Supporting Older Adults with Complex Needs at Home
Support at Home Services - We Travel to You
At Social Sense Allied Health, we provide specialist social work services for older people receiving Support at Home. We operate as an associated provider, delivering services on behalf of approved aged care providers, working in partnership with your provider and care partner. Our focus is to support you, your family and your care team to deliver person-centred, coordinated care that helps you live independently at home for longer.
We support older people with complex care needs, where there are multiple factors impacting daily life, including health, cognition, emotional wellbeing and social circumstances. Our role is to help you maintain independence, stay connected to your community, and ensure your care is safe, appropriate and responsive as your needs change.
Our Accredited Mental Health Social Workers bring experience in ageing, psychosocial support, cognitive change and navigating aged care and health systems. We understand that care needs can change over time, and that support must be flexible, coordinated and aligned with your goals and preferences.
We support older people who may need help with:
• memory loss, dementia and changes in behaviour or mood
• chronic health conditions, frailty and reduced mobility
• emotional wellbeing, including depression, anxiety, trauma and grief
• social isolation and reduced participation in community life
• managing daily activities and maintaining independence at home
• self-neglect, hoarding or reduced awareness of risk
• changes in family support or carer stress
• understanding and accessing aged care services
Social Work and Safeguarding in Aged Care
Social work plays a central role in ensuring care is safe, well-coordinated and responsive to risk within the Support at Home program. This includes working with older people, families and providers to identify concerns early, respond appropriately and maintain stability in the home.
Our practice aligns with the expectations of the Aged Care Quality and Safety Commission, including the Aged Care Code of Conduct, the Statement of Rights and the Aged Care Quality Standards. This means care is delivered with dignity and respect, is person-centred, and actively protects the safety, rights and wellbeing of older people.
We assist with:
• identifying and responding to risks such as neglect, exploitation or unsafe living situations
• supporting decision-making where there are concerns about capacity, consent or risk awareness
• addressing carer stress and supporting sustainable care arrangements
• responding to disengagement from services or changes in care needs
• supporting transitions, including hospital discharge, increased supports at home or entry into residential care
We also contribute to safeguarding by ensuring risks are clearly assessed, documented and addressed in line with aged care quality standards.
We work alongside your provider and care partner to ensure your care plan reflects your needs, goals and preferences, is coordinated effectively, and is reviewed regularly as your circumstances change.
Person-Centred, Coordinated Care
Our approach aligns with Support at Home principles, focusing on maintaining independence, supporting daily activities and improving quality of life.
We provide:
• therapeutic support to assist with adjustment, loss and emotional wellbeing
• support for behavioural and psychological symptoms associated with cognitive decline
• assessment of needs, risks and supports to inform care planning
• coordination with GPs, allied health and aged care providers
• support to access services, equipment or home modifications
• education and support for carers and families
• assistance during periods of change, illness or increased support needs
We work as part of your broader care team to ensure services are coordinated, appropriate and aligned with your goals.
Working with Providers and Families
Social work complements clinical care, personal care and everyday living supports. We focus on psychosocial wellbeing, safety, relationships and decision-making.
For providers, this supports:
• better coordination of care and service delivery
• improved engagement with clients and families
• early identification and management of risk
For older people and their families, this means:
• clearer care planning and support
• improved safety and stability at home
• the ability to remain living at home with dignity, independence and appropriate support in place
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.