Support at Home Social Work Services
Helping older people stay safe, independent and connected at home
Social Sense Allied Health provides mobile and telehealth social work services for older people receiving Support at Home funding.
We work alongside older people, families, care partners, GPs and aged care providers to support independence, emotional wellbeing, family communication and safe decision-making at home.
We can support people experiencing:
• dementia, memory loss or cognitive change
• grief, loss and adjustment to ageing
• anxiety, depression or emotional distress
• loneliness, withdrawal or loss of confidence
• carer stress and family conflict
• clutter, downsizing or difficulty managing the home
• feeling pressured, treated unfairly or unsafe
• difficulty navigating aged care and health systems
• changing care needs or increased support needs
We come to you
Many older people find it difficult to attend clinics. We provide support in the comfort of home across Melbourne, and by telehealth where appropriate, for your convenience.
How social work can help
We provide:
• counselling and emotional support
• psychosocial reablement to rebuild confidence and independence
• dementia counselling, validation strategies and family support
• reminiscence therapy and life review work
• support with grief, loss and transition
• support for carers and adult children
• advocacy and help understanding aged care systems
• hospital discharge and residential aged care transition support
• support with loneliness and meaningful connection
• help protecting personal rights, safety and peace of mind at home
A Good Life, Defined by You
A good life in later years is not measured simply by the services a person receives. It is about what they are genuinely able to be and do, and whether they have the freedom, support and opportunity to live a life they value.
The Capability Approach, developed by Amartya Sen and expanded by Martha Nussbaum, recognises that wellbeing includes:
• good physical and emotional health
• making your own decisions
• maintaining independence and control
• feeling safe, respected and valued
• having meaningful relationships and a sense of belonging
• remaining connected with your home and community
• continuing to learn, contribute, participate and enjoy life
Australian research involving 220 older adults found that 94% identified health as important. Participants also strongly valued independence, personal choice, family and friendships, safety, respect and the place where they lived.
At Social Sense Allied Health, we begin by asking:
What does a good life look like for you?
Our social workers focus on your strengths, identity, relationships, experiences and personal goals, not only your health conditions or care needs. We work with you to build confidence and practical skills, while also addressing external barriers such as unsuitable housing, limited transport, financial hardship, isolation or difficulty accessing services.
This is sometimes described as supporting combined capabilities: strengthening what a person can do while helping create the practical and social conditions that make meaningful choices genuinely possible.
Our approach may include counselling, advocacy, reablement, adjustment to health changes, rebuilding social connections, coordinating supports and helping you continue activities and roles that provide meaning and purpose.
Ageing may involve change and loss, but it should not mean losing your voice, identity or right to make informed decisions. You remain the expert in your own life.
Source: Kimberley, H., Gruhn, R. and Huggins, S. (2012), Valuing Capabilities in Later Life, Brotherhood of St Laurence.
Are you supporting a loved one through dementia?
Dementia changes how families communicate, but it does not erase identity. We support older people and families to understand behavioural changes, reduce distress, preserve dignity and maintain a calm home environment.
Is your family considering residential aged care?
Moving into residential aged care is an emotional family milestone, not just an administrative process. We support older people and families to work through grief, guilt, conflict, decision-making and identity transition.
Are you feeling pressured, treated unfairly or unsafe at home?
Relationships can become complicated as care needs change. We provide a confidential and gentle space to support older people who feel pressured about choices, finances, living arrangements or daily care. The focus is on listening, protecting rights and helping people move safely at their own pace.
Fully funded under Support at Home
Social work sits under the Clinical Care and Allied Health category within Support at Home. Where social work is included in the approved care plan, services can be billed through the Support at Home budget with no out of pocket cost to the older person.
Working with providers and referrers
Social Sense Allied Health works as an associated provider with registered aged care providers, care partners, care finders, GPs and allied health teams.
We can assist with:
• psychosocial assessment and documentation
• dementia-related distress and behavioural change
• family conflict and carer strain
• safety, rights and vulnerability concerns
• multidisciplinary communication
• therapeutic support linked to the person’s goals
We do not provide physiotherapy, falls assessment, gait assessment, personal care, meals, transport or home maintenance. Where these needs are identified, we can help screen concerns and refer to the appropriate provider.
Referrals
Referrals can be made by older people, families, Support at Home providers, GPs, allied health professionals, care finders, hospitals and discharge planners.
Contact us to discuss whether social work may be appropriate within your Support at Home plan.
Clinical Services
We can provide services for older persons experiencing challenges with:
• Dementia support, including behavioural and psychological symptoms, distress, agitation and withdrawal
• Memory and cognitive changes, including assessment of functional impact and support with daily decision-making
• Emotional wellbeing, including depression, anxiety, grief, trauma and adjustment to ageing or illness
• Functional decline, including reduced independence in activities of daily living and need for increased supports
• Mobility, gait and safety concerns, including falls risk, confidence and engagement in daily movement
• Risk assessment and safeguarding, including self-neglect, vulnerability, exploitation and unsafe home environments
• Capacity and decision-making, including support with consent, insight and risk awareness
• Social isolation and loneliness, including reduced participation and loss of meaningful roles
• Behavioural changes, including agitation, resistance to care and changes linked to cognitive decline
• Carer support, including education, burnout prevention and sustaining home-based care arrangements
• Care coordination, including working with GPs, allied health, aged care providers and families
• Transition support, including hospital discharge, increased care needs and entry into residential aged care
Services We Offer Across the Lifespan
Aged Care Social Work (65+ years)
Aged care social work provides person-centred, coordinated support to help older people live independently at home for longer under the Support at Home program. The focus is on working alongside you, your family and your provider to understand your needs, strengths, goals and preferences, and to ensure your care is safe, appropriate and responsive over time.
This work supports older people to remain healthy, active and socially connected to their community, while managing increasing care needs and changes in function, cognition and wellbeing.
Support is provided where there are challenges with:
• memory loss, dementia and changes in behaviour or mood
• emotional wellbeing, including depression, anxiety, trauma or adjustment to illness
• grief, loss and end of life planning
• maintaining independence with daily activities and routines
• social isolation and reduced connection to community or meaningful activities
• safety risks in the home, including self-neglect or vulnerability
• changes in family or carer support, including carer stress or breakdown
• navigating aged care services and understanding available supports
Social work is delivered as part of your broader care and support services, which may include clinical supports, support for independence and everyday living assistance such as personal care, transport, meals and maintaining your home.
Services focus on maintaining independence and supporting participation in daily life. This includes:
• working with you to develop and review your care plan in line with your goals
• supporting decision-making, including where there are concerns about capacity or risk
• providing emotional and therapeutic support to manage changes in health, function and life circumstances
• coordinating with your GP, allied health and aged care providers to ensure care is well organised and responsive
• supporting access to services, equipment or home modifications to improve safety and independence
• assisting carers and families to sustain care arrangements and make informed decisions
• supporting transitions, including after hospital stays or where care needs increase
Care is coordinated with your provider and care partner to ensure services are tailored, regularly reviewed and adjusted as your needs change.
The outcome is clear, older people are supported to remain at home safely, maintain independence for longer, and receive care that aligns with their preferences, rights and quality of life.
Adult Social Work (13–64 years)
Social work is a regulated, evidence-based profession focused on improving how people function in their daily lives. The work is grounded in human rights, social justice and practical outcomes. Social workers assess how biological, psychological, social and environmental factors interact, and how these impact a person’s capacity to live, work, study and maintain relationships. The role involves both direct therapeutic support and addressing systemic barriers such as housing, access to services, discrimination and financial stress.
Emotional wellbeing is shaped by everyday factors such as sleep, physical health, relationships and routine. When these break down, or are not enough, targeted intervention is required. Therapy is structured, goal-oriented and based on current evidence. Safety is prioritised across all areas of life including home, work and social environments. Interventions focus on identifying and shifting unhelpful thinking patterns, improving emotional regulation and strengthening decision-making.
Support is provided for:
• Anxiety, depression and mood instability
• Trauma, including complex and developmental trauma
• Low self-worth, shame and identity difficulties
• Stress, burnout and reduced motivation
• Relationship challenges, attachment patterns and boundary setting
• Neurodivergence, including executive functioning difficulties
• Functional impacts that limit independence, participation or stability
The approach is collaborative but direct. You define your goals, and progress is measured against real changes in functioning. Therapy is not passive, it involves developing practical skills, testing new behaviours and building capacity over time. Without this, patterns tend to repeat and functioning declines.
A recovery-oriented framework is used, meaning you determine what a meaningful life looks like. The role of the social worker is to provide structure, clinical input and accountability to support that process.
There is a strong focus on the body and its role in regulation. Emotional responses are not just cognitive, they are physiological. Interoception, the ability to read internal bodily signals, directly impacts emotional regulation, impulse control and sense of safety. Interventions include body-based strategies to improve awareness and regulation, alongside cognitive and behavioural approaches.
Practice is guided by the Mental Health Act 2014, the Privacy Act 1988 and the Health Records Act 2001, which require safe, ethical and accountable care.
The outcome is clear, improved functioning, stronger coping, better relationships and increased capacity to manage the demands of everyday life.
Paediatric Social Work (0-12yrs)
Paediatric social work supports children through their early developmental stages with a strong focus on prosocial behaviour, emotional wellbeing, and the gradual transition to independence. Our work is grounded in evidence-based approaches that support children, families, and caregivers in promoting growth, connection, and resilience.
Key areas of focus include:
• Emotional regulation – Supporting children to recognise, understand, and manage their emotions in healthy, constructive ways to promote emotional balance and reduce distress.
• Social skill development – Building children’s capacity for empathy, communication, and conflict resolution to help form positive peer and adult relationships.
• Healthy attachment – Strengthening secure, consistent relationships with caregivers, forming the basis for trust, safety, and emotional security throughout life.
• Resilience building – Teaching coping skills and problem-solving strategies to help children manage adversity and build emotional strength and flexibility.
• Behavioural support – Addressing concerns such as aggression, impulsivity, and social withdrawal through tailored behaviour strategies that support emotional and relational development.
• Coping strategies – Equipping children with practical tools to manage stress, anxiety, and change, enhancing their ability to adapt and self-regulate.
• Self-esteem and confidence – Encouraging a healthy sense of identity and confidence in their abilities, helping children value their unique strengths and contributions.
• Problem-solving skills – Supporting children to think critically and approach challenges with curiosity, creativity, and persistence.
• Empathy development – Helping children to understand others' perspectives and feelings, promoting compassion, kindness, and emotional awareness.
• Communication skills – Enhancing both verbal and non-verbal communication so children can express needs, share ideas, and connect with others effectively.
• Mindfulness and self-awareness – Introducing age-appropriate mindfulness techniques that foster awareness of thoughts, emotions, and physical sensations, promoting calm and focus.
• Growth mindset – Promoting optimism, persistence, and the belief that abilities can improve with effort, helping children approach learning and life with confidence.
Paediatric social work prioritises connection, safety, and developmentally appropriate interventions. We work closely with caregivers, educators, and other professionals to support the child’s overall wellbeing, capacity, and sense of self.