Care plans for Home Care Packages

A care plan outlines a person’s assessed care needs and how you will meet those needs to help them stay at home. You must work with the person to prepare a care plan and make sure they understand and agree with it. After services start, you must review the plan at least once every 12 months.

What are care plans?

A care plan is a document that outlines:

  • a person’s home care needs
  • the services they will receive to meet those needs
  • who will provide the services and when

What to include

A person’s care plan should include:

  • their goals, needs and preferences
  • the services that you will provide or organise
  • who will provide the services
  • when services will be provided, such as frequency, days and times
  • care management arrangements
  • how involved the person will be in managing their package
  • how often you will do formal reassessments

How to prepare one

Work with the person receiving care

When preparing a care plan, you must:

  • work with the person receiving care
  • let them decide how involved they want to be in planning their care

This is part of the consumer-directed care approach to home care.

If they choose to, they can have another person (such as a carer or family member) with them to help prepare the plan.

They also have the right to choose an advocate to represent them in their dealings with you. You can help them find an advocate through the Older Persons Advocacy Network (OPAN).

If needed, use the Translating and Interpreting Service.

Discuss personal goals and care needs

Encourage the person to think about their goals. This will help when choosing services to best support their needs. A goal could be something like having a healthy lifestyle or being more independent.

Refer to the care needs that the Aged Care Assessment Team identified when they assessed the person. Identify any other needs as you discuss the care plan with the person.

Decide on services

When deciding services to include in the care plan:

  • confirm they meet the person’s care needs
  • make sure their budget can pay for all the services
  • tell them about the services you provide in-house or through other arrangements
  • consider their request for a service or care worker they would like to use
  • consider the support they already have from carers, family and other services

You may need to set up a subcontracting or other arrangement to provide a service. Tell the person about any extra costs.

Some people may not have enough funds in their budget to cover all the services they need. You can charge additional fees to provide extra services, if they agree.

A person may need care workers to speak the same language as them. If you cannot find one, you can discuss including any costs for an interpreter in the care plan.

When to provide one

You must provide a copy of the care plan to the person receiving care. You must do this within 14 days of entering into a home care agreement.

Reviewing the care plan

Care needs can change over time. You must review care plans at least once every 12 months to make sure your services are meeting the care recipient’s needs.

A person can ask for a review of their care plan at any time.

When discussing changes, keep their budget in mind. You should make full use of their budget to best meet their care needs.

These reviews should be part of your ongoing care discussions with the person.

If needed, use the Translating and Interpreting Service.

Changing the care plan

You cannot change a person’s care plan without their agreement.

You must:

  • discuss changes with them and make sure they understand and agree to them
  • give them a copy of the updated care plan for their records

If needed, update their individualised budget and home care agreement.

Legislation

For full details, go to 19AD — Responsibility to provide written plan of care and services in the User Rights Principles 2014.

Last updated: 
22 January 2020
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