What is a care plan
A care plan is a document that outlines:
- the needs, goals, preferences and choices of a participant
- the approved services that will help them meet these needs and goals.
For the Restorative Care Pathway, you must develop a goal plan instead.
Who prepares care plans
Care partners in provider organisations must prepare the care plans.
Guidance for Support at Home care partners
What to include
A care plan should include:
- the goals of the participant
- strategies, including wellness and reablement approaches, to achieve these goals
- the participant’s preferences, such as:
- the gender or other attributes of care workers
- preferred days and times to receive services
- cultural preferences
- the services the participant has agreed to receive, including:
- who will deliver the services
- when they will deliver the services
- frequency of services
- any assistive technology and home modifications the participant will receive
- review dates for the care plan
- any notes about how you will deliver services to ensure they are culturally safe, trauma aware and healing informed.
Preparing care plans
Care partners must write the agreement in plain language so it is easy to understand.
Work with the participant
Care partners must prepare the care plan:
- with the participant, their carer or registered supporter
- in line with the participant’s Notice of Decision and support plan
- before or on the day care starts.
Care partners must also ensure the participant understands:
- the services and products they have been approved to receive
- what they can afford with their budget.
If needed, they can use the Translating and Interpreting Service.
Care partners should also prepare an individualised budget with the care plan. This ensures the care plan is in line with the participant’s needs and budget.
Tailor care and services
Care management services must also meet Aged Care Quality Standards. This means you must tailor participants using a wellness and reablement approach. For example, when planning care:
- consider any risks to their health
- ensure services are culturally appropriate
- help them make informed choices
- allow them to decide how involved they are in the planning
- if they agree, consider inviting their doctor or other health professionals to provide input.
When and how to provide
Care partners must complete a care plan before or on the day care starts.
They must provide a copy to the participant or registered supporter:
- once the plan is complete
- any time the plan is updated
- if the participant requests it.
Reviewing care plans
Care partners should regularly review the care plan with the participant at least once every 12 months.
Care partners should also review the care plan if:
- the participant requests a review
- their needs, goals or preferences change
- they receive a higher classification
- they are approved to receive assistive technology or home modifications
- they begin the End-of-Life Pathway
- when the participant with interim funding receives their full funding
- they want to change their services or how often they receive them
- a new risk or incident affects them
- the support they receive from family, carers or registered supporters changes.
If care partners change the care plan, they should review the individualised budget at the same time.
Care partners may find that the participant’s Support at Home classification no longer meets their needs. If the participant agrees, you may request a reassessment.
Find out more
Read Support at Home program manual:
- Chapter 7 (starting funded care services)
- Chapter 8 (care management).