Conduct the aged care needs assessment
Once an aged care assessment organisation accepts and triages a referral for an older person in the My Aged Care assessor portal, they assign a needs assessor to conduct an aged care needs assessment. The assessment establishes the older person’s care needs for government-funded aged care services. There are both home support assessments and comprehensive assessments. Usually, the assessment is in person, at the older person’s home.
The assessment relies on the assessor’s expert judgement. The assessor uses this judgement to collect evidence during the assessment, through both questions and observations. They also gather and consider the older person’s records, including their medical records with their consent, action plan and preferences for care.
For more information, read section 5.5 of the My Aged Care Assessment Manual, and Navigating and updating the client record.
Use the Integrated Assessment Tool
Assessors are assisted by the Integrated Assessment Tool (IAT). The IAT helps assessors collect detailed, comprehensive and consistent information about the older person and their circumstances, for an accurate profile of the older person’s care needs.
This part of the assessment has 13 sections with questions, covering topics such as personal health, social supports, and home environment. Some sections have follow-up questions, to discover more information where needed.
The IAT integrates 11 validated health assessment tools, for depth and clinical rigour.
For more information, read the IAT user guide.
Document the assessment
Assessors must document the assessment in the assessor portal. In cases where it is not possible or appropriate to access the portal during the assessment, assessors can use the IAT Offline Form. If the offline form is used, the assessor must afterwards enter all recorded details into the portal.
Create the support plan
The assessor creates the support plan in collaboration with the older person. This record summarises the findings and recommendations of the assessment.
To create the support plan, refer to the guidance in section 5.7 of the My Aged Care Assessment Manual and Completing a support plan and support plan review.
Finalise the assessment
After the assessment, assessors should quality check the information they gathered and their recommendations. They then finalise the assessment.
Information should be complete, accurate and consistent.
If more information is needed, the older person can give consent to contact their general practitioner.
For more information, read section 5.12 of the My Aged Care Assessment Manual and Completing an assessment.
Review and approve recommendations (Assessment Delegate only)
The Assessment Delegate must:
- review the recommendations that assessors make
- decide whether to approve the recommendations
- record the reasons for the decision.
The Assessment Delegate can also unlock a finalised assessment for editing by the assessor, to ensure that the assessment correctly reflects an older person’s care needs and circumstances. This facilitates correction of any errors, and can only be done once for each assessment.
For more information, read Part D of the My Aged Care Assessment Manual and Assessment delegate processes.
Share the outcome with the older person
Assessors must give the older person the outcome of the assessment. This can include a:
- support plan (this may be also provided to others, such as service providers)
- delegate decision letter (if applicable)
- application for care form (if applicable)
- referral code letter (if applicable).
Action the assessment outcome
If an older person is eligible and agrees to it, the assessor can issue referrals for:
- the Commonwealth Home Support Program (CHSP)
- Support at Home program, including the short-term pathways for Restorative Care, Assistive Technology & Home Modifications, and End-of-Life
- residential aged care.
Assessors should follow up with the older person to make sure they are receiving the correct services for their needs. This is particularly helpful for vulnerable persons who may find the process more difficult.
For more information on referrals and follow-ups, read section 5.8 of the My Aged Care Assessment Manual and Referring for services.
More information
Find more information at Single Assessment System resources.
If you are an older person thinking of getting assessed for aged care, you can visit the My Aged Care website to learn more.