Work Together

Coordinate care to plan for and respond to the complex needs of people with dementia.

• See the ELDAC Residential Aged Care, Home Care and Primary Care Toolkits for relevant information on working together in those specific care settings. There is information about facilitating case conferences and palliative care needs rounds.
• Review the palliAGED resources on care coordination and case conferences (1.3MB pdf), to support the provision of palliative care for people with dementia.
• Adopt an informed approach to case conferences involving people with dementia. Support the dignity and rights of people with dementia, aiming to ensure they can remain active participants in their own care and life decisions. Include substitute decision-maker(s), key family members, and multidisciplinary team members. Involve family members in clarifying care goals and planning.

A person with dementia may receive care across a variety of settings. However, 66% of people with dementia were living in the community in 2022. [3] Consider the varied care settings and forms of assistance that may be relevant in these settings for people with dementia, and their family and carers.

The Australian Government has services across the care spectrum:

• The Commonwealth Home Support Program (CHSP) provides entry-level home support for older people who need assistance to keep living independently, as well as respite services to give carers a break. From 1 November 2025, the Support at Home Program replaced the Home Care Packages (HCP) Program and the Short-Term Restorative Care (STRC) Programme. Support at Home is available for older people who require more care than can be provided by the Commonwealth Home Support Programme (CHSP). Support at Home assists older people to stay at home rather than entering residential aged care. The program provides ongoing personal and support services and clinical care. This may include access to an End-of-Life Pathway designed to help people with less than three months to live remain at home during their final months of life.
• The Dementia and Cognition Supplement for home care provides additional funding for people with moderate to severe cognitive impairment. These supplements only apply to people who transitioned from the Home Care Packages Program and were receiving (or were eligible to receive) on 31 October 2025. The supplements are the dementia and cognition supplement or the Extended Aged Care at Home – Dementia (EACH-D) top up supplement.
• Respite programs are available and important for family carers to access for people with dementia who are being cared for at home and require end-of-life care. My Aged care has information on accessing respite or short-term care. Carer Gateway is funded by the Australian Government to support carers and has information on accessing planned and emergency respite.
• For people with dementia who can no longer be cared for at home, residential aged care can provide 24/7 care. More than half of people living in residential aged care have dementia. [4]

The Australian government funds multiple dementia related support services and programs, including:

• Dementia Behaviour Management Advisory Services (DBMAS): This is a mobile workforce provided by Dementia Support Australia (DSA). This service provides on the early on ground support, clinical advice and help for people with living with dementia experiencing change behaviours and their families and carers.
• Severe Behaviour Response Teams (SBRT): This is a mobile workforce provided by DSA to provide support, information, assessment and advice for people living with dementia experiencing severe behaviours and psychological symptoms, and their families and carers.
• Specialist Dementia Care Program (SDCP): This is a tailored program, which funds specialist dementia care units in residential aged care. The units provide specialised care to people with very severe behavioural and psychological symptoms of dementia. The program aims to reduce or stabilise symptoms so people can transition into less intensive care settings.

Providing end-of-life care for people with dementia requires knowledge about the person’s dementia, as well as other health conditions that may cause distress symptoms. Specialist palliative care services may provide support for people living with dementia in the community or residential aged care.

• The Advance Project^® provides triage tools for clinicians to identify if the person with dementia requires referrals to specialist palliative care services. There are specific referral triage tools for primary care, home care and residential aged care. Registration is free to access the tools.
• The Nightingale Program created by Dementia Australia is a specialist nurse-led support and palliative care service for people with late dementia, their families and carers. It is available free in South Australia, and some locations across New South Wales. The program involves a collaboration between general practitioners, nurse practitioners, community palliative care teams, existing service providers and allied health. The Nightingale Program can be accessed by calling the National Dementia Helpline on 1800 100 500.
• Contact your local specialist palliative care service to identify what support is available in your local area. Palliative Care Australia (PCA) provides a National Service Directory.