About care management
Care management supports participants to access and understand their care. It helps ensure the care you deliver reflects individual preferences and cultural practices and adapt to changing needs.
Care management activities include:
- care planning – such as developing or reviewing care plans and budgets
- service planning and management – such as working with workers, participants or their registered supporters to ensure continuity of care across settings
- monitoring, reviewing or evaluating – such as identifying and managing participants' risks and goals
- support and education – such as helping participants and their supporters to make informed decisions or access other ageing-related programs.
What you must do
To meet your obligations under the Aged Care Quality Standards, you must complete care management activities:
- when you start providing services to a participant
- in an ongoing way while they are in your care.
In practice, you must deliver at least one direct care management activity (i.e. communicating or meeting with the participant or their registered supporter) to each participant, every month.
Even if a participant chooses to self-manage parts of their care, you must still carry out some care management activities to meet your obligations.
You can do these activities with a participant or on their behalf.
Funding for care management
For ongoing Support at Home services, we deduct 10% from each participant’s quarterly budget to fund care management activities.
If you provide ongoing services to specialised groups, the care management supplement is available to fund extra hours of care management.
For the Restorative Care Pathway and End-of-Life Pathway, you can claim care management costs from a participant’s budget for the pathway.
There are some activities that you can’t claim as care management services, such as staff training, compliance or keeping records.
Learn more about funding for care management activities.
Care partners
A staff member called a ‘care partner’ carries out care management activities for Support at Home participants.
A care partner:
- helps participants choose, receive and manage their services
- often acts as a liaison between your organisation and your participants (including their supporters, informal carers or family).
Care partners are appropriately trained aged care workers with relevant experience. They may hold health qualifications including in ageing, disability or nursing. However, there are no mandatory qualifications or registrations to be a care partner.
As a provider, you can choose your care management workforce so that it best meets your participants’ needs. For example, you may employ care partners with different qualifications or have clinically-qualified care partners to support participants with more complex needs.
Clinically-qualified care partners
Care partners who hold a university-level qualification in a relevant health discipline, for example a Bachelor of Nursing or Physiotherapy, are called clinically-qualified care partners.
Restorative care partners
For the Restorative Care Pathway, participants are supported by ‘restorative care partners’ who provide clinical coordination and oversight.
Find out more about restorative care partners.
Guidance for Support at Home care partners
Care plans
A care plan sets out a participant’s choice and control over their services. It should also focus on wellness and reablement approaches to help participants meet their goals.
Find out how to prepare a care plan and when to review.
For Restorative Care Pathway, providers must develop a goal plan instead.
Care notes
If possible, all workers, including care partners, direct care workers and allied health professionals, should complete care notes.
The notes should record any:
- important discussions with participants and their registered supporters or carers
- important interactions or observations about the participant or their needs, goals or services
- meetings or case conferences about the participant
- risks, incidents, investigations or near misses and any preventative measures
- billing issues or service delivery changes.
You:
- can choose how to record care notes
- should review care notes regularly to inform ongoing care planning.
Ongoing care discussions
Care partners should have regular care discussions with participants and any registered supporters. These discussions will help ensure a participant’s care meets their changing needs, preferences or circumstances.
Care partners should embed wellness and reablement approaches when discussing care needs, goals and preferences with participants.
These care discussions include reviewing and updating a participant’s:
If your participant’s needs have changed, consider and discuss their options. Depending on their care needs, this may include:
Find out more
- Read Chapter 8 (care management) in the Support at Home program manual
- Care management fact sheet for participants.