Care management and care plans for Home Care Packages

What care management is

Care management is a service you must provide to all care recipients. To provide care management, you must:

• regularly assess the person’s needs, goals and preferences
• review their home care agreement and care plan
• ensure their care and services align with other supports
• partner with the person and their families or carers about their care
• ensure their care and services are culturally safe
• identify and address risks to their safety, health and well-being.

Some people may be more proactive in the management of their home care package. You must still provide care management to ensure you deliver safe and quality care and services based on their needs, goals and preferences.

Your care management service must comply with the Aged Care Quality Standards, including:

• Standard 1 – Support care recipients to make informed choices.
• Standard 2 – Initial and ongoing assessment and planning with care recipients.
• Standard 3 – Deliver safe and effective personal and clinical care.
• Standard 4 – Provide safe and effective services and supports to support daily living and allow independence.
• Standard 8 – Engage and support care recipients in the development, delivery and evaluation of care and services.

What can I charge for care management

Care management is a mandatory service for all care recipients, whether you fully manage them, or they self-manage.

Care management charges must be reasonable and justifiable.

You must publish a distinct care management price in a dollar figure so care recipients can better understand and compare prices. You can publish a different amount for self-managed care recipients.

You cannot charge care management as an:

• hourly charge
• hourly charge on top of the base care management charge.

You should consider lowering care management charges to reflect a reduction in service delivery and to support value for money where a care recipient’s:

• capacity increases
• needs reduce
• circumstances change, such as when they have increased support from their representative(s) or family or choose to self-manage.

 

On 1 January 2023, care management prices were capped based on what level package the care recipient receives. This was part of the Australian Government’s commitment to reducing excessive administration and management costs in home care.

The maximum amount you can charge by level, from 1 July 2023, is detailed below:

 

We have set these prices at a maximum of 20% of the package level and will increase with the basic subsidy each year. They are not the target price for these services or an indicator of what we consider a ‘reasonable’ price.

You can continue to charge for care management at a fortnightly or monthly rate as you have done previously. You do not have to pro rata the price if the care recipient ceases their home care part way through a period.

This means that if a care recipient has agreed to pay the maximum amount for care management in a month but leaves your care midway through the period, you can still charge the maximum amount for the entire month. You cannot charge for care and package management in a period where the care recipient has ceased care for the entire period.

What care plans are

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. There are rules as to how to cover any additional costs. Find out more at third-party services.

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. You must provide this service as part of the care management price.

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.

What to discuss

As part of your ongoing management of people’s care, you must:

• discuss their assessed care needs and goals to ensure you’re meeting them
• work with them to update and create their home care agreement, care plan and individualised budget
• explain the monthly statement, including the funding available in their package and how those funds are being spent
• agree with each person on how involved they will be in managing their package
• monitor and reassess services to make sure they continue to meet their needs
• make sure you’re aware of any concerns or issues
• work towards resolving any issues.

Legislation

For full details on care management, go to the Quality of Care Principles 2014.

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