About care plans
A care plan is a document that outlines:
- a care recipient’s assessed care needs
- the services they will access to meet those needs
- who will provide the services and when.
When to provide a care plan
You must provide a copy of the care plan to the care recipient within 14 days of entering into a Home Care Agreement.
A care plan may be an attachment to the Home Care Agreement.
What to include
A care plan should include:
- the care recipient’s goals, assessed needs and preferences
- all the services that you will provide or organise
- who will provide the services, including subcontracting/third-party arrangements
- when services will be provided, such as frequency, days and times
- care management arrangements
- how involved the care recipient will be in care planning
- how often you will do formal reassessments.
How to prepare a care plan
Work with the care recipient
As part of the consumer-directed care approach, when preparing a care plan, you must:
- work with the care recipient
- let them decide how involved they want to be in planning their care.
Care recipients can:
- have another person (such as a carer or family member) with them to help prepare the plan
- 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 your care recipients to think about their goals. This will help when choosing services to best support their needs. For example, personal goals should relate to their assessed care needs.
Refer to their support plan, which outlines the care needs that the Aged Care Assessment Team (ACAT) identified when they assessed the care recipient.
Identify any other needs as you discuss the care plan with the care recipient.
Decide on services
When deciding on services to include in the care plan:
- confirm they meet the care recipient’s assessed care needs
- make sure their budget can pay for all the services – if they don’t, you can charge additional fees to provide extra services (if they agree)
- tell them about the services you provide in-house or through other arrangements, such as third-party 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
- consider whether they need care workers who speak the same language as them – if you can’t find one, you can discuss including any costs for an interpreter in the care plan.
Reviewing care plans
Care needs can change over time. You must review care needs and update care plans regularly, as part of your ongoing care discussions with the care recipient.
Find out more about updating care plans.
Emergency care plans
You should have an emergency care plan in place with advice on care provision during different types of emergencies, such as viral outbreaks or natural disasters.
You are responsible for:
- supporting care recipients to access alternative care arrangements, if needed
- not ceasing services without arranging an alternative model of delivery
- making sure all care recipient details are current, including emergency contacts and current general practitioner (GP)
- working with the care recipient, their family, their authorised representatives and their GP or other health practitioners to discuss the plan, including what would trigger the plan's use before an emergency.
Developing an emergency care plan with care recipients can be incorporated into the usual care management planning discussions.
Read more about preparing an emergency management plan.