Evaluation of the consumer - directed care initiative - Final Report

5.6 Planning

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Care planning refers to initial and ongoing assessment, planning and management of care by CDC and CDRC providers, with the involvement of the care recipient and their carer. Under the guidelines, this should be documented in a care plan.

Budget planning refers to the development of an individual budget for the provision and purchase of the care, services and materials in accordance with the care plan. The budget also includes provision for administration fees, and contingency funds to be set aside for any changes in participant circumstances (CDC only).

The planning processes adopted by CDC and CDRC providers were very similar.

Eligibility and consent

Following a determination of potential eligibility by a provider, the initial planning processes were characterised by a series of in-person and phone meetings between the coordinator or case worker, the participant, the participant’s carer (for CDC) or the person they were caring for (for CDRC), and often also other family and care network members. Typically, discussion held in the initiation stage (relating to how CDC or CDRC would work, participant’s responsibilities, and high-level discussion about needs and goals) would then merge into the planning stage for those people who agreed to participate.

In most cases, consent was documented in a written agreement between the participant and provider. The provider then undertook a needs assessment.

Needs assessment and planning

Providers used a wide variety of tools to assist in needs assessment. In some cases, this included some form of self-assessment. It was at this point that the assessment and planning processes tended to merge, and discussions about the participants’ goals and objectives would merge into discussions about potential support options and likely budget implications.

In many cases there were a number of meetings or discussions, depending on the participants’ and carers’ insights to their care needs, their ability to identify and articulate goals, and their capacity to engage with self-direction.

Those discussions were usually turned into a draft care plan, perhaps with some budget options, for the participant and carer to consider. Once the plan and budget were agreed, the provider would put the supports in place and usually provide some mentoring support to the participant and carer (i.e. how to use the service confirmation forms, how to check in with the provider, how to manage problems). In most cases, providers reported that a documented care plan and budget was given to the participant or carer, but this did not occur in all cases. Some providers indicated that they documented care plans in client file notes. In many cases (though not all), the participant were given a copy of the final care plan and budget documents.

In some cases, planning was able to be completed in a single meeting, though typically it occurred over a series of meetings.

While this broad approach to assessment and planning was generally consistent across CDC and CDRC providers, there were variations in the process. For CDC, there were two approaches to planning: either goal-based or menu-based, which are described below.Top of page

Goal-based planning focussed on identifying the goals, desires and objectives of the participant and carer, before then looking to identify possible support options.

For CDC, this approach used the ACAT assessment as documented in the Aged Care Client Record as a starting point, generally supplemented with other assessments that explored the participant and carer’s interests, preferences and social activities. Tools such as self-assessments, the International Wellbeing Group’s Personal Wellbeing Index, and resilience care plans – and variants thereof – were used by several providers.
CDRC providers used tools including adapted versions of the Carer Eligibility and Needs Assessment (CENA) tool, the Zarit Carer Burden scale, and guiding questions from the Carer Strain Index.

Providers did not consider that a common assessment tool would be useful at this point – they liked the ability to ‘mix and match’ tools, and to try out different approaches.

Menu-based planning focussed on the ACAT needs assessment and provision of a list of available supports, providers and price list to the participant or carer. It was particularly used with CDCL participants, by CDC providers who used the ‘enhanced choice’ service model described earlier in this chapter, and by CDC providers who tended to use more in-house services than brokered.

The level of information provided about available service providers varied considerably: some CDC providers maintained extensive lists of all available service providers and their prices, and made these available to participants and carers.

Others used a ‘default’ approach to use in-house services, but would engage a specific service provider or support worker based on the individual participant’s wishes (for example, if they wanted a support worker that spoke their native language, or one they had previously used).

“Everything is on the table – whatever sustains the carer.”

CDRC provider
The goal-based approach was more individualised and allowed more scope for innovative use of the package funds, and was clearly a different approach to the standard packaged care approach. The menu-based approach was easy for some participants and carers to understand (particularly those with no prior experience of community care), and was easier and less-time consuming to complete. However, the approach tended to focus on pre-defined service types and allowed less scope for innovation.

For CDRC providers the planning process was completely new from that used in NRCP. The approach they took was predominantly that of goal-based planning rather than menu-based. While traditional respite services formed a significant part of most care plans, they were always seen as only one aspect of ‘respite’ and participants were encouraged to consider a wide range of options which supported them in their caring role.

While all CDC and CDRC providers indicated that some form of care planning occurred, there was some inconsistency in documenting the care plan. The majority of providers gave copies of the plan to participants, whereas a small number indicated that they either did not give copies to participants and merely placed them in the participant files, or did not produce a formal care plan but documented the planning discussions in file notes.

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13. See http://www.deakin.edu.au/research/acqol/instruments/wellbeing-index/ for a description of the Personal Wellbeing Index.

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