability Ideally delivered No systematic review (cluster No dedicated
and loving touch. unclear, but with 1:1 staff: identified randomised space or

Calm environment (e.g. more than 15 resident ratio. Selected observational controlled specialised staff
music, soft lighting) care homes. Resident not left studies reported trial) required.
Unhurried loving Can be alone during improved behaviour and underway.
approach to activity and delivered in Namaste session. decreased antipsychotic
interaction (e.g. brushing residential or use.
hair, massage, life story community
communication), pain care.
management and
hydration.
Families can be involved.
Key features
Care Coordination for advanced • Ensures client with advanced dementia has supports required to live out their life with the greatest degree of comfort and choice possible.
dementia • Surrounds client with a multidisciplinary team of practitioners, who are organised by a case coordinator.
Scottish Scotland People 8-pillars model of Implemented Dementia practice Nationally implemented. Limited Funded through Government Information
advanced with community support for nationwide, coordinator plus Integrated approach. evaluation; Scotland’s guaranteed not available
dementia advanced dementia, including case evaluation advanced Promotes wellbeing and evaluation National access for all.
practice dementia coordinator plus ongoing. dementia quality of life of people ongoing. Dementia
model [77] and at end Advanced Dementia Launched specialist team with advanced dementia Strategy.
of life. Specialist Team. 2015. (geriatrician, allied and their families and Government
Provides the essential health supports. support, funded
support to care homes professional, ‘Promoting Excellence by local
and those providing day- district dementia Framework’ ensures health/social
to-day care. nurse, minimum skills of staff. care boards.
psychiatrist,
psychologist,
palliative care
specialist).
Key features
Community of practice for • International community of practice facilitates the sharing of experiential learning and education of practitioners
advanced dementia • Virtual platform allows reiterative approach to best practice, involving consumer voices
• Online technology allows the efficient dissemination and development of advanced dementia care practices
Dementia Scotland, Care Provides the platform to 7 European Best-practice Includes consumer Depends on Technical Good access. Includes
Palliare [78- Czech model create a virtual countries, framework voice/narrative. staff support for consumer
80] Republic, targets international dementia project educates variety technology website. Resource voice/narrativ
Finland, individuals academy (which hosts completed of practitioners Supports qualified access and efficient. e.
Portugal, with accredited higher between 2014 who are involved dementia workforce skills. Local access to
Slovenia, advanced education modules and 2017. in advanced through education. internet.
Spain, dementia focusing on dementia dementia care
Sweden. who are care). (e.g. doctors, Efficient, utilises
not yet Experiential learning and nurses, knowledge and provides
requiring prudent healthcare psychologists). education across
end-of-life approaches. borders. Delivers services
care but Virtual international Framework across health and social

are community of practice. designed for care.
becoming Creation of an European
reliant on interprofessional learning workforce. Has an evidence-
the framework (best-practice informed focus on
support of statement). Community of advanced dementia.
others. practice to share
experience and Includes long-term care.
learn.
Key features
Intergenerational communities • Elderly residents needing care reside alongside members of the general public
• Emphasis on resident interaction with children, students and other members of the community
Humanitas The Apartment 195 supported Model Information not Encourages Paucity of Information not People living To measure
Bergweg # Netherland s for older apartments, central emerged in available. independence, Small- robust available. at Humanitas the perceived
[81, 82] s people atrium, bar, restaurant, 1980s in group living, community evidence. rent or buy an quality of care,
needing library & café. Complex is Rotterdam, connections, utilises apartment, a client
care and service hub for home care the informal supports. designed to satisfaction
communal in neighbourhood, Netherlands. adapt to their survey is
facility for ‘memory museum’. needs. conducted
people Staffing has a “Yes twice a year.
with culture”. Relationship-
dementia. centred approach, focus
on belonging and
community bonding.
People not clustered by
need, age or
sociodemographics.
Inclusive – open to
everyone.
Gojikara Japan Main Along with residential Organisation Staff reminded to Opportunities for Paucity of Residents pay Care is Information
Village # campus of care, community also began with “not work too socialisation between robust for housing and government not available.
[83] communit consists of a preschool, childcare in hard, and relax”. carers, residents and evidence. meals, plus 10% subsidised.
y offers nursing school, café, and 1981, and in Staff encouraged community members of care. Other Model
services accommodation for 1987 opened to reduce their fostered and encouraged Japanese 90% is ‘embraces
for elderly family. a skilled pace of work and through design of village. houses and subsidised by diversity and
and Multigenerational nursing home, make time to some areas in government multigenerati
younger community where with other socialise with the village do not universal long- onal
generation residents are able to care services residents. offer term-care interactions’.
s, including experience usual lifestyle. established Mothers of complete insurance.
skilled Traffic restricted and over time. preschool accessibility –
nursing residents encouraged to children, nursing possible
care walk. students, and safety
(including Buildings designed on retired people concerns.

dementia domestic scale. from community
care), AL, All residents have views all participate in
home care and access to gardens. non-clinical care.
and adult
day care.
Homelike
environme
nt.
The Mount US About 200 Neighbourhood contains Implemented Each Based on comparison of Paucity of Staffing: Overall Information Information
neighborho residents cluster of private and in 1994 in neighbourhood key metrics using before- robust payroll costs not available. not available.
od # [84] live in shared rooms, and large Seattle, WA, staffed by after design: moderate evidence. roughly the
clusters of communal US. permanent team evidence that residents same as before
rooms kitchen/dining. Since 1998, including are more engaged, use implementation
known as Residents free to furnish The Mount neighbourhood less medication, and are of the new
neighbour living spaces with familiar has worked coordinator, more active in new model.
hoods. objects, plants and pets. with the resident assistants model compared to Building
There are Focus on independence, Pioneer (nurse aides), traditional care. Also redesign and
nine autonomy, dignity, and Network. dining staff, reportedly a significant addition of new
neighbour community. nutrition staff, drop in staff turnover features cost
hoods, Residents with dementia social worker, a since new model roughly $9
each not separate. nurse, and implemented. million.
housing ‘Intergenerational housekeeper. All
20–23 Learning Childcare staff assist
residents, Center’ serves 125 residents with
including children, who interact daily living needs
residents with residents. and activities.
with The new service
dementia. delivery model led
to a major staffing
reorganisation.
Cooinda Australia General Students from University About to be Information not Encourages Paucity of Information not Information Information
Aged Care aged care, of Sunshine Coast live in trialled in available. intergenerational social robust available. not available. not available.
Centre # some decommissioned rooms Queensland engagement. evidence.
[85] residents in aged care facility. town of
with Students have reduced Gympie in
dementia. rent in exchange for Australia.
doing volunteer work
with aged care residents.
Humanitas The General University students live in Model began Information not Fosters intergenerational Paucity of Information not Students live Information
Deventer’s Netherland aged care, aged care facility free of in 2012 in available. communication, prevents robust available. free of charge. not available.
# [86, 87] s some charge in exchange for 30 town of loneliness for residents. evidence.
residents hours of volunteer work Deventer in
with per month. the

dementia. Focus on reducing Netherlands.
loneliness and improving
resident wellbeing.
Judson US General University students live in Program Information not Encourages Paucity of Information not Information Information
Manor # aged care, aged care facility free of started in available. intergenerational social robust available. not available. not available.
[88] some charge in exchange for 2010 in engagement. evidence.
residents volunteer work. Cleveland,
with Focus on reducing Ohio, US.
dementia. loneliness and improving
resident wellbeing.
Key features
Teaching nursing homes • Links aged care and education sectors to create synergy in education and training, research and clinical care
• Supports clinical placements and professional development
• Similar to teaching hospitals, some but not all education and partner aged care providers are research and learning centres
Teaching Australia, General See above. Australian University-based Systematic review: Staffing issues Government Information Information
and USA, residential model funded clinical educators Promotes workforce (turnover, funding/support not available. not available.
Research Canada, aged care for 3 years and vocational training and lack of .
Aged Care Norway, settings. (2012–2015). education competencies teaching/men
Services The providers and Generates positive toring skills, Learning
[89, 90] Netherland US foundation aged care attitudes to working in work burden). infrastructure in
s funded for 5 organisation- aged care. Culture and aged care
Robert years (1982– based care staff Selected studies indicate system facilities is
Wood 1987). providing increases research. differences required.
Johnson Canadian mentoring during between aged
Foundation model has student care and
three centres. placements. education
The Ontario sectors.
Centres for Norway Negative
Learning model attitudes to
Research implemented working in
and into national aged care.
Evaluation practice since
2004. No systematic
Norwegian evaluation of
Program The impact on
Netherlands resident
Physician model outcomes.
focused expanded to
approach multiple aged
care homes.
# Located in the peer review literature, * Located in the grey literature

Table 2 Innovative community models of care
Key examples Countries Settings, Key features Extent Delivery Strengths Challenges / Resources Impact on Consumer
available population implemented weaknesses inequity views
Respite care
Community-engaged scholarship Key features
• University students participate in structured sessions with older people as part of placement
Community – Canada Simulation Educational hub Students from Once per Purpose-designed Paucity of robust Program Fees exist, but Information
college apartment at for personal one week for day, space that is safe evidence. coordinator 0.8 full and half- not
partnership # the college support university. cognitive and and comfortable, full-time subsidies are available.
[91] (specifically workers, physical with flexibility to equivalent and available.
designed for occupational activities, with rest as needed. two program
student therapy and meals support workers
learning). physiotherapy provided. at 0.8 full-time
students. equivalent each.
Structured and
proactive
communication.
The Houseguest US In-home Community Students from Education Model developed Paucity of robust University Information not Information
Program # [92] education and engaged one workshop for incorporating evidence. student available. not
respite for scholarship – university, caregivers teaching, coordination. available.
people with working with engaging and service research and
dementia and university eight plan (student- service.
their caregivers. students caregivers. engaged Improved
Modified from activity with psychosocial
Families Matter care outcomes for
program. recipient). caregivers.
Rapport building.
TimeOut@UCLA US People with Engages Students from 8-week Program manager Paucity of robust University Information not Student
# [93] dementia and undergraduate one campus-based matches students evidence. student available. views very
their caregivers. students in university. drop-off with person with coordination. positive;
intergeneration respite dementia based assists in
al service. program. on shared reinforcing
background and career
interests. choices in
gerontology
.

Social and/or community integration Key features
• Collaborations with existing community services and centres
• Draws on existing resources to supplement programs
Meeting The Nursing home- Transition of 120 meeting Activity, Socially Inflexible staff. Program Information not Mixed; staff
Centres Support Netherlands, based day care nursing home- centres across psychosocial integrated with Fixed work coordinator; available. found the
Program # [94, Italy, Poland, centres for based day care the country, and emotion- other care and patterns training of staff transition to
95] UK people with centre to the with six oriented welfare Limited and volunteers. a new way
dementia and meeting centre nursing approach. organisations. experience of of working
caregivers. model. homes in this Case Compatibility for working with challenging
Outcomes trial management. each context other care and at times.
focused on both transitioning Carer considered. welfare
care recipient to this model. information Transformation of organisations.
and caregiver 1 trial site in sessions. a current centre Threats to
Greater input NSW Weekly into a new way of ongoing funding.
requested from (3Bridges). consultation working.
the dyad. hour. Involves
Regular volunteers.
centre Moves the day
meetings to centre program to
discuss needs an easy-to-access
and wishes. community
location.
Kintun program Chile People with Day service Initial pilot in Complete Fully integrated Paucity of robust Geriatrician and Intended for Information
# [96, 97] dementia and incorporating Santiago assessment. into daily life of evidence. allied health families of not
their caregivers. interdisciplinary (reaching 259 Day care community involved. limited means. available.
team. dyads to centre. (based in civic Transport for day
Geriatric date), with Home visits. centre). centre program.
assessment. support from Caregiver Close connection
Enhances Ministry of training. with local
participation Health to Case authorities.
and open nine management. Support from
engagement of more centres Other actions government.
people with across Chile. to integrate Committed and
dementia. with flexible team.
Culturally community.
significant
activities.

Respitality * Scotland, US, Hotels across Respite and Operates Social Complements but Paucity of robust Staff time and Information not Information
[98] Canada, New Scotland for hospitality across 14 franchise does not yet evidence. funding to available. not
Zealand carers/care whereby hotels local authority model for replace the Some develop and available.
recipients. are encouraged areas in hotels to provision of government expand into other
to gift short Scotland (44% provide respite by local investment still areas.
breaks to coverage). accommodati authorities. required.
carers. on or other Relationships with
services (e.g. providers need to
events, dining be nurtured and
or therapies). sustained.
Can be for
just the carer
or the
caregiver and
care recipient
together.
WISER Australia People with Recognises a Four centres Client- Based on Paucity of robust Training of all Information not Information
(incorporating dementia and person’s with one centred, understanding a evidence. staff in available. not
Montessori their caregivers. individuality more site in purposeful client’s life story, Trial currently Montessori available.
principles) *[99- and transition. activities building underway. principles
101] incorporates promoting relationships and Barriers to organisational,
their strengths, communicatio integrating into general financial,
skills, abilities n and self- required support. implementation educational, and
and interests. care. Encourages staff of Montessori individual
Based on autonomy and include support.
individual’s creativity. insufficient
abilities. funding, negative
Montessori attitudes towards
Champions activities, major
and monthly cultural change
caregiver required.
support Staff may lack
groups assist basic knowledge
adoption of of dementia.
Montessori
practice in the
home.

DAYS BLG! Japan People with Focus on One day Attend when Change of Paucity of robust Program Provided 365 Information
*[102-104] dementia. supporting centre only. they would approach from evidence. coordinator. days per year at not
participants to like and people with For some jobs, Collaboration affordable available.
be involved and undertake dementia being payment and with private costs.
active in activities of care recipients to employment companies and
community. their choice. being citizens. contracts would community.
Volunteer work Publicly funded. disqualify
and chore participants from
opportunities pension.
such as school
crossing patrols,
keeping public
spaces tidy,
washing cars,
selling
vegetables,
cooking in
facilities.
CASCADE * UK, the Older people Exploits existing Not yet Not available. Opportunities for Being built from Not available. Information not Information
[105] Netherlands, with dementia. unused public widely shared use and the highly available. not
Belgium and housing stock to implemented. everyday successful, but available.
France (jointly create Development interactions unevaluated,
funded by the guesthouses program to Provides small-scale care
European with care run 2017– economic model
Regional facilities to 2021. Plan for regeneration in (guesthouses).
Development provide short- three case coastal areas of
Fund). term respite study sites. the involved
care (and countries.
longer-term
residence).

Social and care farming Key features
• Services that have been adapted from a farm setting, using farm resources to promote health
• Use of commercial farms and agriculture to promote physical and mental health, by partaking in normal farming activities
• Supervised, structured program of farming-related activities
Farm-based day Norway People with Farm-based day 29 Operating Individually Limited health- Dedicated Information not Information
care # [106] dementia. care with or municipalities over ~5 hours tailored activities educated facilities required. available. not
without animals of Norway of the day. due to the personnel on available.
and access to (~7% across Indoor and diversity of some farms.
natural the country). outdoor resources. No outcomes
environment. activities. Seasonal related to older
activities. people.
Greater exposure
to sensory
experiences.
Green Care The People with Combines 1,100 farms Structured Access to outdoor Funding reform. Dedicated Information not Enables
Farms # [107- Netherlands, dementia. agricultural across the activities environments. Requires space facilities required. available. social
110] US , Italy, UK, activities with Netherlands, outdoors , Stimulation to and selection of interaction,
Belgium care services. with 15% including engage in appropriate farms activities of
open to gardens, activities. and staff. interest and
people with farmyards, Meaningful for enhanced
dementia. stables and those from rural social
greenhouses. or agricultural participatio
Activities such backgrounds. n.
as caring for Simulates normal
animals, daily life setting
walks, rather than
gardening and institutional care.
meals.
Cottage and homelike respite Key features
• Provision of overnight respite care in a dedicated cottage facility (purpose built or family home conversion)
Hammond Care Australia Older people A more ‘normal’ 1 Hammond Provision of Consumers Paucity of robust Dedicated Information not Information
Cottage Respite and their environment for Care cottage, overnight strongly value this evidence. facilities required. available. not
* [111, 112] caregivers respite as with ~76 respite in a form of respite. Evaluation report available.
receiving opposed to a respite cottage. Suitable for 1-2 not publicly
assistance in residential care cottages nights of respite available.
the community. facility, offering across rather than a More expensive
more Australia. block option.
personalised Takes pressure off
care in a residential care
homely respite beds.
environment.

Enabling Australia People with Person-centred 3 dementia Centre-based Evidence-based Requires Staff training Information not Both carer
Household dementia and approach. houses in day care therapeutic significant required. available. and older
model their caregivers. Targeted social Perth, Albany, services. approach. changes in Changes required people rate
(incorporating care and Operate day Physical practice, culture, to physical experience
Eden philosophy. Mandurah. and night and environment outcomes environment to very
Alternative) # Hierarchical 11 day have ~12–16 guided by 10 measurement, support positively.
[113-115] model broken. centres. people a day evidence-based staff skills, staff maximum
Household Eden visiting each dementia design attitudes and enablement.
members Alternative household. principles (e.g. environmental
involved in more Embraces a familiarity, size design.
decisions as are prominent in person- and scale). Evidence-
volunteers. residential centred Improvements in informed, but
Intergeneration care. approach; day medicine use, limited formal
al groups visit created to infection rates, evaluation,
regularly. enhance sociability, particularly in the
Goal is a home wellbeing, satisfaction with respite setting.
away from promote care and physical
home while connection functioning.
providing strong and support Low staff
therapeutic personhood. turnover;
outcome for Meaningful volunteer
every activity to recruitment and
household maximise retention is
member. abilities. strong and
volunteers feel
valued and
supported in their
roles.
Adult placement Key features
• Adults supported in the home of others
Shared Lives #* UK Older people, People are 12,000 Shared Can be Carers are trained Evaluation often Program Information not Older
[116-118] people with included in the Lives carers, residential and matched to focuses on people coordinator. available. people
intellectual family and over 140 (long term), the person with intellectual Dementia-friendly valued
disabilities. community life Shared Lives respite or requiring support disabilities. house being part
of the Shared schemes short breaks, to ensure placements. of the
Lives carer. across the UK. day support, compatibility. Matching of family and
Mutuality of Currently 48% rehabilitative, Some evidence participant and increased
relationships. of Shared or outreach. exists for older carer. opportuniti
Lives people. Training for es for social
arrangements Reduces social carers. contact.
provide short isolation,
breaks and promotes
day support. independence,

provides
emotional
support and
increases
wellbeing.
Costs appear
compatible with
traditional respite
models.
Elderly foster Finland Finnish Family carer Marginal Arranged, An alternative Paucity of robust Program Information not Interviews
care # [119] communities. paid to provide service: 346 supported between living at evidence. coordinator. available. with foster
them a home – people in 138 and home and carers
meals, laundry, foster care supervised by institutional care. showed the
place to sleep homes. the Carer receives work to be
and someone to municipality. income, is emotionally
talk to. Private homes compensated for draining and
Can be short or that offer expenses and is with
long term. assisted living entitled to leave, adverse
are either insurance and effects on
permanent or health social
temporary. examinations. relationship
s; however,
they see
themselves
as
purposeful.
Foster families Russia Remote Pairs older Across several A foster Beneficiaries and Difficulties in Remuneration Specifically Older
* [120] northern people with regions of family the foster families finding paid monthly. targets those people feel
Russian adoptive foster Russia, 148 organiser can become comprehensive who are less lonely
territories. families who foster families assists an resources for one monitoring and vulnerable and or bored
are responsible since 2012. older person another. evaluation need support. with
for providing in basic life Has direct metrics. increased
care to them. tasks, e.g. connection to the There are no opportuniti
cooking and Russian social formal linkages to es for social
serving food, care services. the health interaction.
helping Reduces social system. Foster
maintain daily isolation and Bureaucracy families
hygiene, loneliness in rural involved in setting increase
shopping and areas and up the foster companions
keeping increases access family. hip, mutual
appointments to social care Support needed moral
at medical services. in difficult support,
centres and periods. personal
government satisfaction.
agencies.
Day centre Key features
• Day centre-style respite programs co-located in a residential care facility
ElderServe at US For people with Provides a ‘day One centre in Provided with Night respite Paucity of robust Additional staff Covered by Information
Night * [121, dementia. care’ service at New York; transport to designed to evidence. on night shift. Medicaid. not
122] night to address one in the facility, enhance the available.
sundowning. Worchester. spending 12 wellbeing of the
hours there person with
between 7pm dementia,
and 7am. allowing the
Activities and caregiver to
rest provided rest/sleep.
as needed.
Support worker
Integrated care Key features
• Management and delivery of services to ensure a continuum of care, according to needs over time and across different levels of the system
Te Whiringa Ora New Zealand People with Full Collaboration Focused on Pooled budget for Limited formal Nurse and Deliberate focus Viewed
program # [123, complex, long- involvement of between a multidisciplin integration of evaluation. community-based on reducing positively by
124] term health ‘whanau’ community ary teams and purchaser and Relies on care coordinators. disparities in GPs.
needs and high extended care access to provider of care. contractual health
users of family. organisation community Goals-based relationships outcomes.
hospital Core group of and three services. approach with between
services. professionals, merged Use of performance providers.
plus access to a physician telehealth for measurement.
wider range of practices. self-
services. management
and detection
of early signs
of
deterioration.
The Norrtalje Sweden Older people Funding All older Care Fully integrated Limited formal Program Information not Improved
model # [124, with complex responsibility people in the managers, horizontally evaluation. coordinator. available. information
125] health and for the whole Norrtalje plus (community- Took much time and
social needs. county lies with region of developed based care to change services communicat
the joint Sweden pathways and coordination) and to be fully ion amongst
committee of (12,000 plans for vertically integrated. professional
County Council people in transition (transition from Required a s.
and Local 2011). in/out of hospital to home) commitment by
Authority. hospital. through a newly organisations to
Focused on created ‘change the rules’
building chains organisation to of usual care.
of care rather merge purchasing

than a single and provision of
point of care.
referral. Pooled budget for
Core group of integration of
professionals, purchaser and
plus access to a provider of care.
wider range of
services.
The Salford UK People 65 years Large-scale Salford, UK Integration by Randomised Increase in Whole-of-system Information not Patient
Integrated Care and over, transformation pooling health controlled trial emergency approach, available. experience
Program # [126] carers, and for older people and social and admissions. needing funding, of health
health and with long-term care budgets, implementation No significant relationship coaching
social care conditions and developing trials: Some impact of health building, shared was largely
professionals. social care alliance increase in the coaching. assessments and positive.
needs. agreement use of community Increased quality tools. Improved
Three core between four assets and care of life but self-
mechanisms of organisations, plans. Improved increased cost. managemen
integration: and shared healthcare Single site t experience
community care record. utilisation and evaluation. and quality
assets, reduced costs. of life.
multidisciplinar
y groups and
‘integrated
contact centre.’
My Care, My UK Older people in Integrated care 24 of 40 GP Integrated Whole-of-system The disconnect Training required Unclear. Not
Way * [127, West London. team. practices in care service in approach. between staff this of all involved available.
128] Case managers West London partnership Holistic care. modeland those staff.
and health and with with GPs. Less fragmented working in older
social care nationwide Holistic care. models of care.
assistants rollout system of
(patient-facing planned. health and
roles) in GP social care.
practices.
Multidisciplinar
y assessment
and extended
appointments.
Whole-of-
system
approach to
self-care,
prevention and
social
prescribing.
Care coordination Key features
• Using care coordinators or care managers to facilitate a streamlined approach to care
Caring for Older US Veterans with Individualised, 600 veterans Intervention Psychiatric Has not been Interdisciplinary Must have Improved
Adults and dementia who multidisciplinar over 6 years. plan involvement. rigorously tested team, including a family member access to
Caregivers at live in their own y person- Provided as developed by Return on and no evidence program involved in care services.
Home (COACH) home and their centred part of multidisciplin investment. to date of coordinator. to be able to Evidence of
Program # [129] caregivers. approach using routine ary team, led Operational benefits for Comparison of participate so clinical
care practice at a by social feasibility person with data with similar not available to impact.
coordination. Veteran’s worker and Strong dementia or cohort did not those who live Customer
Focus on Affairs Centre registered interdisciplinary carer. reveal differences alone. satisfaction.
counselling, in the US. nurse, partnerships Requires clear in time until Not currently Valued by
advance care together with and/or working communication admission to available in stakeholder
planning, geriatrician, relationships. about program residential care. Australia. s.
education and psychiatrist Links with primary purpose,
support, with and geriatric care. leadership and
care transitions pharmacist. Aligns with resourcing, and
for as long as Home visits processes strong Veteran
the person and phone deemed to be Affairs and non-
remains in their calls provided. ‘quality dementia Veteran Affairs
own home. Can include care’. coordination.
Iterative home-based
modifications to dementia
treatment plan care.
to address
evolving needs.
Includes remote
accessibility.
Support and US People living in Individualised 54 panels Provided in Connects people Paucity of robust Full-time Unclear. Not
Services at or near approach. Links throughout person’s with community- evidence. coordinator and a available.
Home # * [130, affordable to existing local Vermont home by to based services Duplication of 0.25 full-time
131] senior housing services. (2018). promote and promotes services. equivalent
communities, Works with Continuing to greater care coordination of wellness nurse.
receiving participants’ expand, with coordination. health care.
Medicare health care training at the Reduces growth
benefits. providers. state level. of costs to health
Participants system.
become part of
a group focused
on staying
healthy at home
Supported by a
network of
community

partners in
affordable
housing, home
health, ageing
services, mental
health and
primary care.
Gerontology New Zealand Primary health Specialist Three primary Comprehensiv Care co- Paucity of robust Specialist nurse Unclear. Older
nurse specialist care for high- knowledge, health e ordination for evidence. required. people
# [132, 133] risk older reducing practices in gerontological frail older adults valued the
people. burden on over- Auckland. assessment with co- proficiency,
stretched and care morbidity. positive
primary care coordination Viewed positively physical
system. designed to by other health health
take the load professionals in impact,
off the GP. their provision of improved
education, time care
saving and ability coordinatio
to complete in- n and
home emotional
comprehensive support of
assessments. the nurse
specialists.
8-pillars model Scotland People with Integrated Implemented Dementia Nationally Minimal Link worker Government Carers
[134-136] moderate to community nationwide; practice implemented. evaluation (99 funded through 8- guaranteed welcome
severe support centred evaluation coordinator Acknowledges recipients). pillars program. access for all. the
dementia. around a ongoing. coordinates complexity of Ensuring Government Designed with additional
dementia multiple multimorbidity. continuity of care support for all equity in mind support.
practice services. “This Has been and preventative eligible for more and equity
coordinator is a named, operationalised approaches. than 1 year from reported as a
who increases skilled, throughout Resource diagnosis, funded key
care practitioner Scotland with constraints. by local performance
coordination. operating at success. Developing staff health/social care index.
Includes the Enhanced Support for competencies on boards.
personalised Level of the people with therapeutic
and carer Promoting moderate to interventions.
support, Excellence severe dementia
interventions Framework.” to live in
for symptoms, community for as
physical and long as possible.
mental health
care, and
environment
and community
connections.
Case management Key features
• A collaborative process of assessment, planning, facilitation and advocacy for options and services to meet holistic individual needs
• Intervention effects for the client may include mortality, physical/cognitive functioning, unmet service needs, re-hospitalisation and
satisfaction with care
• Intervention effects for the carer may include stress/burden, satisfaction, psychological wellbeing and social consequences
Specialist UK For people with Focuses on the ~ 250 nurses Home care by Help predict High levels of Extensive Unclear. Highly
dementia dementia needs of the working qualified which services emotional labour training, plus valued by
nurses (admiral approaching the whole family, across the UK. nurses and might be needed for the staff. effective clinical carers
nurses) # [137- end of life and working other health in the next step of supervision planning for
139] their caregivers. particularly at and social the journey and practice. end of life
transition care promote and
points professionals confidence in the supporting
(deterioration who have carer (or act as aspirations.
in condition, advanced their advocate, if
transition to communicatio needed)
residential care) n skills,
and on reflective
maintaining practice and
relationships. emotional
self-
awareness.
Home UK, Australia Older people Non-health Pilot program Home care Used an existing Paucity of robust Training of staff. Unclear. Not
Independence eligible for professionals as underway in delivered by effective model evidence. Multidisciplinary available.
Program community care managers Perth, WA. non-health but trialled with a One care team.
Coordinator # services who providing Similar professionals different provider.
[140] are interested reablement, approaches through workforce.
in a restorative supported by broadly assessment,
approach to multidisciplinar available in goal-oriented Evidence for
care. y team. the UK. care planning, fewer deaths and
Interventions targeted transfers to
included in an evidence- residential care or
individual’s care based hospice, and
plan based on interventions, more clients no
an individual’s telephone longer requiring
goals, support to home care
capabilities and minimise face service.
difficulties. to face
contact,
education,
effective
communicatio
n to promote

autonomy,
social
support, and
use of local
resources.
Collaborative care Key features
Working in collaboration with disciplines/other services outside of usual scope
CAPABLE # US Older people Person– Medicaid Occupational Functional Unclear. US$3,300 per Unclear. Recipients
[141, 142] requiring environment fit. funding to therapist, changes, moving person. have
assistance at Formal and implement registered from disease Medicare savings reported
home. informal case the program nurse and management US$922 per positive
sharing. in 27 sites handyman to goals to function. member per outcomes.
Clinical across 14 US achieve Early intervention month.
coordination. states. functional focus.
Patient goals. Multidisciplinary
directed, not (uses nurse,
just patient occupational
centred. therapist and
Addresses self- handyman).
identified Reduces health
functional goals care expenditure
by enhancing (hospitalisations
individual and
capacity and institutionalisatio
the home n).
environment.
Coordinator and navigator Key features
• Overarching philosophies of relationship-centred, enablement, holistic and accessible
• Definition of the role includes referral and linkage to services, navigation of service system, responding to individual needs, education and
information provision, listening, emotional support, practical support, point of contact and advocacy
• Balancing medical and non-medical needs
• Improved outcomes if started before discharge
• Involves stepping outside strictly defined roles
Aged care Australia Older people, Activities Partnered Community Evaluation to No formal Training of staff Located in Not
navigator * their families, include with 30 hubs, assess people’s evaluation (pilot and volunteers. urban and rural available.
[143] friends and community organisations information diverse needs. study underway). areas.
others who workshops, to pilot in hubs (locally Volunteer training
want to link assistance with every state targeted and support to
with aged care filling in forms, and territory information) guide people in
supports. contacting My and evaluate and specialist supports that
Target Aged Care, 62 different support meet their needs.
population providing navigator workers Help local people
considers factsheets and activities (referral from build knowledge

rurality, gender other resources, across community or of information,
diversity, outreach Australia. information assessment and
limitations to services and hubs). care availability
internet access, group and should they need
risk of individual it.
homelessness support
and whether sessions.
they have
dementia.
Dementia - UK Support within Dementia Not yet Dementia Post-diagnosis Program in Dementia support Increasing Community
Person Aligned general practice support worker implemented. support care for people development. worker, GP access through member on
Care Team * for people living intervention worker to with dementia practices willing GP clinics. the
[144] with dementia that provides work and their carers. to participate and committee
with or without ongoing alongside GPs Prioritises experienced to develop
caregivers. support. and practice physical mental health the
nurses, as healthcare workers. program.
well as linking alongside social
with and emotional
community need.
resources.
Supervised by
experienced
mental health
care workers.
Uses a
coaching
approach to
set goals
linked to
personal
priorities,
including
decisions
about future
care.
5-pillars model Scotland People newly Minimum 1 Implemented Link worker Nationally Limited Link worker Government Recipients
[145] diagnosed with year link worker nationwide; has implemented. evaluation; funded through guaranteed indicate
dementia living support. evaluation professional Linked to policy evaluation local health/social access for all. program
in the Delivered to ongoing. qualification and standard ongoing. care boards. works well.
community. Scotland’s In Scotland, in social care/ (HEAT). Support Government
Health 46.7% newly work, nursing, continues for Increasing support for all
Improvement, diagnosed occupational duration of living numbers of eligible for more
Efficiency, with therapy, with dementia, people late with than 1 year (from
Access and dementia counselling or until needs significant care 2013); funded by
Treatment referred other related change or needs (eligible for local health/social
(HEAT) (2016/17). occupations. recipient requires 8-pillars care boards.
Standard. care coordination. program).
Planning for
future decision-
making and
care, peer
support,
community
connections
and education.
Workforce optimisation Key features
• Utilising and upskilling non-clinical or less qualified staff for roles that extend their scope of practice into care coordinator or navigator roles
Maximizing US People with Multidimension Trial sites only Delivered by Able to remain at No formal Geriatric clinicians Unclear. Not
Independence memory al community- in Baltimore. non-clinical home for longer. evaluation of Training for non- available.
at Home disorders and based care A new community Reduced unmet intervention clinical
(MIND); and their caregivers. coordination streamlined workers needs. delivery costs or community
MIND-S (MIND intervention version trained and Self-reported impact on workers
streamlined) # (using non- currently overseen by quality of life and direct and indirect Travel to
[146] clinical staff). being geriatric caregiver burden. costs of care of participant
Individualised evaluated. clinicians in relevance to homes.
care planning, older people’s healthcare
referral and home. providers and
linkage to insurers.
services.
Provision of
dementia
education and
skill-building
strategies.
Care monitoring
by
interdisciplinary
team.
Comprehensive US Primary care. Use of non- 30 primary Training of Fill a gap in the Single institution, Training of staff, Unclear. Not
care licensed staff to care sites at staff (40 usual care model practice-level plus supervision. available.
coordinators # coordinate care, University of hours) plus 2 through reliable analysis.
[147] rather than California, Los weeks of communication,
relying on more Angeles. shadowing. navigation of
expensive Responsible health system and
personnel. for accessing
assessment of community
barriers to resources.

care and
interventions
of
coordination,
monitoring
and linkage.
Daily huddles
with
professional
staff.
Patient Care US People with Non-clinical 12 oncology Navigator One point of Paucity of robust Training of staff. Specifically Contact
Connect cancer and their navigators to practices in supports contact for evidence. designed for with
program # [148] caregivers. empower, the southern people with information, under-served navigator as
connect with, states of the cancer by advocacy and populations. primary
support, US. being the first support reduces source
advocate for point of emergency prevented
and liaise with contact rather department visits. unnecessary
people with than Specifically emergency
cancer and their accessing designed for department
caregivers. emergency under-served presentatio
services. They populations. ns.
provide
services in the
home, in
hospital, in
the
emergency
department
and by phone.
Enhancing Australia Older people Building Trial in SA: Training Optimising Paucity of robust Training for social Support worker Improved
support living within the capacity of five delivered in existing large evidence. worker and being more quality of
workers # [149] Southern existing support community single module workforce of coordinators. inclusive of interactions
Adelaide Local workers to services or full support workers, Time needed for clients. with clients.
Health Network enact chronic tasked with workshop to supporting them the training.
and are condition care care accommodate to work to the
frequent users plans and coordination service needs. limits of their
of rehabilitation and direct. scope of practice,
hospital and regimens. Support and have them as
other acute workers assist a member of the
care services. clients to care team.
improve self- Interprofessional
management learning
of their opportunities
condition, with
focusing on clear value of
person- learnings
centred care, between support
motivation workers and
and behaviour coordinators.
change.
Dyadic caregiver interventions for people with dementia

Key features
• Nonpharmacological intervention that may be provided by allied health, a nurse or a combination of both
• Tailored based on capabilities of the person with dementia (reablement focus, strengths-based approach)
• Addresses concerns of carers and works to build carer skills
Care of Persons US, Australia People with Focus on skills Implementati Each dyad Tailored. Resource Economic analysis Must have Responds to
with Dementia mild to building (role on in sees an Delays functional requirements (up of Connecticut family member calls from
in their moderate play, modelling, Philadelphia, occupational decline and shows to 12 healthcare study currently involved in care consumers
Environments symptoms of validation, joint Connecticut therapist (up positive outcomes consultations). being conducted. to be able to about need
(COPE) [150- dementia who problem (US) and to 10 for person with participate so to access
153] # live in their own solving). some consultations) dementia and Requires further Cost-benefit does not apply programs
home and their availability in and nurse (up carer. training of the analysis to those who that
carers. SA and NSW to 2 Can be delivered workforce. conducted in live alone empower
(including consultations) within the Australia showed and
non-metro . Designed to Australian Effect on time the program to be Not currently promote
areas). be delivered context. until beneficial in available in all independen
in the home. Evidence of cost institutionalisatio terms of cost states of ce.
Work benefit. n has not been savings in health Australia and
underway studied. and social care, more work People with
demonstratin with savings in needed to dementia
g feasibility of hospital and long- sustain in SA and their
telehealth term care and NSW. carers who
delivery. spending and have
health care received the
services accessed program
in the community. provided
There were also positive
reductions in the feedback.
time spent
receiving informal
care.
Going Away to Australia People with Residential Limited Range of Combined benefit Resource Economic analysis Must have Appears to
Stay at Home dementia who program in availability in allied health, of respite for requirements costed the informal carer have good
program [154- live in their own which both the Sydney. psychogeriatri person with (staff to provide program at to be able to acceptabilit
158] # home and their carer and cian and dementia and training for carers A$3,755; participate so y with only
carers. person with Has been run nursing staff skills building in plus staff to preliminary does not apply 1 drop-out

dementia stay as temporary provide caregivers. provide care for modelling to those who from
for 5 days in a program in educational Elements of peer people in indicates could live alone program
RACF cottage. rural NSW. content. support. residential break even on without (out of 90).
Nurses and Single respite). costs by 5 months informal care
careworkers observational (predominantly to support. Higher than
provide the study: Limited evidence governments) and expected
structured Comparison with for effectiveness after this there Has been run in proportion
activity similar cohort (randomised could be cost rural location of
program and showed marked controlled trial on savings. out of serviced attendees
care for the reduction in earlier 10-day Program apartments had
people with permanent version of delivered with with temporary younger
dementia placement over program respite funding modifications. onset
during their months. delivered out of for person with dementia
residential Randomised hospital; dementia and Not currently (22%).
stay. controlled trial: observational out-of-pocket available in all
Evaluation of an data with costs for carer. states.
earlier iteration of potential
the program confounding only
showed that available for
people who current program).
received the
program stayed
home longer.
REACH, REACH US (Alabama, People with Focus on skills Veterans 12 in-person Rigorously tested Resource Neither REACH II Must have Program
II, REACH VA Tennessee, dementia who building Affairs (US), and/or and adapted and requirements. not REACH VA family member has been
[159-163] # Philadelphia, live in their own (problem some telephone translated to suit intervention was involved in care refined over
American home and their solving, stress community sessions and 5 multiple settings, Requires further associated with to be able to time based
Indian and carers. management, agencies in 6 telephone agencies and training of the additional participate so on feedback
Alaska Native mood US states, support group populations. workforce. healthcare costs does not apply from carers.
Communities) management) Vietnam, meetings. Intervention has for caregivers or to those who
to manage their American Modified been tested and Effect on patients; in fact, live alone.
own wellbeing Indian and REACH has 4 refined. admission to for VA patients,
and their care Nebraska core sessions Results show residential care there were Not currently
recipient. native with better outcomes not reported. significantly lower available in
communities additional for carers in healthcare costs. Australia
(via Indian sessions as terms of burden,
Health Service required. depression and Has been
and Tribal Delivered by stress and less implemented in
Health clinical staff frequent USA indigenous
programs). (allied health behavioural populations
or nurses who symptoms in
are trained person with
and certified). dementia.
Community The People with Focus on Limited Occupational Relatively early Resource Cost savings in Must have The
Occupational Netherlands, dementia who improving availability in therapists intervention requirements. the Netherlands family member research
Therapy for UK, Germany live in their own activities of the provide up to approach (focus mostly related to involved in care trial
people with home and their daily living, Netherlands. 10 on people with Requires further informal care. to be able to currently
dementia and carers. carer abilities Being tested consultations. mild symptoms). training of the Effect on participate so evaluating
family carers and sense of in research Evidence of cost workforce. admission to does not apply this
(COTiD) [164, competence. trial in the UK effectiveness in residential care to those who intervention
165] # at present. the Netherlands. not assessed. live alone. in the UK is
conducting
Not currently interviews
available in with people
Australia. who have
received the
program,
but not yet
available.
Danish Denmark People with Focus on early Not Nurse Early intervention Resource and Economic analysis Must have No data
Alzheimer dementia intervention – implemented; provides 7 approach. time not conducted. family member available.
Intervention (within 1 year of program for only tested in counselling 12-month follow- requirements. involved in care
Study diagnosis) who people in the randomised sessions (2 for up suggested. to be able to
(DAISY)[166] # live in their own first year post controlled caregiver, 2 ome benefits for Requires further participate so
home and have diagnosis and trial. for person person with training of the does not apply
involved carers. focus on with dementia workforce. to those who
counselling. dementia, 2 (reduced live alone.
for the dyad depression, Research trial
and 1 with improved quality found limited Not currently
extended of life); however, benefits of available in
family effect on other approach. Australia.
network), outcomes limited.
phone calls, Only tested in
log books and randomised
information controlled trial
and education and not
delivered over translated.
8–12 months. Effect on
residential care
placement not
assessed.

Other community care models

Age-friendly cities and communities Key features
• Enable people of all ages to actively participate in community activities
• Everyone is treated with respect, regardless of their age
• Make it easy for older people to stay connected to people that are important to them, help them to stay healthy and active, and provide
appropriate support to those who can no longer look after themselves
Age-friendly Worldwide Evaluated in 24 items 760 Whole-of- The importance Need longitudinal Extensive whole- Socioeconomic Physical and
communities # Rotterdam representing communities system of age-friendly studies to assess of-system gradient related social
*[167, 168] districts, the the eight and cities approach communities for causal pathways approach. to attributes
Netherlands. domains worldwide. across all the wellbeing of and a whole-of- neighbourhood necessary
Older people identified by domains. community- system approach. ageing in place. for ageing
surveyed and the World dwelling older in place.
compared with Health people has been
those living in Organization for empirically
non-age- the promotion shown.
of active ageing:
friendly cities.
social
participation,
transportation,
outdoor spaces
and buildings,
housing, civic
participation,
communication
and
information,
respect and
social approval,
and community
support and
health services.

Senior-friendly community living Key features
• Emphasis on promoting ageing in place
• Coordinated efforts of voluntary and formal support systems
• Enhances access to existing services
• Older residents are active contributors
Villages model # US, Australia Community- Not-for-profit. Over 300 Operated by a Volunteers Health care Staff required for People who are Self-
[169-171] dwelling older Grassroots villages mix of paid provide help to utilisation various roles. older, have reported:
people within membership existing or are staff and other members. increases and Funding: annual greater improved
geographic organisation. in volunteers. Provision of frequency of membership fees functional social
proximity. Offer support development Paid information and social and civic which may be impairment, engagement
and social in the US. coordinator referral services engagement can supplemented and more , civic
engagement. manages to existing decline. through grants unmet engagement
Membership- 2 sites in vetted list of community Support is and donations. needs are more , health and
based, member- Australia (not service providers who are sometimes not in likely to wellbeing,
driven and self- evaluated in providers and ‘vetted’ and may localised area. discontinue. health care
governing. Australia). community provide discounts. Members need utilisation,
Primary goals partners. discretionary time Predominantly unmet
are to promote Emphasises and money. middle to high needs,
members’ economic Funding. class. Less measures of
independence self-reliance Adequate accessible to confidence
and prevent rather than membership. rural and low and ageing
undesired obtaining Retaining socioeconomic in place.
relocations. financial leadership. communities.
Australian site: support from Meeting
For an annual governmental and increasingly
fee of A$40, organisational medically
members can sources. complex needs
access a range
of activities.

Care- The Older people Modelled on a Cooperative Care No formal Requires Start-up funded Information not Information
Cooperative Netherlands living in the traditional farm model with cooperative evaluation. individual by subsidies from available. not
Village village. cooperative. more than including leadership and Social Support available.
Hoogeloon * 250 members. volunteers, Ageing in place cooperation in Act. Running costs
[172] paid for as long as village community through personal
coordinators possible. that may not be budgets.
and health easily Members pay
care transferable to annual
professionals. urban / deprived subscription.
Meals cooked places.
by volunteers,
domestic
help,
transport, day
care, locally
recruited
staff.
Providing care
for 60 older
people.
City Village The Older people in Community More than Social Increased Requires Start-up funded Core Information
South * [173] Netherlands an urban cooperative 360 members. interaction volunteering, leadership and by external membership not
environment. based on and support. social support and community grants. Running tends to be available.
intergeneration Provides sense of commitment/soli costs funded by middle-aged
al activity. information community. darity to get membership fees. and older
on services. established and women.
Volunteer grow.
support (e.g.
meals cooked
and
delivered).
Negotiated
contract with
home care
organisation
to provide
ADLs etc.

Schlegel Canada Long-term care Villages 9 villages Carer teams Residents’ needs Paucity of robust Information not Information not Information
Villages* and retirement designed with across offer regular routinely assessed evidence. available. available. not
[174] villages. town square Ontario. training and residents can available.
and main street programs, choose to add
concept to including additional
promote social specialised services to their
interaction and training in plan without
quality of life. dementia requirement to
Programs aim care. move to a higher
to involve and care residence.
engage local Residents can
community in ‘age in
village life. community’.
Partners with a
research
institute to
drive research
and innovation
to enhance
quality of life
and care.

Naturally US Geographic Community- At least 25 Typically led Designed to be Insecure Funding to pay for Consideration Not
occurring locations with level states in US by private, connected to government service supports. of vulnerable available.
retirement dense intervention in had non-profit existing housing funding. people.
community concentrations which older 100 NORC organisations, and service Serves older
Programs of older adults, building programs with organisations and adults based on
(NORC)# [175, persons. owners and around the US professional emphasises residence and age
176] managers, in 2013. staff collaborations as opposed to
service responsible among diverse economic or
providers, and for overseeing stakeholders. functional
other the day-to- requirement.
community day activities Largely case-
partners create and services studies and
a network of of the anecdotal
services and program. evidence; single
volunteer High-density sites.
opportunities. apartments
generally
designed to
be led by
social workers
and other
social service
providers
trained to
work with
vulnerable
populations.
University – US College/universi Two-directional 6 universities Co-located Creates a Paucity of robust Funding and link Unclear. People feel
based ty campus. programming in near community that evidence. with university. younger
retirement (i.e. community Pennsylvania university enhances physical and enjoy
communities # members can and Florida. campus. and social the benefits
[177] attend Opportunity wellbeing across of college
lectures). to participate the lifecourse. life.
Access to in campus Also provides
continuing care. activities, intergenerational
Transportation including benefits to the
support. healthcare university
Facilitating and needs- communities.
activities. based support
in older age.
Health at Home UK Social housing Health, housing Trialled with Employed Patient activation Further Unclear. Social housing Incorporate
* [178] tenants. and social care 261 residents health measure evaluation on cost residents. s resident
are not seen as within social navigators suggested that effectiveness co-
separate housing. and people gained the required. production.
entities. volunteers to skills and
coach and confidence to
connect effectively
residents with manage their
the relevant health without
health, further support
housing and after the initial
community intensive
services they intervention.
need.
Intergeneration Sweden, Five projects Variable In pockets Generally Strengthen social Paucity of robust Appropriate Unclear Older
al co-housing # Germany, UK active in three approaches but around the small house / ties. evidence architecture, people are
[179] countries. reflect solidarity world. residence. Strong sense of fundraising. concerned
between security. Older people are Legal framework about how
generations. Involvement in concerned about or environmental they can live
the planning and how they can live considerations as when they
day-to-day when they need well as human need more
management of more care. factors that care.
their support
environment. continued
Communal communal
aspects for those engagement.
who selected this
approach and
with whom they
live.
Intergeneration The Low-income Intergeneration Not Housing Improved sense Paucity of robust Existing housing. Helps older Unknown.
al housing or Netherlands, housing al living: older widespread. specifically of belonging in evidence. Community people gain
apartment Belgium, projects (Spain) adults with constructed the community planning. income and
blocks # [180] Scandinavia, and ageing immigrant for and overall social support.
Spain, US seniors living families, college intergeneratio wellbeing for Provides
alone (Belgium, students or nal both parties. housing support
the young adults. congregate Prevent older for low-income
Netherlands, Shared spaces living; people feeling earners.
Scandinavia). available. otherwise isolated.
using Re-establish a
traditional sense of
family houses. intergenerational
solidarity.
Senior Co- US, Australia, Regional Qld – Intentional form California, Shared and Companionship, Paucity of robust Planning, No. Negative
housing*# [181, the case study of of community Virginia, New private spaces mutual support, evidence development and perception
182] Netherlands, older living, with a Mexico and with and a better Financial, governance of co-
Sweden, Australians. mix of private Colorado – consideration ageing property and structures. housing;

Denmark and communal adaptation of of age and experience. ownership risks. the
spaces. Northern health needs Planning, design, sentiment
Combines European through development, that ‘it’s a
autonomy and approach of design. financing and great idea
privacy with the collective. implementation for other
advantages of Very limited of co-housing. people’.
community in Australia.
living housing in
high rise
apartments
buildings.
Asset-based approaches Key features:

• Places the emphasis on people’s and communities’ assets, alongside their needs
• Taps into the wealth of resources, capabilities and networks that are the natural fabric of communities
• Signpost people to, and connect them with, the types of support that are more appropriately provided by the voluntary, community and
social enterprise sectors.
Community France, Older people Postal workers More than 10, Five-minute Potential to Paucity of robust Training for postal Not articulated. Positive
enterprise Jersey, UK, living in their check on older 000 Call & visits address evaluation. workers. feedback
development Singapore, own home. vulnerable Check visits incorporated increasing Potential overall, with
Finland, community were into normal demands on automation of the no
Call and Check Iceland members and conducted in rounds. Postal health system. postal workforce. complaints
Visits (Postal refer to health one Jersey workers lodged.
Workers) * and social care parish over deliver
[183-185] services where three years. prescription
necessary. Trials refills, remind
underway clients of
with Royal upcoming
Mail in UK. medical visits,
and ask about
their health
and social
needs.

Community UK Vulnerable Includes fire Implemented Expansion of Integrated with Paucity of robust Training for Aiming to tackle Not
Enterprise people and and rescue across UK Fire home safety existing evidence. existing fire and deep rooted available.
Development those with personnel in and Rescue visits to be community rescue personnel. inequalities.
Fire and Rescue complex needs. improving Services. Safe and Well services for
Service – Safe health and Extended visits, with mutual benefit.
and Well Visits wellbeing of version some degree
* [186-188] older people, as focusing on of health
many of the risk winter-related assessment
factors to illnesses is with or
health are also being piloted. without
risk factors for intervention,
fires (e.g. alongside the
smoking and traditional
alcohol assessment of
consumption). fire risk.
Approx. 30–
45 minutes
additional in
total.
Compassionate UK Older people at Link people to Frome Care planning Use of volunteers Building trusting Training of Unclear. Not
communities: high risk of their Medical through who act as relationships volunteers available.
Frome model # unplanned communities Practice in primary community takes time and (community
[189] admission to using elements Somerset, health care connectors; effort. connectors).
hospital. of social servicing a followed by extensive
prescribing but population of referral to the community
bring the 28,000 community resources
network to the people. development identified.
person. service for Significant
goal setting reduction in
and social unplanned
network emergency
enhancement. department visits.
This may
include one-
to-one
support
and/or
identification
of relevant
services /
resources.

Dementia UK Older people A group of Four sites Bring together Dementia- For those with To be led by the People living Enabling
Circles of with dementia people help the across the UK: ‘natural’ and specific. Can be limited capacity person with with dementia environmen
Support * [190] and their person to think Devon, ‘professional’ particularly to form a circle of dementia, early in who are t with
caregivers. about what Dorset, support and powerful if the support; the journey. normally mutual and
they would like Hampshire involving a approach is unfamiliarity with Handbook excluded from peer
to do in their and West mix of people adopted before person-centred available for being able to do support.
life and what London. Total in the circle. people lose their care approaches; circles of support. what they
support they of 86 people connections, and logistical barriers; would like to.
need to do supported. when existing system
these things natural supports boundaries.
(including any can be harnessed.
changes to
current support
arrangements)
and then
support them to
make these
things happen.
Community UK Older people. Based on 1800 Utilising local Draws on local Requires local Each area would Unclear. Viewed
Catalysts * releasing local community people to resources. government need a catalyst more
[191] people’s enterprises support older support. employed for 2 positively
capacity to care, across 50 people at years. than
with one areas of UK. home, traditional
coordinator providing domiciliary
supporting ~200 local agency.
local self- employment
organising opportunities
enterprises and support
(micro- for older
enterprises). people in
their homes.
Cares Family* UK Older Community North Main projects Creates Primarily relies on 2 professional Can assist those Improves
[192, 193] neighbours and networks London, include Love intergenerational charitable delivery with limited self-
young mobilising South London Your relationships; donations of professionals, mobility or confidence,
professionals. young and Neighbour preliminary data £200,000+ per supported by a unable to leave connection
professionals to Manchester. (one-to-one show reductions year per branch. Chief Executive the house. and
volunteer to regular catch- in isolation and and an Income Winter enjoyment
spend time with ups), social increased Development Wellbeing with the
and support clubs, a connection to Coordinator. program world.
their older winter others and improves access
neighbours. wellbeing community. to services and
Mutually outreach Volunteer-led grants.
beneficial, project, and modelthat is
providing new community neighbourhood-
opportunities to fundraising. based.
share time,
cultural
exchange and
friendship.
Social UK Underserved Streamlined More than Primary care Potential to Paucity of robust Dependent on Vulnerable Participants
Prescribing * # areas and referral from 100 schemes, professionals greatly benefit evidence; client needs; groups report
[194, 195] people with local agencies. more than 25 ‘prescribe’ individuals with available requires specifically overall
complex care Co-produced of which are and refer complex health evidence is comprehensive targeted. satisfaction
needs. and in London. clients to and social care qualitative and service mapping with
personalised local, non- needs. relies on self- and well- reduced
support. clinical reported established feelings of
services, outcomes. community links. loneliness
assisted by a No reduction in and social
navigator. GP workload. isolation
and
improved
mental and
physical
health.
Volunteer Vietnam Older citizens in Elderly Public 110 Visit Volunteer Paucity of robust Training and Not articulated. Older
programs various Health volunteers in households to delivered; evaluation. financial support. people
Vietnamese Volunteers: 2 communes check and benefits for Need to invest in perceived
Elderly helping provinces. health in 2010. provide volunteers as well capacity building; improveme
elderly – promotion advice about as recipients; elderly helping nt in health
Vietnam * [120] activities. 92 volunteers health. local; no issues elderly volunteer knowledge
working in 10 Provide with retention of schemes may and health
communes of primary volunteers. reinforce social status.
Retired Health five provinces healthcare hierarchies. Volunteers
Workers in 2009. services to Wider impacts also
Volunteers older people include more received
program: Volunteers in their local positive view of benefits
provide primary working in area. older people such as
healthcare 2016 were Provide within regular
services to older half of all physical, communities. health
people in their communes in mental and check-ups,
local area. the country. social care reduced
services and treatment
Elderly Home help with costs and
Care daily activities health
Volunteers: or provide insurance.
provide home social
care help and support.
assist with daily
living.
Volunteer- Brunei, 2 groups of Identify and 3,697 Volunteer Increases time Need link to good Tailored training Targeting Improved
based home Cambodia, older people: select clients; volunteers visits older older people can health system. to support client. vulnerable older self-esteem,
care: ROK- Indonesia, self-managing; needs provided person at live at home Need to people. respect,
ASEAN * [196] Laos, or frail and assessment; home care to least once a physically, socially overcome social
Malaysia, dependent. develop care 5,080 older week in their and functionally. bureaucracy. interaction
Myanmar, plan; match people across own home Service was and access
Philippines, with volunteer Southeast and provides acceptable and to services.
Singapore, who provides Asia. personal and favourable to all Greater life
Thailand, services. social care. stakeholders. satisfaction
Vietnam Improved and
psychological improved
wellbeing of quality of
family members. life.
Wigan UK Wigan County. Volunteer One county in Link workers Formative Maintaining the Volunteer training Unclear. Positive
Community link community England. spend time evaluation: volunteer and support. views
worker * [197] members. understandin consistently high numbers regarding
Promotes a shift g their clients’ levels of required. feeling
in service individual commitment and supported
culture. situation, buy-in to the and
Creates new needs and service from receiving
relationships aspirations stakeholders. The assistance
between and then help joint when it is
citizens and them to commissioning needed.
service access team are
professionals. community- champions and
based support active supporters
and activities of the service.
and to utilise The service is
their skills and encouraged to be
experience used as an initial
through filter or triage for
volunteering. social and medical
needs.

Autonomous team working Key Features:
• Geographically or ‘neighbourhood’ based working
• Small, autonomous or self-managed teams
Buurtzoog The Primary care. Neighbourhood Across the Neighbourhoo Multiple sources Less evidence Needs change in Unclear. Positive for
Model # [198, Netherlands -based nursing Netherlands. d care model: of evidence of outside the the organisational both
199] team. Efforts Self-directed effectiveness in Netherlands. structure and employee
Onion model, underway to teams of up the Netherlands. Cultural context is funding to and client
starting from adapt in to 12 nurses UK pilot: Evidence a potential support this satisfaction.
the client Japan, provide gathering was a barrier. approach, plus
perspective and Norway, personal and strength. staff training.
working Sweden, UK clinical holistic
outwards. and US. care for 50– Reduced costs
60 patients. due to reduced
Care is service and
delivered on administrative
principles of needs.
reablement
and
relationship-
based.
Wellbeing UK For older Small Six pilot Small teams Regain and retain Requires local Health and social Unclear. Not
teams * [199- people. neighbourhood teams in work to independence for municipality care available.
201] self-managed England and support older older people; framework for professionals, but
teams, with Scotland. people at coaches support support. via a different
community home and teams to focus on model.
circle connect to culture.
connectors. community
services.

Table 3 Innovative models of care for rural/remote living populations
Outreach Key features
• Required to reach rural and remote areas, where isolation and difficulties of service provision exist
Dementia Australia People with Outreach One coastal Delivery of Sector leadership. Limited Clinical and social Specifically Not
outreach dementia living services with a community. services Flexibility and generalisability. care personnel as targets a rural available.
service # [202] at home in a bio-psycho- through a responsiveness. Paucity of robust for other services. community.
rural coastal social approach. theoretically linking; evidence.
community. Building a based Program
cohesive sector practice innovation;
is critical, with model. Building cohesion.
the outreach Clinical
service being consultation
pivotal in Case
working management.
alongside
community
partners.
Mobile respite Australia People with Multi- Multiple sites Six main Overall positive, Limited New paradigm Specifically Carers
service * [203] dementia and component across NSW. components with suggestions improvement in and multi- targets experienced
their caregivers. intervention to help for improvement caregiver quality component rural/remote increased
with flexibility caregivers: to increase of life. Single approach. and carers who wellbeing
in delivery of psychosocial services from region pilot. have difficulty and
when (e.g. time support; three to five Paucity of robust accessing other satisfaction
of day); where general days/week. evidence. services or with caring.
(e.g. in-home or support; dyad Delayed entry where existing
centre-based); relationship into residential support services
what (e.g. support; care. are limited and
meaningful respite; focus Decreased carer insufficient.
activities, on meaning burden.
support for and Decreased
carer social reablement morbidity and
networks); who for person mortality.
(e.g. staff with
matched to dementia;
consumers); and support
and how (e.g. for transition
personalisation into
of services, residential
transport care.
options).

Community engaged scholarship Key features
• University students participate in structured sessions with older people as part of their placement
Rural Caregiver US Small rural Coalition One small Unique Integrated formal To make it Student Unclear. Not
Network Project town in US. building in an rural town; student (existing services appealing to placement available.
# [204] area struggling 15 students learning and programs) students. commitment.
to keep older over 3 years, configuration and informal Single site.
people ageing with 400 to encourage (volunteer Paucity of robust
in place with learning placement. networks and evidence.
scarce hours. Stipends civic groups)
resources. provided and resources.
Building students from Students
capacity in local participating in
gerontological community macro-, meso-
social work. encouraged. and micro-level
activities.
Friendly communities Key features
• Initiative to make rural communities accessible and acceptable to older people in general and those experiencing dementia
Dementia RED UK Older people Bio- North Wales. Manning a A citizenship Paucity of robust Community team Unclear. Not
(Respect, with dementia psychosocial booth (in the model approach evidence. from the health available.
Empathy, residing in a approach to community) to raising and social care
Dignity) # [205] rural building a to debunk the awareness and sectors, plus
community. dementia- myths of supporting people engaging with
supportive dementia and with dementia in individuals in the
community. promote need their local community who
for early community. can champion
diagnosis. dementia locally.
Dementia
care
champions.
Locality action
plan.
Key ring to
identify those
with
dementia.
Road show.

Coordinator and navigator Key features
• Referral and linkage to services, navigation of service system, responding to individual needs, education and information provision,
listening, emotional support, practical support, point of contact and advocacy
Nurse-led Canada People Building rural Single centre. Nurse-led More intensive Observational Nurse navigator Unclear. Participants
navigation for receiving community navigator. contact than study only. supported by highly
palliative care # palliative care. capacity usual models. Paucity of robust nurse practitioner satisfied as
[206] through local Focused beyond evidence. and GP. it
champions and health services. contrasted
leveraging with
inherent system-
accountability oriented
where personal care
and (structured,
professional hurried and
relationships overwhelmi
co-exist. ng). Known
and trusted
source of
support and
information.
Care China Rural China. Care model to 34 rural Older Care coordinators No formal Care coordinators Reaching older Beneficiarie
coordinators * address the community peoples’ deliver the linkages with the require training. vulnerable s appreciate
[120] growing needs volunteers association supports. health and social Funding for people in rural the help
of disabled and looking after manage the Care coordinators care system. activities, China. they receive
semi-disabled 180 activities and are usually equipment and and the
older people in beneficiaries. distribution of neighbours and coordinator. human
rural areas. funds, with have been connection
community acquainted with that they
aides each other since have with
providing before the start of the care
advice and the project. coordinator.
oversight. The care
coordinator
also
receives
benefits.

Table 4 Innovative models of care for Aboriginal and Torres Strait Islander populations1
Culturally specific aged care Key features
• Provides aged care services on country.
• Designed in a manner that maintains and respects Aboriginal connection to land, meets the needs of older Anangu and is culturally
sensitive.
Tjilpi Australia (SA) Residential, respite Culturally The Day centre Program employs Difficult to Program operated Provides Information
Pampaku and community appropriate residential incorporating local people as recruit, train, and by Aboriginal services specific not
Ngura aged aged care for care, care services clinical care care providers. retain staff in very Community to Aboriginal available.
care [207, Aboriginal and recognising, are regional, by registered On-site training. remote location. Controlled locals 50 years
208] Torres Strait respecting and and referrals nurse and Anangu culture is Organisation, and older and
Islanders in remote nurturing the come from access to a Opportunity to highly mobile; Nganampa Health occasionally
setting. unique cultural across the range of build capacity often people Council. younger people
Occasionally identity of Anangu visiting health within community move between for palliative
palliative care for Anangu care Pitjantjatjara services, by employing and communities to care.
younger people. recipients, Yankunytjatja including training local attend to family
retaining ra (APY) podiatry, workers. issues, so staff
significant link Lands. physiotherapy Ensures residents continuity is
with family and and oral retain links to difficult.
community. health. family and
24-hour country and to
emergency continue
clinical interests.
services
available.
1
See also REACH as summarised under ‘Dyadic caregiver interventions for people with dementia”, page 34
Remote dementia support program Key features
• Strengthens capacity within the local aged care and health workforce and community organisations through education and development of
training resources
• Community empowerment to build the skills and knowledge to be able to support their elders living with dementia.
Bidyadanga Australia Aged care (respite Ageing in place Bidyadanga Information Capacity building Geographic Program operates Information not Information
dementia care model) and on traditional Aboriginal not available. (staff and remoteness. from Bidyadanga available. not
support community care. country. community in community). Health and available.
model (WA) Remote setting. Increasing W with 750– Personalised care. Extreme climate. Community
[209, 210] dementia 800 residents. Improved Care Centre.
literacy through communication
community Will expand to between clinical $1 m funding
education. 6 WA sites in and allied health from Australian
Creation of the and aged care Government to
personalised
Kimberley, services. expand (May
box with
Pilbara, 2019).
objects to
Gascoyne,
accompany
resident during and Goldfields
hospital visits, regions
respite or (2019).
residential aged
care.
Collaborative community service model Key features
• Locally designed community care model targeting older people as well as people with physical or mental disabilities in remote Aboriginal
setting
• Developed through collaborative process and widespread community consultation
• Provides of range of services, including home services meals, advocacy, transport, personal care and respite
Lungurra Australia Older people and Model structure Looma Facilitator Increase in service Sense of lack of Initial funding Care services Information
Ngoora people with developed using community collaborations delivery. ownership of the through NHMRC accessible to not
model (WA) disability and/or a collaborative (Kimberley between Community project by grant (458793). rural available.
[211] mental health process, region), services and members have community Subsequent 12 community
problems. including approx. 350 community. more confidence members. months funding members.
Remote aboriginal community people Local action to speak up and Challenges through
community. members, group to train feel empowered regarding negotiations with
council and and support in service conflicts/relations the Western
stakeholders. community planning. hips/roles. Australian
Establishment staff. Partnership Workforce issues Department of
and Coordinator establishments. concerning Home and
maintenance of as key contact Greater input of management, Community Care,
partnerships. for service workers and literacy, computer Western
providers, decision-making skills, staff Australian
clients, within service. turnover. Country Health-
families and Improved Complicated Mental Health

community. coordination and funding Service and the
Provides communication arrangements / Disability Services
home between agencies council Commission.
services, and service involvement in
transport, providers. ongoing
respite, Cultural development and
personal care, protection and evaluation.
meals, culturally
advocacy, appropriate care.
education.

For culturally and linguistically diverse (CALD) populations, specific innovative models of care were not
identified. Instead, supports for this older population generally focus on education, awareness and training
programs such that existing services can be accessed and provided appropriately. Some culturally specific
existing approaches and supports developed to support CALD populations are described in Table 5.
Table 5 Models of care and supports for CALD groups

Program name Provider Location Details
Partners in Culturally Department of Australia; available Support for older CALD people, their families and
Appropriate Care Health in all states and their carers to understand and access Australian aged
(PICAC) [212, 213] territories care services. The program includes a national
website hosting documents and links to multicultural
resources, and facilitation of expos through
partnerships with a range of other organisations.
Workshops cover topics including support for older
migrants who have suffered torture and trauma, how
to use language services, and management and
cultural diversity in residential and home care
Cultural Diversity St Vincent’s Melbourne, Series of workshops aimed to develop the cultural
Training Program Hospital Australia knowledge, skills and competence of its staff, in order
[214, 215] to ensure effective service provision for CALD clients.
Specialist dementia Developed by Melbourne, Consumer-directed dementia care pathway that aims
nurse (SDN) model researchers from Australia to assist people with dementia from CALD
[216] the Royal District communities and their carers to overcome barriers to
Nursing Service, accessing Australian health and social care services.
embedded within This model was developed in Melbourne using
a not-for-profit participatory action research, co-designed using
home nursing feedback from people with dementia, their carers and
service families, and experts in the field.
Diversity Conceptual Developed by Melbourne, Aimed at supporting Australian aged care workers to
Model [216] researchers from Australia understand and resolve problems associated with
the Royal District diversity, using a visual tool.
Nursing Service
Penn Asian Senior Penn Asian Senior USA Provides culturally competent home care services to
Services [217] Services Inc. elderly Asian American. This organisation trains
bilingual immigrants to become certified nursing and
home health aides, who then provide culturally
tailored home care services to the client (e.g. cooking
traditional meals) with knowledge of cultural norms.
Cultura app [218, Dementia Australia ‘Cultura Care model’ housed within the Cultura
219] Australia application, which helps care workers access quality
information and resources that enable culturally
appropriate care for people from different cultures
living with dementia. The app focuses on 21 different
cultures and provides cultural and dementia care tips,
and information on topics such as religion,
communication style, food and diet, that can be used
in discussion with the care recipient and their
families.
50
Table 6 Innovative models of care for younger people (under 65 years)
Key examples Countries Settings, Key features Extent Delivery Strengths Challenges / Resources Impact on Consumer views
available population implemented weaknesses inequity
Integrated/co-located housing Key features

• Young people with a complex disability co-habit in the same apartment development as other members of the general public
• Individual units, customised for young people with disabilities, built within new apartment developments
• Smart-home technology enhances accessibility, usability and communication, facilitating on-call support
Abbotsford Australia Young people Communications 534 new 1–2 Technologies Community integration Initial evaluation 2011–2014: No examples Information not
Housing and with complex technology and bed that alert and connectedness (Abbotsford) In Vic of this available.
Support disabilities. 24-hour access specialised staff to facilitated by location. identified issues A$300,000– model in
Demonstration to on-call disability support Supports in retaining $400,000 per rural/remote
Project * [220] support workers accomodation needs. independence, own consistent person. In SA, locations
Hunter Housing as required. apartments in unit. support staff. A$200,000– identified.
Support Customised to development Initial evaluation $266,000 per
Demonstration individual around (Abbotsford) showed person.
Project * [221] needs. Australia increased home, social
Summer Non-identifiable (2019) 2. and economic
Housing * [222, from other Summer participation of tenants
223] apartments. Housing: 12 6 and 12 months after
The Square Location sites across moving into apartment.
Woodville West accessible to Australia with
Project * [224] community 10
services. apartments
Smart-home each, under
technology. development.
Integrated into
mainstream new
apartment
developments.
2
This figure is likely to include integrated housing and individual living units with shared supporting services. That is, the support services that the occupants will receive in these specialised disability
accommodation units is not specified.

Individual units with shared Key features

• Residents occupy their own unit equipped with smart-home technology
supporting services
• All apartments in complex are occupied by individuals with a disability
• Residents share support services and facilities with one another
Perth Fern River Australia, Fern River: Fern River: Fern River: 3 Fern River: Enables married Fern River: Only No reporting Unclear. Information not
High Support US 6 independent nursing level faciliites, 32 On-site couples to continue to those in receipt on resources. available.
Accommodation living units home care in places. manager live together and of individual
* [225-227] with shared community (often remain on site in case funding through
services; can setting, with use nurse), of illness. the Disability
Harmon support 10 of smart-home assistant Sense of community for Services
Apartments * young people technology and coordinator people with high Commission or
[228-230] with complex affliations with and support support needs. the NDIS are
medical needs local medical workers eligible.
(primarily practice and provide 24 No formal
multiple hospice service. hour on-site evaluation of
sclerosis). Harmon: support. programs has
integrated been conducted.
Harmon: 39 technology and
units with 1-2 supportive
beds in services,
apartment expanding on
building. The Boston
Home program.
Shared housing with supporting Key Features
• Residents with high-level support needs live within one house, each with their own room
services
• Residents share support services (i.e. nursing, general care, recreational activities)
Frankston Australia Young people Common indoor Brightwater: Support for Positive client/family YPIRAC 2011–2014: Unclear. YPIRAC participants
Accommodation (17–65) with and outdoor 8 houses. nursing and feedback regarding participants who Vic capital who moved from RAC
(Vic)* [231] complex needs areas. SACARE: 5 daily living. independence and moved from cost (incl. to shared supported
and conditions Shared support houses. quality of life of client. RAC to shared land) accommodation:
Brightwater (e.g. acquired services. supported A$250,000– perceived greater
Supported brain injury, 24-hour 449 new 4+ Sense of community. accommodation: $300,000 per freedom of
Independent Huntington’s support. bed houses in lack of person (5–6 choices/independence,
Living (WA)* disease). development compatibility bed homes) enhanced quality of
[226, 232] Individual Australia- between [224]. life, feeling of
bedrooms in a wide. (2019) residents who homelike environment
SACARE, The shared house [223] share and belonging [234].
Gums (SA)* with 6–12 commonalities
[233] rooms. and interact
with one
another [234].

Combined aged and disability service Key Features

• Co-habitation of young people with a disability and their parents
for families
• Allows independence for the young person with a disability, while maintaining close proximity with their parent for care/companionship
Kemira at IRT Australia, Young people Co-located Kemira: 12 Kemira: on- Allows independence Formal Kemira: govt Unclear. Information not
William Beach US with a housing for on-site villas. site support for the young person evaluation A$2.9 m, IRT available.
Gardens disability and younger adult LFCL: single worker and with the option of lacking. Group $2
(NSW)* [235- their and parent, in centre. lifestyle support/companionship million
237] parents/elderly adjoining units/ manager. from a familiar person (funding and
residents. facilities. LFCL: (i.e. parent). in-kind
Wintringham Young person is household of Maintains relationships support).
Eunice Seddon primary tenant. 10 has 2 between parents and
Home (Vic)* Individual care universal young people, while LFCL:
[238] support. staff both receive specialised Building:
LFCL: Green members; 1 care. US$23 million
Leonard House model in registered Leonard Florence: with
Florence Centre multistorey nurse serves Achieved sense of investment
for Living (LFCL) context ≥2 community/belonging, per resident
(Chelsea MA, households. spaces for community US$230,000.
US) * [239, 240] integration.
Abbreviations: RAC, residential aged care.


Table 7 Innovative models of care for LGBTI populations
Key examples Countries Settings, Key features Extent Delivery Strengths Challenges / Resources Impact on inequity Consumer
available population implemented weaknesses views
LGBTI affirmative assisted living Key features

• Elders reside in assisted living community where LGBTI values are embraced and accepted
Lebensort Viefalt Germany Multigenerati LGBTI-focused Single centre in Staff with Includes Providers may Funding Information not Information not
(Dwelling Place onal living: services (e.g. Berlin LGBTI- facilities that not be able to supported by available. available.
Diversity), Berlin # approx. 60% day care, HIV specific improve offer viable lottery and
[241-243] residents gay counselling and knowledge. community LGBT-specific foundation,
men >55 support) connectednes services due to private and
years, 20% located nearby. s, such as factors such as public loans,
women, 20% Assisted library, funding, donations and
younger gay independent restaurant interest, sponsorship.
men. living and and garden. financial ability Approx. €6
shared care and uptake. million
homes. invested, with
24 private more than half
residences, 1 funded by the
assisted living Stiftung
flat for person Deutsche
with dementia. Klassenlotterie
Berlin (charity).
Naturally occurring retirement community Key features
• Community intervention that allows older LGBTI people to age in place with easy access to appropriate services, community support and
friendship networks
• A network between building owners, service providers and other community partners
• LGBTI-specific services visit the community or are otherwise located nearby
SAGE Harlem * US Spread across Partnering with Single Significant Provides: safe No formal Project received Program started at Information not
[244, 245] a local hospitals, neighbourhood support place for evaluation. start-up request of older available.
neighbourhoo clinics and HIV community in from social and philanthropic LGBTI people of
d for older programs. Harlem, US. volunteers, recreational trust foundation colour, wanting
LGBTI people. Legal who are activities, funding. services closer to
Different representation also community home.
types of and clinics. program participation Services provided in
housing. Bilingual case participants. and advocacy. English and Spanish.
Predominantl management. Culturally and
y African Nurses. Safe linguistically
American and meeting space competent
Latino. provided in services.
offices.

Multiagency collaboration Key Features

• Collaboration of LGBTI-friendly agencies to enhance accessibility awareness of services
• Education initiatives and cultural competency training enhances LGBTI awareness of community members, doctors and allied health
professionals
Aging as US Community- Intake through Conducted 1 FTE Questionnaire Lack of 2007 budget: Improved access to 83% had
Ourselves, * [246] based collaborating 2005–2009 in Community s of 139 standardised $USD 250,000. services for LGBTI specific issues
collaboration agencies. San Diego centre participants: data collection elders. resolved.
of agencies to Network of County. Ended manager Improved protocol for Increase in life
improve LGBTI-specific due to lack of and 1 case access to program satisfaction,
access to services (case funding. manager services and evaluation. coping skills and
culturally management, plus. mental health willingness to
sensitive counselling, volunteers. via disclose sexual
resources and etc). counselling. orientation.
services for Community and Increased
LGBT seniors. worker social
education. interaction.

Table 8 Innovative models of care for homeless populations
Residential/supported accommodation for Key features:

• Shared residential facilities with additional supports
aged homeless
• Individualised care planning with the inclusion of behaviour-modification strategies to encourage harm minimisation regarding substance
abuse
• Care coordination with external health and social services
Wintringham Australia People older - Full care 11 sites across Recreation Exploratory Paucity of Uses existing Low Information not
Aged Care [247- than 70 years accommodation Victoria. officer with research: evidence. subsidies. socioeconomic/vuln available.
250] with high - Supported 288 beds, 6 volunteer Reduced Building cost: erable older people
incidence of accommodation aged care help. impact and Perceived A$2 million targeted.
acquired brain - Safe, facilities, 679 Manager. frequency of unequal staff Investment per
injury, affordable home care 6 hours of challenging workload resident: A$66,
psychiatric housing and packages, 532 care per behaviours, compared with 400 AUD.
illness or access to mostly 1-bed day. depression traditional care. Incentives to
premature transport and units. and anxiety, retain staff (e.g.
ageing. Some community alcohol paid parental
have early services. consumption. leave, five-year
onset Inconspicuous Improved service award).
dementia. (i.e. no signage). health and Government
Building 24-hour care. wellbeing. cost savings
design Ideals of Decreased $20,900 per
incorporates options, rights, hospital, crisis participant.
natural and dignity. and criminal
resources, Behaviour- justice usage.
curves and modification
verandas. strategies for
alcohol
consumption
and harm
minimisation.
Hearth Service Boston, US Multiple sites. Service- 196 units in Interdiscipli Survey Paucity of Government Low Survey of 97
Enriched Housing Homeless enriched eight residences nary team Indicated evidence. housing socioeconomic/ residents:
[251, 252] elders, housing in Boston. comprising 1400 adults Varying and subsidies. vulnerable older 78% express
multicultural (subsidised site have been fragmented Medicaid and people targeted. satisfaction
clients. rental units). directors, helped, with funding sources Department of with their living
Promotes licensed majority results in Mental Health environments.
continuum of social choosing to significant gaps funding of
care and self- workers, remain long- in support. eligible services.
sufficiency. registered term. Local and state

Attends to their nurses, Holistic, funding

physical, mental resident tailored sources.
and social assistants approach
needs. and addresses
On-site services personal substance
to address care abuse
substance use. homemaker behaviours,
s. social issues,
wellbeing.
Care
coordination
with external
health/social
service
providers.
Charles Chambers Australia Permanent Regulated Three facilities Qualified Personalised No formal Information not Specialised aged Information not
Court, Annie accommodati under aged care in NSW: 192 nursing care evaluation. available. care for particularly available.
Green Court and on for older legislation but bed places. staff. evidenced vulnerable clients
Benjamin Short homeless specialised for Resident: through (e.g. homeless or at
Grove [253] adults. vulnerable staff ratio arrangement risk).
clients. unclear. of funeral and
Person-centred memorial
care. Access to services for
24-hour care. allied health residents.
Social support.
services.
Access to health
services and
funeral
arrangements.
Old Colonists’ Australia 53% of Continuous care Four villages in Information Positive social Paucity of Philanthropic Low Unclear.
Association of residents are model, allowing Victoria. not outcomes evidence. gifts of land and socioeconomic/vuln
Victoria (OCAV)* homeless or ageing in place. available. reported for donations. erable older people
[253, 254] vulnerably Option of clients, family targeted.
housed. personal care members, One-off, means-
and respite. volunteers tested donation
79% of [254]. and on entry from
residents are 24-hour care. governments. those who can
women. Social support. afford it, and
Visits from
Provides commitment of
volunteers and
affordable 50% of their
medical and
accommodati housing for
personal service
on and those who
providers. support to cannot.

vulnerable Monthly fees:
elderly. 25% of pension.
St. Australia Specialised 24/7 supported Unclear. On-site Individual and No formal Information not Example service Information not
Bartholomew’s residential accommodation primary andgroup lifestyle evaluation. available. only available to available.
House: James aged care for . allied health
activities males.
Watson 40 men over Individual care personnel. encourage
Hostel*[255] the age of 50 planning and community
who are personal care. reconnection
homeless or Leisure activity and
at risk of programs. engagement.
homelessness Cooked meals
. reviewed by
dietician.
Laundry and
cleaning
services.
Permanent Housing and Support Services Key Features:
• Assistance to secure housing and provide case management to maintain tenancy, facilitating access to services, providing emotional support
and organising logistics (e.g. connecting utilities, sourcing white goods, organising removalists)
• Personalised ongoing case management to safeguard against client returning to homelessness
Aged Homeless Australia Vulnerable Collaborative Metropolitan Social Support No formal Clients housed Low Information not
Assistance people aged case- Adelaide and 12 workers. provided for evaluation. on a 12-month socioeconomic/vuln available.
Program, SA [256, 50 and over. management services across Housing as long as fixed-term lease erable older people
257] plan between Victoria. partners. needed. agreement. targeted.
client and social
Housing Support worker. Ongoing
for the Aged outreach
Program, VIC support to
[258] help clients
transition to
property and
build
independence
.

Hearth Outreach US People 50 Case managers Serves over 250 Each case 96% of elders Paucity of Funding: Low Information not
Program [251] years and visit 10 Boston homeless manager placed in evidence. combination of socioeconomic/vuln available.
older who are homeless elders annually. works with housing stay McKinney- erable older people
homeless or shelters weekly Since 1995, up to 25 for more than Vento Homeless targeted.
at risk of and assist with have placed clients, 1 year, which Assistance Act
becoming application and over 1000 supervised surpasses funds,
homeless. housing process clients in by licensed national Emergency
Provide other permanent social benchmark. Solutions
assistance as housing. worker; 1 Continuation Grant funds,
needed. works
of care: and donations.
Mutual aid specifically
support is
offered via Back with older
provided even
on Our Feet adults at
support group. risk of once housing
homelessne is secured.
ss.
Housing First (At Canada, Does not Recovery- Model Multidiscipli Selected Program not Cost of housing Low Clients (not
Home/Chez Soi Austria, specifically oriented implemented in nary studies: specifically offset by rent socioeconomic/vuln elderly only)
Study – 5 cities Finland, target older approach first Vienna, support Randomised targeted to supplements erable older people reported higher
across Canada: Sweden, people; secures housing Helsinki, teams controlled older homeless ($CAD375 to targeted. rates of positive
Moncton, Belgium, however then other Gothenburg, (client:staff trial: people. $CAD600). feedback
Montreal, Ireland, older people supports. Ghent, Dublin, ratio ≤10:1). improved Clients pay up regarding life
Toronto, Portugal, have been Rights-based, Lisbon, housing Increased to 30% of course
client-centred Glasgow, Intensive
Vancouver, Scotland, included in stability and attention to income. compared to
approach Copenhagen, case
Winnipeg)[259- Denmark, program. Improved medical Early reports clients receiving
supports client Budapest, managemen
263] Hungary, the mental health vulnerability have shown treatment as
choice. Amsterdam, t available
Netherlands, and quality of and mortality. financial usual.
24/7 services San Diego. 12 hours, 7
Full-service US days. life. sustainability:
available,
partnerships, separate from Observational for every dollar
California, US housing. Staff ratio study: spent on
[264] ≤20:1. decreased Housing First,
days spent 54 cents is
homeless and saved through
in justice reductions in
system. other shelter
and health care
use.

Table 9 Selected examples of innovative technologies to support LTC for older people
Technologies Key Countries Settings, Key features Extent Delivery Strengths Challenges / Resources Impact on Consumer views
impacting on examples available population implemented weaknesses inequity
models of
care
Humanoid Pepper Europe, Independent Mobile, A few simple Stand-alone Provides Safety issues Expensive Potential to Low perceived
robots as in- Japan, US and assisted movable limbs commercial product, users with imposed by and overcome usefulness and
home living for people and extremities. products exist supplied with social mechanical complex to some physical acceptance.
assistants with limited Chest display. incorporating user-specific presence components configure, and mental User concerns
[265-268] mobility and Voice adaptive training and and extends and computer deploy and limitations. on synthetic
physical abilities recognition and artificial support their control. maintain: Reduce form and
or mental and synthesis. intelligence programs. independen Limited require isolation by personality.
social decline. Computer control ce. strength and third-party social Ethical issues of
vision. functions. dexterity for commercial substitution. reliability and
assistance support. Assist in daily bonding.
capabilities. activities
management.
Health smart Tigerplace Australia, Independent Embedded Few one-off Installation Replace Current Expensive Occupants Moderate
homes for Canada, and assisted sensors and experimental within human implementati and receive perceived
ageing [269- Europe, US living for people Internet of examples exist existing built carer ons are complex to continuous usefulness and
279] with mental and Things devices. incorporating environment, presence simplistic with maintain: observation, acceptance.
social decline or Wearable inbuilt decision- with care and provide limited task require allowing early Ethical issues on
chronic disease. trackers support response daily living and specialist intervention covert
Audio and video functions. service. activities interaction developer and reduction surveillance and
capture. monitoring capabilities. support. of adverse personal data
Activity support. Require health privacy/security.
classification considerable events.
algorithms. training for
Telecommunica individual
tion link characteristics
Care response .
service.

Technologies Key Countries Settings, Key features Extent Delivery Strengths Challenges / Resources Impact on Consumer views
impacting on examples available population implemented weaknesses inequity
models of
care
Conversationa AvaChat Australia, Independent Voice Few simple Stand-alone Provide Conversationa Inexpensive Users can Moderate
l agents for Europe, US and assisted recognition and commercial product users with l product and obtain perceived
health care living for people synthesis, products exist supplied with social sophistication simple assistance at usefulness and
assistance with mental and conversation incorporating user-specific presence limited to support any time so acceptance.
[280-286] social decline. generation and adaptive training and and extend predetermine services. not reliant on User concerns
understanding artificial support independen d templates. external carer on persuasive
algorithms. intelligence programs. ce. Require availability. behaviour-
analytic considerable change roles.
functions. training for Ethical issues of
individual reliability and
characteristics bonding.
.
Chronic VHA CCHT Europe, US For people with Physiological Numerous Stand-alone Remote Limited scope Moderately Accessible for High perceived
disease care chronic disease. measurement commercial product subjects. to particular expensive remote usefulness and
management devices. products and supplied with health and subjects. acceptance.
systems [287- Telecare services exist user-specific application moderately Reduces Ethical issues on
294] station. incorporating training and without open complex acute events personal data
Telecommunica inbuilt decision- support standardis- support and privacy/security.
tion link. support programs. ation or services. hospitalisatio
Care response functions. interopera- n.
service. bility.

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Innovative models of aged care Appendix 3

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Small-scale, domestic living Key features

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Community-based shared Key features

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Dyadic caregiver interventions for people with dementia

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Other community care models

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Asset-based approaches Key features:

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# Located in the peer review literature, * Located in the grey literature

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Table 5 Models of care and supports for CALD groups

Innovative models of aged care Appendix 3