Client Support (Care) Plans
Each service user and/or their representative, participates in the development of a care/service plan that is based on assessed needs and is provided with the care and/or services described in their plan. Community Care Common Standards Guide, Australian Government, Department of Health and Ageing, October 2010, P 43 Care planning is a critical element to active service model implementation. Care planning is the link between assessment and service delivery. The care plan or service plan is the means of communicating tasks and activities with the service user, the carer and with any other organisations involved. It can be a means of empowering people to make their own decisions and thereby maintaining control over their lives. This can lead to a higher level of satisfaction with care, and can provide motivation and a sense of purpose. Care plans and service plans should be guided by a person’s goals, personal interests and aspirations. It should build on their strengths and capacities. It should include opportunities for health promotion, early intervention and self-help strategies. Where possible care plans/service plans should identify the goal of care provided, a time frame for the service provision/support, review points and actions – who is going to do what. All Home and Community Care Program for Younger People (HACC PYP) and the Commonwealth Home Support Programme (CHSP) -funded organisations should be working towards implementing goal-directed care planning. All HACC PYP and CHSP -funded organisations: The care plan resulting from a service specific assessment should be goal focused, developed with the service user (and carer), and should detail the exact nature of the care to be provided, when it will be delivered and the applicable fees. The plan should address any occupational health and safety issues. A copy of the plan should be left with the service user. The care plan resulting from a living at home assessment should be goal focused and include:
- a holistic plan including actions for referrals to other organisations which support a capacity building restorative approach and builds client independence
- service specific care plans for services provided by the assessing organisation which supports a capacity building restorative approach and client independence
- information provision on health promotion and social activities
The development of care plans should involve other expertise, for example allied health, as relevant to the needs of the consumer. This includes implementation of the CHSP and HACC PYP policies and procedures for the implementation of the Grampians Region Personal Care Policy and the policy Assistance with medication by HACC community care workers (2009) Interagency protocols including mechanisms for determining the lead agency when a client requires care coordination and processes to identify a key worker or care coordinator. Victorian Home and Community Care (HACC) Quality Review Resource, June 2012, P15
To assist CHSP and HACC PYP funded organisations in the Grampians Region we have compiled a set of material which looks at Client Support (Care) Plans, audit tools, and additional reading material to learn more about goal directed care planning. Client Support (Care) Plans
Shared Support Plan: Service Coordination Tool Templates (SCTT)
Client Support (Care) Plan: HACC Grampians Region, Sample tool
Moorabool Shire Council – CLIENT SUPPORT PLAN version 6 2015
Template Audit Tools
Additional Reading Material for Goal Directed Care Planning Strengthening assessment and care planning – A guide for HACC assessment services in Victoria: Department of Health, Victoria 2010: