For Aged Care Professionals

Daily Check-In Calls as a Care Plan Supplement

You've completed the assessment. The care plan is approved. But the package won't start for months — and the client lives alone with no family nearby. What happens in the gap between assessment and service commencement?

This guide is for aged care assessors, case managers, and support workers who understand the system's limitations and are looking for practical tools to bridge service gaps. Daily structured check-in calls provide continuous monitoring that complements CHSP, HCP, and NDIS services without replacing face-to-face care.

The Service Gap Problem

The aged care system is designed for staged assessment and service delivery. In practice, significant gaps exist at every stage — and clients deteriorate in those gaps.

3–6 mo

Average wait for HCP Level 2 assignment

9–12 mo

Average wait for HCP Level 3–4 assignment

40%

of CHSP clients receive less than 2 hours/week total service

The Critical Window

Research from the Aged Care Royal Commission found that 16% of people approved for a Home Care Package died while waiting for their assigned package level. A further 20% entered residential care before their package started. The period between assessment and service commencement is when clients are most vulnerable — they've been identified as needing help, but help hasn't arrived.

Gap Type	Duration	Client Risk	How Daily Calls Help
My Aged Care registration to assessment	2–8 weeks	Moderate	Baseline monitoring, early deterioration detection
Assessment to HCP assignment	3–12 months	High	Continuous monitoring, family alerts, evidence for reassessment
Between CHSP service visits	5–6 days/week	Moderate	Daily touchpoint on non-visit days
Hospital discharge to community service restart	1–4 weeks	High	Post-discharge monitoring, medication changes tracking
Carer respite or absence	Days to weeks	Moderate–High	Substitute daily contact during carer breaks

How Daily Calls Fit into CHSP, HCP, and NDIS Care Plans

Daily check-in calls are not a substitute for in-person care. They are a monitoring and alerting layer that sits alongside existing services, providing data and continuity between face-to-face contacts.

Commonwealth Home Support Programme (CHSP)

CHSP provides entry-level support for older Australians who need a small amount of help to stay independent. Services typically include 1–3 hours per week of domestic assistance, transport, or social support.

• Gap: CHSP workers visit 1–3 times per week; 4–6 days have no professional contact
• Daily calls fill: Medication reminders, meal check-ins, mood monitoring on non-visit days
• Reporting: Daily summaries sent to nominated family members; trend data available for CHSP review meetings
• Funding note: Not currently funded under CHSP. Families pay directly from $1/week

Home Care Packages (HCP Levels 1–4)

HCP provides a budget-managed package of services tailored to individual needs. Packages range from $9,500/year (Level 1) to $57,000/year (Level 4). However, even Level 4 packages typically fund only 10–15 hours per week of direct care.

• Gap: Even at Level 4, 112+ hours per week have no professional oversight
• Daily calls fill: Continuous wellness monitoring between care worker visits; early warning for package level reassessment
• Potential funding: Under the new Support at Home program (commencing July 2025), telehealth and remote monitoring may become eligible expenses. Check current provider guidelines
• Case manager benefit: Objective daily data supports care plan reviews and level reassessment applications

NDIS (Disability & Early Onset Dementia)

NDIS participants with early-onset dementia or other disabilities that affect daily living may benefit from daily monitoring. NDIS plans often include “Increased Social and Community Participation” and “Daily Activities” funding.

• Gap: NDIS support workers visit at scheduled times; cognitive decline may accelerate between visits
• Daily calls fill: Orientation support, routine reinforcement, social engagement on non-support days
• Funding potential: May be claimable under Core Supports — Daily Activities (category 1) if included in plan. Discuss with LAC/planner

What Gets Monitored — and What Gets Reported

Each daily call follows a structured wellness conversation covering key domains relevant to aged care planning. The information gathered is useful for case managers, assessors, and the client's care team.

Monitoring Domain	Daily Call Coverage	Aged Care Relevance	Alert Trigger
General wellbeing	Self-reported mood and energy	Mental health monitoring, quality of life	3+ consecutive low-mood days
Nutrition and hydration	Meals eaten, fluids consumed	Malnutrition risk assessment	Skipped meals 2+ consecutive days
Medication compliance	Taken/missed, side effects noted	Polypharmacy review, GP communication	Any missed dose or new side effect
Sleep quality	Hours slept, disturbances	Pain indicators, anxiety screening	Disrupted sleep 5+ consecutive nights
Pain levels	Presence, location, severity changes	Chronic disease management	New pain or escalating severity
Social engagement	Visitors, outings, phone calls received	Isolation risk, community access needs	No social contact 3+ days
Safety and mobility	Falls, near-misses, environmental hazards	Home modification needs, falls prevention	Any fall or near-miss event

Reporting for Case Managers

Nominated family members receive daily call summaries by email. These include mood rating, key health observations, and any concerns raised. Trend data over weeks and months provides objective evidence for care plan reviews, ACAT reassessments, and HCP level-change applications. This is particularly valuable when clients downplay their difficulties during formal assessments.

Cost Comparison: Daily Calls vs In-Home Visits

Daily monitoring calls cost a fraction of in-person visits while providing more frequent contact. This comparison helps case managers and families evaluate the cost-effectiveness of adding daily calls to an existing care arrangement.

Service Type	Frequency	Cost per Contact	Monthly Cost	Contacts per Month
In-home care worker (CHSP)	1–2x/week	$50–$80/hr	$200–$640	4–8
Community nursing visit	1x/week	$80–$120/visit	$320–$480	4
Personal alarm monitoring	Reactive only	N/A (reactive)	$30–$60	0 (no proactive check)
Telecross volunteer call	1x/day (weekdays)	Free	Free	~22 (no weekends)
Kindly Call (Daily Plan)	7x/week	~$1.30/call	$39	30

The Cost of Not Monitoring

An avoidable hospital admission for an elderly Australian costs the health system $11,000+ on average. A hip fracture from an unmonitored fall costs $30,000–$50,000 in acute care and rehabilitation. Daily monitoring at $39/month ($468/year) represents a fraction of the cost of a single preventable adverse event.

How It Works in Practice: Case Scenarios

These composite scenarios illustrate how daily calls integrate with existing aged care arrangements. Names and details are fictional but representative of common situations.

Scenario 1: Bridging the HCP Waitlist

Client: Margaret, 82, lives alone in suburban Sydney. Approved for HCP Level 2 after ACAT assessment. Estimated wait: 4–6 months.

Problem: Margaret has mild cognitive impairment, takes 6 medications, and her daughter lives in Brisbane. During the wait, there is no structured monitoring. Margaret's GP flagged medication non-compliance at her last visit.

Daily calls provide: Daily medication reminders and compliance tracking. Meal and hydration checks. Mood monitoring to detect depression onset. Alerts to daughter if concerning patterns emerge.

Outcome: After 3 weeks, daily call data showed Margaret was consistently missing her evening blood pressure medication. Her daughter shared the trend report with Margaret's GP, who simplified the regime to a single morning dose. Margaret's compliance improved from ~50% to ~90%.

Scenario 2: Post-Hospital Discharge Monitoring

Client: Frank, 78, recently discharged after a hip replacement. Lives alone in regional Victoria. CHSP provides 2 hours/week domestic assistance.

Problem: Frank has a new medication regime (pain management, blood thinners, antibiotics), limited mobility, and needs to attend physiotherapy twice weekly. His nearest family member is 90 minutes away. The hospital discharge plan notes “community follow-up” but CHSP visits don't start for 2 weeks.

Daily calls provide: Pain level tracking (critical for rehab progress). Medication compliance monitoring for complex new regime. Mobility confidence assessment. Detection of post-surgical complications (infection signs, unusual pain).

Outcome: On day 5 post-discharge, Frank reported increased wound pain and feeling “hot and sweaty.” An immediate alert was sent to his son, who arranged a GP visit. Early-stage surgical site infection was detected and treated with oral antibiotics, avoiding readmission.

Scenario 3: Supplementing Weekly CHSP Visits

Client: Edna, 88, receives weekly CHSP domestic assistance (2 hours) and Meals on Wheels (weekdays). Widowed 18 months ago. No children.

Problem: Edna's CHSP worker noticed she seems increasingly withdrawn, the house is less tidy than usual, and delivered meals are piling up in the fridge uneaten. The worker suspects depression but only sees Edna once a week.

Daily calls provide: Daily mood assessment that builds a longitudinal picture. Nutrition tracking (is she eating the Meals on Wheels deliveries?). Social engagement monitoring. Gentle conversational companionship to reduce isolation.

Outcome: Two weeks of daily call data confirmed a clear downward mood trend and revealed Edna had not eaten a proper meal in 4 days. The CHSP case manager used this data to expedite a GP referral for depression assessment and requested a CHSP service level review.

Referral Process for Aged Care Workers

Daily welfare calls do not require a formal referral. However, aged care workers are often the first to suggest the service to families. Here is a practical guide for incorporating the recommendation into your workflow.

Step 1

Identify the Need During Assessment or Visit

Look for clients who live alone, have limited social contact, are on multiple medications, have a history of falls, or show signs of nutritional decline. The need is greatest during service gaps (waitlist periods, between visits, post-discharge).

Step 2

Discuss with the Client and Family

Frame daily calls as a friendly check-in, not medical monitoring. Many elderly clients respond well to the idea of a daily phone conversation, especially when positioned as companionship. Emphasise that it works with any phone (landline or mobile), requires no technology setup, and costs from $1/week.

Step 3

Connect the Family with Kindly Call

Provide the family contact with kindlycall.au or (03) 9999 7351. The setup is managed by the family member (not the client). A 7-day free trial allows them to assess whether the client enjoys and benefits from the calls before committing.

Step 4

Incorporate into Care Planning Documentation

Document the daily monitoring recommendation in your case notes or care plan. For HCP clients, discuss with the package provider whether daily calls can be included as a care plan line item. For NDIS participants, raise with the LAC/planner at the next plan review.

Step 5

Use Call Data in Reviews

At care plan reviews, request that the family share daily call trend reports. This objective data can support applications for increased service levels, additional allied health referrals, or ACAT reassessment.

Aged Care Quality Standards Alignment

Daily welfare monitoring aligns with several of the 8 Aged Care Quality Standards under the Aged Care Quality and Safety Commission.

Quality Standard	How Daily Calls Contribute
Standard 1: Consumer dignity and choice	Clients choose their preferred call time, conversation topics, and can pause or cancel at any time. Supports independence and self-directed care.
Standard 2: Ongoing assessment and planning	Longitudinal daily data supports ongoing assessment. Trend reports provide evidence for care plan adjustments and reassessment applications.
Standard 3: Personal and clinical care	Medication reminders support clinical care goals. Pain and symptom monitoring informs clinical decision-making.
Standard 4: Services and supports for daily living	Daily nutrition and hydration check-ins complement meal delivery services. Identifies when additional daily living support is needed.
Standard 5: Organisation's service environment	Safety monitoring detects hazards reported by clients. Falls and near-miss reporting supports home modification recommendations.

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