July 11, 2023


How your care plan informs your services and support for in home care.

When receiving coordinated services and support through any government subsidised aged care program, one very important document needs to be created – the care plan.

Whether the older person has received approval for a flexible care package such as Short Term Restorative Care (STRC) or Transition Care Program (TCP), or a longer-term package of funding such as a home care package (HCP), when the services are set up, the care plan is an essential document.

What is a Care Plan?.

The care plan is a document that takes into account a person's medical history, any functional or mobility impairment and any tasks that the older person needs help with from day to day.

The care plan reflects any religious, spiritual or cultural considerations for the individual.

It should document the personalised needs and goals of the older person, the recipient of care.

It should be developed with these needs and goals as a priority and aim to address what services and support can be put in place to meet them.

A care plan is not a generic form that is a “one size fits all”, nor is it a document that is completed once and then filed away safely.

A care plan evolves with the changing needs of the client, being updated to reflect the elderly client’s situation, whether that be their general health, cognition, mobility, or any other aspect that impacts their ability to live well at home.

A care plan should be reviewed at least annually, more often if there have been significant changes in the person's health or wellbeing.

What detail should be in a care plan?

A good care plan is developed in conjunction with the older person.

Home care package providers often task the care manager with writing the care plan.

While this might be acceptable for the lower-level packages, there is an expectation that for higher level packages, the level 3 and 4 packages, that a nurse is involved in the development of the care plan.

People who are approved for the higher level packages usually have more complex needs associated with health conditions and having a registered nurse involved in the development of the care plan ensures a person's needs are comprehensively assessed and incorporated into the care planning.

A registered nurse will also be able to detect unmet needs in the care planning and screen and apply for other Government schemes outside the aged care program.

A care plan should be a detailed document and take into account the preferences of the older person.

The care plan should never be developed solely from the perspective of the package provider.

Considerations for care planning should include:

Any medical conditions that need to be addressed? Can the package fund purchases that will help relieve these conditions?

Respiratory conditions such as asthma or Chronic Obstructive Pulmonary Disease would indicate maintaining a clean house free of allergens and the care plan should include regular cleaning of all surfaces as well as cleaning air conditioners to decrease the risk of the person having an exacerbation of their condition.

There is much discussion around cleaning of air conditioners since January 2023, with the updated home care package manual excluding this service, but if you can demonstrate the risk to your health by not having this type of cleaning attended, your provider should support this request.

Having your respiratory condition documented in your care plan, as well as the support the provider is offering to mitigate the risk to your health, will help you get this service approved and help your provider justify to auditors, why they have allowed this kind of expenditure.

People who have diabetes should have included in their care plan regular reviews with a podiatrist to ensure monitoring of the nerves in their feet occurs and if the podiatrist recommends protective or supportive footwear, this could also be included in package expenditure.

People with diabetes should also have included in their care plan the option to see a dietician.

And purchases such as a robotic vacuum cleaner that could be programmed to clean the floors every day, if the older person cannot manage to keep their floors free of hazards that could embed in their feet, is appropriate to include in package expenditure.

Having your health conditions reflect your needs, as identified in your care plan, allows you as the recipient greater opportunity to have your provider agree to funding expenditure from your home care package.

Is there any cognitive impairment? Does a daily drive or outing help alleviate sundowning? Would a therapeutic doll or pet make a difference to your loved one's mood or decrease their agitation?

A carer to take the person for a drive each day could be funded from the package or reimbursement for a portion of the petrol cost each week. Therapeutic dolls or pets can be purchased from package funding.

A registered nurse can screen for and make the application for the dementia and cognition supplement.

Nursing assessment for continence, changing catheters or skin integrity and wound care.

Allied Health support.

Physiotherapy for management of pain, continence or issues with balance (vestibular practitioners).

Physiotherapists are so specialised now, if you have health issues that would benefit from seeing a physio, and you cannot access this service under any other program, a physio can be paid from you package funding.

Dietician for dietary intolerances, malnourishment or unintended weight loss.

Speech pathology for issues with communication or swallowing.

An assessment with an Occupational Therapist (OT) to review the home and ensure any equipment or modifications are considered, such as grab rails, shower benches or chairs, an over toilet frame, bed stick, mobility aids and any devices to assist in the kitchen, such as a kettle tipper or specialised cutlery and crockery.

Exercise physiology for a personalised program of strength and balance. Is group exercise or one on one appropriate?

Support that might be indicated around the home, including personal care.

Does the older person need assistance to have a shower or manage their medications?

Is the older person able to drive, shop, prepare meals or manage finances independently?

What services are needed to maintain the house (cleaning, gardening, etc)?

Consideration for a fall detecting alarm or a key lock box to enhance safety within the home.

Each person’s needs and goals are different, so one care plan should not be identical to the next.

Remember, the care plan informs what supports and services the older person may receive.

The more comprehensive it is, the more options the older person has in utilising their package funding.

Care planning is something we're passionate about and we work with home care packages providers and recipients of packages to ensure the care and support people receive from their home care package is tailored to their needs.

We're happy to chat with you in our Let's Talk Consultation or you can send us a query via the form below to see if you or your loved one has a care plan that reflects your individual needs.

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