Seamless by Design: Continuum of Care in Retirement Living
Authors: Michael Kirch MBA (Senior Director of Digital Transformation), Mike Jeffrey, MBA and CEO PlussCommunities.com, & Aged Care/Allied Health Industry Thought Leader, May 2025.
Version v4.0: 10/06/25
Preface: The new reality in home care, retirement living, and aged care
Australia’s aged care sector is shifting under the weight of generational change. Our population is ageing, expectations are rising, and legislation is catching up, bringing with it a new level of urgency, complexity, and opportunity. What was once a segmented landscape, home care over here, retirement villages over there, aged care on the far end, has started to blur. And with that convergence comes pressure: on systems, on leadership, and on how we define “care” itself.
The truth is, people don’t live their lives in silos, and they don’t age in clearly defined stages. Yet too often, our services, policies, and technologies still behave as if they do. Residents and families want continuity across the care journey. They expect digital access, joined-up support, and clear pathways from independence through to higher care when needed.
How aged care reform is reshaping expectations in retirement living
The 2025 introduction of the new Aged Care Act represents the most significant shift in care legislation in more than two decades. While it is technically targeted at residential aged care and home care, the cultural and operational ripple effects extend well beyond. Retirement village operators, long seen as outside the formal care system, are increasingly being drawn into the reform agenda. Why? Because resident expectations don’t stop at the village gate, and neither do family concerns or community standards.At the heart of the reforms is a bold reimagining of care as a rights-based service. The new Statement of Rights, enshrined in the Aged Care Bill 2024, reframes older Australians as active participants, not passive recipients. It sets the tone for transparency, responsiveness, and personalisation principles that apply just as strongly to village life as they do to funded care settings.
Key objectives of the reform include:
Person-centred care: Older people are to be empowered in care decisions, with dignity, autonomy, and informed choice front and centre.
Improved quality and safety: Stronger oversight, clearer quality standards, and greater accountability mechanisms for providers.
Greater transparency: From fees to staffing ratios and performance data, transparency will no longer be optional.
Sustainable funding models: A rebalanced financial framework to support long-term system viability.
Support at home: A stronger push to support older Australians to age at home longer, via the new “Support at Home” program beginning in 2025.
These reforms are more than compliance updates, they are reshaping how care is understood, delivered, and expected. For retirement living operators, this means engaging in conversations and solutions that might once have been outside their remit. But in an era of blurred boundaries and rising expectations, standing still is no longer an option.
Hence, Retirement living is increasingly involved in aged care reforms, despite initially being lifestyle-focused. The Aged Care Bill 2024 allows registration as providers, but also brings new regulatory obligations and funding changes. Cultural shifts driven by the Bill's Statement of Rights have raised expectations across all care sectors. In home care, clients want tech-enabled coordination; in retirement living, residents expect care access and digitally connected communities; and in residential care, families demand safety and transparency. Meeting these expectations requires better coordination, integrated technology, and a shift towards shared accountability.
Sector strain and structural challenges
While reforms intend to improve care, they've added complexity and pressure. In home care, the Support at Home transition creates urgency with new regulations. Retirement villages face ambiguity regarding registration and care provision. Residential care is heavily impacted by staffing and reporting requirements. Overall, consumer expectations have risen, demanding responsiveness and personalization.
The cost of getting it wrong
The reforms have raised the stakes. Providers who fall short on service, communication, or continuity, risk not just compliance penalties, but reputational and commercial damage.
Families now view the care journey holistically. A poor handoff from home care to residential care, or unclear offerings in a retirement village, undermines trust across the board. Negative experiences spread quickly, and occupancy risk is real.
The opportunity is trust and growth
For the most successful providers will be those who align people, systems, and strategy to deliver continuity across the care journey. That means integrating digital tools, investing in governance, and fostering a culture that sees the whole person—not just the service phase.
In this new landscape, getting it right means more than meeting the minimum. It means becoming a trusted, responsive partner in ageing and that’s the new standard.
Pressure points across the Continuum of Care
To earn trust and achieve growth, providers must first understand where the real pressure points lie across settings, systems, and expectations. The following table outlines the shifting landscape providers must navigate to deliver on the promise of continuity and care in the reform era.
Setting
System pressure
Operational challenge
Consumer expectation shift
So what is the answer to this suite of challenges 2025-2026?
Delivering continuity across the care journey requires more than compliance, it demands integrated systems, unified communication, and a shared commitment to resident dignity and choice. Luckily for the industry overall, valuable lessons have shown Pluss the way in terms of organisations attempting customer services optimisations with digital solutions.
Responding to reform: Why a lifecycle lens matters?
Due to increased pressure from regulations, operational needs, and consumer expectations, service providers are now shifting their perspective to view services through the lens of the complete aging process. This enables them to respond with greater clarity, strategy, and confidence. Rather than addressing compliance or rising expectations in isolated parts, forward-thinking organizations are taking a step back to evaluate
“What does continuity, dignity, and wellbeing look like across this person’s broader and smaller, ageing journey?”
The lifecycle view shifts the focus from managing fragmented programs to designing integrated experiences that align with a person’s evolving needs, relationships, and preferences. It also allows providers to respond proactively to the convergence of care and lifestyle across the sector. This customer journey & service view is even more relevant as retirement villages become care-enabled and home care becomes more personalised and increasingly digital.
Key benefits of thinking in customer & services lifecycles
Note: The following table summarises the core benefits of applying a lifecycle lens to service design. It shows why providers who think holistically about the resident journey are best positioned to thrive in this era of reform and rising expectations
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Ultimately, residents benefit most. Research shows that a person-centred, continuous care journey improves health outcomes, social connection, and life satisfaction.
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Providers can plan service offerings, staffing models, and partnerships with the full journey in mind—ensuring each phase supports the next rather than operates in isolation. This leads to stronger business models and more coherent operational plans.
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Residents and families experience less friction and anxiety when transitions are managed smoothly. Trust grows when clients feel known, remembered, and supported as their needs change.e
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A lifecycle approach encourages investment in interoperable tools, shared communication channels, and consolidated records, reducing duplication and improving handover quality.
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Staff benefit from knowing where they fit into the broader picture of someone’s life, not just their task list. This creates stronger culture, better onboarding, and improved collaboration across disciplines.
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In a competitive environment, providers who can demonstrate a true continuum of care, grounded in personalisation, digital readiness, and emotional intelligence, will stand out to residents, families, and partners.
What we’ve learned about transformations from working with villages and communities
After 20+ enterprise-level integrations with care and retirement living providers, one truth stands out: digital community platforms are becoming a central pillar of transformation across the ageing sector. Strong and effective "residential and community services" don't emerge by chance, they are the product of intentional design, values-driven leadership, and digitally enabled infrastructure that can adapt to residents’ evolving needs.
Retirement villages, in particular, are at a pivotal moment. They sit between wellness and clinical care, between independence and support. As more retirees opt into village life expecting lifestyle, purpose, and continuity, digitisation must be more than admin automation, it must be a resident-centred framework that brings together service design, operations, and communications across the continuum of care.
What this case study reveals about sector wide transformation
Our work with providers like TriCare highlights a critical insight: the shift to a digitally enabled, resident centred model is not only possible, it is already underway. But it is not easy. Even for progressive organisations, aligning people, systems, and services around the continuum of care takes more than good intentions. It requires new capabilities, fresh thinking, and a readiness to confront legacy barriers. What we have learned through this and other implementations directly informs the challenges now facing the sector.
Case Study: https://www.plusscommunities.com/case-studies/tricare-app
A Case Study for transformation and delivering the extended Services Lifecycle supporting Care with PlussCommunities.com
Key challenges providers face in responding to this moment
1. Rising complexity in service development
Creating care-focused products and experiences now requires navigating tighter regulations, higher expectations, and deeper integration across providers and systems. Few providers are resourced to design truly interoperable or adaptable service ecosystems without external support.
2. High cost and slow delivery of digital capability
Building the right infrastructure, while hiring or upskilling internal teams, takes time and money many providers don’t have. This delay often leads to fragmented rollouts and inconsistent digital experiences for staff and residents alike.
3. Workforce and resource misalignment
As needs grow more complex, traditional workforce models no longer cut it. Providers must rethink the skills, roles, and resources needed not only in clinical care, but in service coordination, digital engagement, and resident advocacy.
4. Strategic and technology debt
Legacy systems and outdated ways of working stall transformation. Providers are carrying hidden “debt” in their workflows, org structures, and tech stacks, debt that now limits agility, visibility, and responsiveness.
5. Ballooning operational costs in BAU systems
The day-to-day complexity of operations has grown exponentially. Without integration and simplification, providers risk being overwhelmed by the admin load of simply “keeping things going.”
6. Outdated financial models
New funding structures across Support at Home, retirement villages, and residential aged care demand financial frameworks that can flex, co-fund, and scale. Too many providers are still applying yesterday’s models to tomorrow’s realities.
Bringing continuity to life in the village context
* A convergence of care & lifestyle.
As the retirement living sector becomes more deeply integrated into the broader aged care system, the expectations placed on villages have shifted significantly. Residents no longer see their village life as separate from their care journey, they expect a seamless experience that supports wellness, independence, community connection, and peace of mind as their needs evolve.
At Pluss Communities, we’ve designed our platform to meet this challenge. The Resident Services Lifecycle outlines how technology can support every stage of the resident journey within a village, from pre-settlement engagement and community integration, through to service coordination, aged care transition, and eventual property resale.
What this model shows is that the retirement village is no longer just a place to live, it is a node in a broader care journey, where timely communication, accessible digital services, and resident-led control become central pillars of quality. It also reflects what families now want: visibility, reassurance, and the confidence that their loved ones are supported, not just in a crisis, but every day.
By centralising communications, enabling service access, and integrating with systems like CRMs, clinical tools, and finance platforms, the Pluss platform empowers residents to engage meaningfully and independently with their community, while giving operators and families the tools they need to respond, support, and plan.
How the Pluss Platform supports Continuum of Care and sector reform
*The Pluss Communities Platform supporting Native App for community Residents of all types and Web Portal for Management and Services capabilities. “A total Game Changer”.
The convergence of lifestyle, wellness, and care expectations in retirement villages is no longer theoretical, it's playing out in real time. Providers are being asked to operate with the governance and responsiveness of aged care, while delivering the lifestyle, autonomy, and digital experience expected in modern retirement living. Add to this legislative reform agenda and a growing workforce. It is clear, success now requires a platform to orchestrate resident experiences across the Continuum of Care.
The Pluss Platform Continuum of Care in a residential village
PlussCommunities is a platform purpose built for these moments
The Pluss Communities platform was designed from the ground up to help retirement living providers manage this shift. It offers a single, integrated ecosystem for resident engagement, service delivery, and operational coordination, with the flexibility to meet people where they are, whether they’re booking a yoga class or transitioning into aged care support. The resident lifecycle can support both day-to-day connection and long-term planning, all within a resident- and family-friendly interface.
Addressing key sector challenges with Pluss
The result? A platform designed not just to digitise tasks, but to solve the real, system-wide pressures facing providers today. Here's how Pluss directly addresses the key challenges across the sector:
*Providers often are confronted by the challenges of scaling and the maturity level required to overcome these.
Building operational readiness for Continuum of Care
Delivering a consistent, resident-centred experience across the ageing journey doesn’t happen by accident. It requires providers to be deliberate about how they organise people, systems, and services around the lifecycle of ageing. That means not just responding to legislative change—but building the internal capabilities that allow for agile delivery, cross-functional collaboration, and continuous improvement.
The good news?
There’s already a proven framework for this kind of transformation. It comes from product management—an approach long used in technology development that retirement living providers can now adopt to design, deliver, and sustain person-centred services at scale.
What this means for providers now?
As retirement living operators move further into the care space, they must become ecosystem managers, not just service deliverers. The challenge is not just to digitise, but to do so in a way that’s sustainable, measurable, and centred on residents’ real lives.
Implementing the continuum of care model is not a one-time project, it’s an ongoing commitment to:
Redesign services around the resident lifecycle
Invest in operational systems that can scale with care complexity
Foster cultures of accountability, empathy, and agility
Guardianing continual improvement processes and service standards
With the right approach PlussCommunities.com accelerates achievement for all of these outcomes and more. The right platform to support change is a game changer! With this providers can move from reactive service delivery to proactive resident engagement as a new way of working. This depicts a clear approach to residents and staff creating improved cultures of value, benefits, engagement, and trust enabling the dignity with aging that is critical and deserving.
How you can evolve from siloed service models to a fully integrated, resident-centred continuum of care?
To respond strategically to reform pressures and rising expectations, providers need a pathway to evolve from siloed operations to a fully integrated, resident-centred model. The roadmap below outlines how organisations can progress across five stages of maturity in delivering a true continuum of care:
* Table outlining the Continuum of Care Roadmap for maturing providers.
Conclusion: Rethinking retirement living through the lifecycle of care
The aging journey is no longer a linear progression through disconnected services, it’s a dynamic, deeply personal continuum that spans wellness, lifestyle, and care. For retirement living providers, this means rethinking how communities are designed, how services are delivered, and how technology can bridge the gap between independence and support.
Understanding the lifecycle of engagement for older Australians provides a powerful lens for transformation. It enables providers to anticipate needs, build trust through continuity, and offer environments where wellbeing, purpose, and connection are woven into everyday life. It’s no longer enough to offer amenities and social programs, today’s residents and families expect clear pathways to care, accessible communication, and personalised support at every stage.
Why Pluss Communities Is the right platform partner
Pluss Communities Application and Portal Platform is purpose-built to support the evolving role of retirement living in the broader care ecosystem. Our platform isn’t just a communications tool, it’s a foundation for delivering operationally ready, resident-centred services across every phase of the ageing journey.
By centralising digital engagement, streamlining service delivery, and connecting residents, staff, and families through a unified experience, Pluss empowers providers to:
Simplify operations while enhancing service responsiveness,
Support independence and self-direction for residents,
Give families visibility and peace of mind,
Integrate with existing care, clinical, and vendor systems,
And most importantly, align their services with the expectations of today’s, and tomorrow’s, ageing Australians.
Whether it’s through internal service teams or trusted local providers, Pluss helps make continuity of care not just possible, but effortless. We exist to support organisations who want to deliver the best of both worlds: vibrant, connected communities with seamless access to care when it’s needed
APPENDIX : Questions to consider
Vision & Organisational Alignment
Are we organised around our programs or around our residents’ lives?
Do we have a clear view of how a resident’s needs evolve over time?
Is our strategy built to support the entire care journey, not just our part of it?
Where are the boundaries between our service offerings artificial to us, but invisible to the resident?
Continuity & Coordination
Do our teams, systems, and services come together to support a whole person across time?
How seamless are our transitions between service types or departments?
Can a resident or family member tell a consistent story of their care experience with us?
Who "owns" continuity for a resident as they move between home care, village life, and aged care?
Staff Culture & Capability
Do our staff understand the full context of each resident’s life, not just the service they're providing today?
Are we training our workforce for continuity, empathy, and shared responsibility?
How well do staff across care settings communicate with each other about the same resident?
Technology & Systems
Do our systems share information across services, or do we make residents and families repeat themselves?
How many logins or platforms do our staff and residents have to juggle?
Can we see a full picture of each resident’s engagement, care history, and evolving needs?
Communication & Engagement
Are residents and families clear on what we offer, what we don’t, and what comes next?
Do we make it easy for families to stay informed, involved, and reassured?
How do we listen to residents across the care journey, and how do we respond?
Measurement & Accountability
Do we measure success in terms that matter to residents, like dignity, connection, and confidence?
What happens when continuity breaks down, and how often are we measuring that?
Are we learning from the whole resident journey, or just the phase we deliver?
APPENDIX Next Steps — A roadmap checklist
Continuum of Care in Retirement Living
Map Your Resident Lifecycle and Service Catalogues
Define key phases (e.g. onboarding, community life, care transition, post-occupancy).
Identify service gaps and friction points.
Audit Current Systems and Processes
Are your tools integrated across teams and care types?
Can residents and families access what they need, when they need it?
Engage Residents and Families
Establish formal feedback channels.
Involve them in co-designing services and communications.
Establish a Care Continuity Taskforce
Bring together cross-functional leaders (care, ops, lifestyle, tech) to align on resident-first priorities.
Invest in Scalable Technology
Choose platforms that enable communication, coordination, booking, and family involvement.
Prioritise interoperability (CRM, clinical, asset, finance).
Build Workforce Readiness
Train staff on digital tools and the full resident journey, not just their functional area.
Shift culture from program ownership to resident ownership.
Pilot, Measure, Improve
Start small with a digital service improvement or new onboarding process.
Collect feedback, measure outcomes, and iterate.
Plan for Integrated Future Models
Prepare for Support at Home and care convergence by developing flexible service, staffing, and funding models.
Stay ahead of compliance through proactive design, not last-minute.
APPENDIX : References
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Technology Enhancement (CREATE); http://userpages.umbc.edu/~norcio/papers/2009/Gurley-HCII2009/Gurley-Tech-HCII2009.doc
Psychology and aging, 21(2), 333: http://userpages.umbc.edu/~norcio/papers/2009/Gurley-HCII2009/Gurley-Tech-HCII2009.doc
Berkowitz, B. (2018). Community building: What makes it work. Sage Publications.
Moos, R. H., & Lemke, S. (1996). Evaluating residential settings for elderly people. In Handbook of the psychology of aging (pp. 569-591). Academic Press.
Lawton, M. P. (1999). Environmental taxonomy: Classification of environments for adults. In Handbook of the psychology of aging (pp. 98-114). Academic Press.
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Kitwood, T. (1997). Dementia reconsidered: The person comes first. Open University Press.
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Weiss, R. S. (1973). Loneliness: The experience of emotional and social isolation. MIT press.
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Peek, S. T., Wouters, E. J., van Hoof, J., Luijkx, K. G., Boeije, H. R., & Vrijhoef, https://scielo.org.za/scielo.php?script=sci_arttext&pid=S2071-97362020000100014
Factors influencing acceptance of technology for aging in place: a systematic review https://scielo.org.za/scielo.php?script=sci_arttext&pid=S2071-97362020000100014
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Donabedian, A. (1988). The quality of care. How can it be assessed?. Jama, 260(12), 1743-1748.
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Legislative Impacts in Australia 2025;
Department of Health and Aged Care. (2024, February 29). Aged Care Bill 2024. Retrieved from Australian Parliament House: https://www.aph.gov.au/Parliamentary_Business/Bills_Legislation/Bills_Search_Results/Result?bId=r7129
Aged Care Quality and Safety Commission. (n.d.). A new model for regulating aged care. Retrieved from https://www.agedcarequality.gov.au/aged-care-reform/new-model-regulating-aged-care
Department of Health and Aged Care. (n.d.). Navigating aged care. Retrieved from https://www.health.gov.au/our-work/aged-care-reforms/navigating-aged-care
Department of Health and Aged Care. (2023, October 24). Aged Care Taskforce Final Report. Retrieved from https://www.health.gov.au/resources/publications/aged-care-taskforce-final-report
Department of Health and Aged Care. (n.d.). Support at Home program. Retrieved from https://www.health.gov.au/our-work/aged-care-reforms/support-at-home-program
Department of Health and Aged Care. (n.d.). New fees and charges for aged care from 1 July 2025. Retrieved from https://www.health.gov.au/our-work/aged-care-reforms/new-fees-and-charges-aged-care-1-july-2025
