Q&A with Professor Phillippa Carnemolla, University of Technology Sydney
As Australia transitions to the Support at Home program, more care is being delivered in people's homes than ever before. This shift raises an important question for universal design: what happens when the home becomes a place of care and work?
Professor Phillippa Carnemolla
School of Built Environment, Faculty of Design Architecture and Building, University of Technology Sydney
We sat down with Professor Phillippa Carnemolla from the University of Technology Sydney and member of the CUDA Steering Committee, to discuss her Australian Research Council (ARC)-funded research into aged care delivery in the community.
Professor Carnemolla shares what she is hearing from home care workers and older people receiving care, and why universal design has a vital role to play in shaping a sustainable and inclusive Support at Home program.
We're in the middle of one of the biggest shifts in aged care in a generation, why is understanding how home environments shape care delivery more important now than ever?
Australia is shifting significant levels of aged care into people's homes through the Support at Home reforms, yet we still know surprisingly little about what a sustainable system of delivering higher and more complex aged care services in people's own homes looks like - or what the levers are that make it better for older people, or more sustainable and viable for providers.
My research examines how a home-based model of care can be made more sustainable through more systemic thinking, treating our housing and neighbourhoods as care settings. Homes are now becoming one of the primary sites of healthcare and support, but unlike hospitals or residential care facilities, they were rarely designed with care delivery, or diverse levels of self-care, in mind.
This research is also taking place at a time when the aged care sector is facing increasing workforce pressures associated with an ageing population, workforce shortages and rising demand for care. The interviews I am undertaking reveal that the relationship between policy decisions and the design, condition and location of homes, and the distances between them, directly influences workforce sustainability, safety, efficiency and the quality of care older people receive.
What does your research tell us about how the condition of someone's home affects the care they receive?
The condition of a home can profoundly shape both the quality and type of care a person receives. Through interviews with home care workers across Australia, we are hearing about situations where cramped bathrooms, broken appliances, poor lighting, stairs, lack of storage, or inadequate heating and cooling create significant challenges for both older people and staff.
We are also hearing from workers about homes in poor repair, and situations involving significant clutter or hoarding. These conditions can directly affect their ability to deliver care in line with Aged Care Act requirements around safety, dignity and quality. These environments increase physical strain on workers, reduce privacy and dignity for older people, and can limit what care can safely take place in the home. Small environmental issues can have significant consequences for health, safety and wellbeing.
This raises an important question: how can care systems better support safe and effective care delivery when the home environment itself presents risks or constraints?
Why do both the experiences of home care workers and older people need to be considered together?
Care at home is relational and interconnected. The experiences of older people and workers are deeply linked. If workers are spending large parts of their day driving between appointments, navigating inaccessible homes, or working in environments without the equipment or conditions needed to provide safe care, this affects the continuity and quality of support that older people receive.
We are also seeing a significant workforce shortage- for example not enough domestic assistants for cleaning and community visits, and not enough people to deliver personal care. This is placing real pressure on the system.
Broader issues such as housing affordability are also shaping the workforce itself. In some metropolitan areas, providers are struggling to recruit care workers because workers cannot afford to live locally, creating workforce shortages and long wait times for older people needing support. Good care systems need to work for both the person receiving support and the people delivering it.
How can universal design help us think about the home as part of a wider care system?
Universal design encourages us to consider how environments can better support people across different stages of life and levels of need. In the context of aged care, it helps us see the home not as an isolated dwelling, and ageing or aged care as not an isolated time or need, but as part of a broader care ecosystem- connected to transport, neighbourhoods, health services, family support and the care workforce. It shifts the conversation towards holistic strategies that include proactively designing homes and communities that can better support ageing, care and everyday life.
Should we be thinking beyond the home itself when designing for community care?
Absolutely. Care does not begin and end at the front door. My research is increasingly showing that neighbourhoods, transport systems, parking availability, local services and housing affordability all shape how care is delivered and experienced.
This is especially stark in regional and rural areas. For many people, transport costs can sit outside of their funding, which means older people living outside of towns can be charged per kilometre for support staff visits. This has been stressful givne the current petrol price volatility. For someone living 50 kilometres from the nearest town, that cost adds up to a significant and often prohibitive personal expense.
Workers in outer suburban, regional and rural areas may also spend many unpaid or compressed hours travelling between clients. In som of our interviews I heard how many older people in these areas can become isolated if neighbourhoods are inaccessible or when disconnected from services. If we only focus on the inside of the home, we miss the wider systems and infrastructure that make community care possible.
How should housing design standards and policy respond to the reality that more care is being delivered at home?
Housing policy and design standards need to recognise that homes are increasingly places of care delivery - both informal (unpaid) and formal (paid). This means thinking about accessibility, circulation space, bathrooms, lighting, storage for equipment and the capacity for homes to adapt over time.
Importantly, housing policy also needs to be connected to workforce and care policy. Questions about where care workers can afford to live, how far they travel between appointments, and how care is coordinated across communities are now central to the sustainability of the Support at Home reforms.
What would it look like to truly design neighbourhoods and communities with care in mind?
Designing communities with care in mind would mean creating neighbourhoods that support connection, accessibility, safety and participation across the life course - accessible housing, walkable streets, reliable transport, accessible public toilets, accessible information, local health services and places where people can remain socially connected as they age. It is a perfect opportunity to engage Universal Design principles!