What to discuss
Care needs can change over time. As part of ongoing care management, each month you must:
- discuss your care recipients’ assessed care needs and goals to ensure you are meeting them
- work with your care recipients to update and create their Home Care Agreement, care plan and individualised budget
- provide a monthly statement to each care recipient every month
- explain the monthly statement, including the funding available in their package and how those funds are being spent
- agree with each care recipient on how involved they will be in managing their package
- monitor and reassess services to make sure they continue to meet care recipients’ needs
- provide ways for care recipients to safely raise concerns or questions
- work towards resolving any issues.
If your care recipients’ care needs have changed, consider and discuss their options. Depending on their care needs, this may include:
- residential respite care
- permanent residential aged care
- short-term Commonwealth Home Support Programme (CHSP) services
- a Support Plan Review if they need to upgrade their package.
Reviewing care plans
When to review the care plan
You must review care needs each month, in line with the legislation. You must update the care recipient’s care plan any time their care needs change, or at least once every 12 months.
A care recipient can ask for a review of their care plan at any time.
You can include reviews and updates as part of care management charges.
When discussing changes, keep their budget in mind. You should make full use of their budget to best meet their care needs.
If needed, use the Translating and Interpreting Service.
Changing the care plan
You or the care recipient can add, change or remove services in the package, but you cannot downgrade the level of a package.
You cannot change a care recipient’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.
Reviewing Home Care Agreements
When to review a Home Care Agreement
You must review a care recipient’s Home Care Agreement if:
- their care needs change
- your prices change
- they ask you to.
Some providers update Home Care Agreements and other associated documentation as frequently as needed. This may be as frequently as when care plans are changed, such as quarterly or annually.
If needed, use the Translating and Interpreting Service.
Before updating a Home Care Agreement
Before you make changes to an agreement, you and your care recipient must discuss, understand, and agree to the changes.
You must actively support care recipients to understand any changes by giving them all necessary information.
Information provided to care recipients should be in an accessible format, tailored to them and include:
- what is changing
- why it needs to change
- what the new terms or prices include
- when the new terms or prices will start
- who to contact to discuss the proposed changes.
Reaching an agreement with care recipients
Following adequate consultation, you must reach an agreement with care recipients before making any changes, noting:
- you may need to review care plans and individual budgets to accommodate changes, requiring a reassessment of needs and priorities
- care recipients may renegotiate the terms of their agreement
- care recipient ‘agreement’ means they are adequately informed and understand all the changes and the terms of the proposed agreement
- notifying the care recipient of changes is not sufficient unless decreasing prices to meet legislated price caps – instead, you must discuss and reach mutual agreement to make any changes to a care recipient’s Home Care Agreement.
You should give care recipients a minimum of 14 days to respond to proposed changes unless the care recipient needs those changes urgently.
Documenting changes
When you reach agreement with a care recipient, you must document it with both you and the care recipient (or their legal representative) signing the new agreement.
Some care recipients cannot or choose not to sign their Home Care Agreement. The Home Care Agreement can still be considered ‘in place’ if the care recipient has not signed it but agrees to the proposed changes and continues to access services.
You will need to record their agreement through other means, such as:
- keeping a copy of the agreement you offered the care recipient to sign, including how it was sent and received
- adding a detailed file note to the Home Care Agreement of the discussion with the care recipient about the changes being implemented
- keeping evidence that you are delivering the package of care and services as described in the agreement.
You must provide a copy of the updated Home Care Agreement as soon as possible after finalising it and before the services start at the different price.
When a care recipient does not agree to changes
If a care recipient does not agree to the proposed changes:
- you should negotiate to reach agreement with the care recipient – provide a detailed rationale in a format that the care recipient will understand
- they may seek independent advice from consumer advocates, family members, or legal advisers
- they may wish to change providers (My Aged Care's Find a Provider tool can support the choice).
You cannot change a care recipient’s Home Care Agreement unless they agree, following adequate consultation.
If they do not agree or do not respond to a notice of changes, you cannot make the changes or stop providing care.
Read more about when you can cancel services.
Reviewing individualised budgets
When to review budgets
You must review a care recipient’s individualised budget if:
- they ask you to
- you want to change their services
- the costs of providing their care or services change.
Always discuss changes before making them.
Changing the budget
After you have made any agreed changes, you must give the care recipient a copy of the revised budget.
If the care recipient requested the changes, you must give them a revised copy within 14 days of the request.