What is a care plan?

Every person who is receiving a home care package should have a care plan that reflects their needs and goals, and includes the kind of support that will enable the older person to fulfil those needs or goals.

The care plan should be completed with the involvement of the older person and their family member or carer, if indicated.

The care plan should include any assistance the older person might need with their day to day activities, and any clinical support and associated equipment or modifications of the home that would make things easier for the older person.

In this episode:

When is a care plan developed?
Who should be involved in developing the care plan?
Consumer directed care
A care plan is not a “one size fits all”
What should be included in a care plan?
Should you give your provider a copy of your GP health summary?
The things that package funding can be used for
How often should a care plan be reviewed?
Care management fees cover care plan reviews
Consent must be given before changes are made to a care plan

Resources mentioned:

Blog – What is a care plan?
Blog – What is Care Management?
Blog – What are the fees for home care packages?
Coral’s book - My Parents Are Ageing, What the Heck Do I Do?
Let's Talk Consultation

Related Episodes:

Episode 7

Connect with Coral Wilkinson:

More about Your Aged Care Compass podcast:

Are you supporting an older loved one at home and ready to give up because it’s just too hard? Your Aged Care Compass is aimed at anyone who is caring for an older loved one who still lives at home and is wondering what support is available to them.

We're Coral and Michelle, the sisters behind our business, See Me Aged Care Navigators.

Coral is a registered nurse with over 30 years’ experience in both health and aged care. A former assessor with the aged care assessment team, an advocate and author, there’s not much Coral doesn’t know about Australia’s aged care system.

Michelle is a former pharmacist with over 30 years in the public health and private sectors of pharmacy. Michelle is now client care manager for our business.

Our story started as one of supporting our parents to remain in their own home, to be as independent as possible and remain connected to their community. We reached a point however, of needing extra support and we achieved this because we know Australia’s aged care system so well, we knew what programs could assist us and our parents.

This podcast, Your Aged Care Compass, brings together not only our personal experience in supporting our own ageing parents but also our vast professional experience in supporting other families to keep their loved ones at home.

We will help you makes sense of Australia’s aged care system, from your first contact with My Aged Care through to the different funding streams and assessment workforces, management options for home care packages and extra funding that people might be eligible for.

There's so much more. Topics relating to dementia and legal and financial considerations will be covered, as well as real life stories of where it went wrong for people and how we guided them to get it right.

Your Aged Care Compass will guide you clearly and compassionately to the right support at the right time for your ageing parents and loved ones.

Like what you hear? Please leave us a Rating and Review. We’d love you to share this podcast with any friends or family who have older loved ones.

Michelle: 00:00:31

Today we're discussing care plans, specifically in the

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: 00:00:35

context of home care packages.

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: 00:00:38

Every person who is receiving a home

care package should have a care plan

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: 00:00:43

that reflects their needs and goals,

and includes the kind of support

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: 00:00:47

that will enable the older person

to fulfill those needs or goals.

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: 00:00:52

As a team of nurses, care planning

is central to our approach for

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keeping older people well and able

and living independently in their

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: 00:01:01

own home for as long as possible.

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Coral, tell us how a person

would come to have a care plan.

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Coral: When a person is assigned

their home care package shell, they

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have 56 days to choose a provider

who will administer the package.

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Within those 56 days, the recipient

of the package will enter into a

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service agreement or a home care

agreement with their chosen provider.

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Essentially, this is a contract, and both

the older person receiving the package

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and the provider will sign this agreement.

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Within 14 days of signing the

agreement, the provider is

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required to develop a care plan.

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The care plan should be completed with the

involvement of the older person and their

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family member or carer, if indicated.

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The Department of Health and Aged

Care's website notes letting the older

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person decide how involved they want

to be in planning their care, but from

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my perspective it's not negotiable.

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The older person and their

family or carer must be involved

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in the planning of their care.

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Michelle: Consumer directed

care underpins the approach to

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care planning, doesn't it Coral?

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What does this mean?

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Coral: So consumer directed

care is just that shell.

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The consumer, being the recipient

of the home care package, should

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be encouraged to direct the kind

of services and support they'd like

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to receive to help them at home.

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These services and support will

be what the package funding

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or subsidy will be spent on.

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It's not okay for the provider to

develop a care plan without the

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involvement of the older person and their

family member or carer, if indicated.

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Thank you.

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Michelle: Yep.

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And we've seen this, where a provider

has dismissed the older person wanting

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to have input into their care plan, and

the provider saying they'll just use

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the care plan they've already developed.

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Coral: Yeah, we have seen this

though, look, it's not common,

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Shel, thankfully, but it's not

okay for a provider to dismiss the

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older person if they are wanting

to have input into their care plan.

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And it's certainly not okay for a

provider to use a generic care plan

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or a generic approach to planning

the care of the older person, because

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it's about their specific needs.

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Thanks.

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Michelle: Exactly.

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And it's not a one size fits all.

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Coral: No, it's not.

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Michelle: So how should

a care plan be set out?

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And what should be

included in a care plan?

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Coral: So when I'm creating a care

plan, I include as much detail as

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possible to give a complete picture

of what the older person needs to

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remain as well and able as possible.

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I always encourage people to supply

their provider with a GP health summary.

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Some people do feel uncomfortable with

this, saying their medical history

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is confidential, but not having the

person's health conditions included

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in the care plan limits the scope

for optimised service provision.

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As a nurse, seeing a person's

health conditions means that I can

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reasonably predict the trajectory

of a person's health journey.

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It means I can take an educated guess at

what the person might need in the future.

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It also allows me to look at what

strategies we can implement now to

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help the older person retain their

independence and mitigate some functional

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decline we would see if the older person

didn't address their health needs.

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The care plan should include any

assistance the older person might need

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with their day to day activities and that

might be assistance with personal care,

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meal preparation, transport assistance,

domestic assistance, any maintenance

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required around the house and any clinical

support and associated equipment or

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modifications of the home that would

make things easier for the older person.

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This would also include addressing pain,

continence issues, mobility issues,

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and declining strength and balance.

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Michelle: Yeah, so there's a whole

lot that can be included there.

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Coral: There is, yes,

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: 00:05:14

Michelle: So should the initial

ACAT assessment be referenced by the

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provider for developing a care plan?

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Coral: it should, if this is

the first care plan that the

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older person is having drafted.

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But as time goes on and the older

person's needs change, it may not

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be appropriate to keep referencing

the ACAT assessor's summary.

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So, five years down the track, if the

provider is still referencing that

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initial ACAT assessment, I would say

that that's probably Not appropriate

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because things will have changed

over that time and, there should

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have been at least five care plan

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Michelle: Reviews.

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Coral: exactly over that period of time to

reflect the older person's changing needs

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Michelle: Yep.

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Coral: and also keeping in mind that the

older person may not have disclosed all

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the information they could have during

that ACAT assessment, so taking the time

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to extract detail during the meeting with

the provider will ensure that the care

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plan is as comprehensive as possible.

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Michelle: And I know people

often say to us, I don't know

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what to include in my care plan.

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What advice do you give

them in this instance?

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Coral: I always tell people to reflect

on what support they might already

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be receiving from family or friends.

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The kind of support family and

friends offer is often the kind

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of support a person can use their

home care package for, freeing up,

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you know, the family member's time.

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If they have someone mowing their yard,

this could be included in the care plan

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and the package funding could pay for it.

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People often think about carer support

in developing a care plan, but not

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everyone will need or want carer support.

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You can use your package

funding to support you as

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your individual needs dictate.

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You could use your package

funding for pre packaged meals.

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continence aids, clinical support, or

purchases of mobility aids if you like.

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You could also use your package funding to

see a physiotherapist to help manage pain.

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You could use your package funding

to see a podiatrist and have a

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biomechanical assessment of your feet

possibly being recommended orthotic

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inserts or orthotic shoes to help

with your stability if indicated.

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What one person will have

documented in their care plan will

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be different to the next person.

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A care plan should be tailored to the

older person's specific needs and goals.

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Michelle: And I can see here, Coral,

this is why you're saying a provider

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should not be using a generic care plan.

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Coral: Exactly because everybody is

different and like you already said,

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Shell, it's not a one size fits all.

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Every person's care plan should

be tailored to their needs.

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Michelle: So how often should

a care plan be reviewed, Coral?

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Coral: The care plan should be reviewed

at least every 12 months, Shell,

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and whenever there's a significant

change in the person's health and well

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being, such as a hospital admission.

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Essentially, if something happens that

changes the kind of support or service

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that the older person needs, the The care

plan should be updated to reflect this

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Michelle: And on this point, Coral, is

it up to the package provider to start

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this process, or can the home care

package recipient ask for a review?

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Coral: look either or, but really, if the

older person's needs are changing, unless

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they're informing their provider, the

provider's not going to know, are they?

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So the provider won't become

aware that they need to do

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an update of the care plan.

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If they don't know that, the

older person has had a fall and

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has been admitted to hospital.

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Maybe they've fractured a bone

which means that they might actually

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need a different kind of service

provision, different kind of support.

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So really it comes back to the person

themselves, the recipient of the

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package, or the family member informing

the provider that something's changed.

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And then You know, with those changes,

if the person needs different kind

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of support or increased support then

they would have a discussion with the

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provider about that and the provider

should initiate a care plan review.

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And, , the other interesting point that

I'll just bring into this here is , during

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these care plan reviews, Particularly if

there's been a significant change, this is

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the point where it might be revealed that

the person might need a package upgrade.

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So if the person's on a level two package,

and that's all they've needed for the

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past one or two years, And perhaps they've

had that fall, they've broken a bone,

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they've got impaired mobility, they've

lost their confidence at this point.

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And if, they're relying more and

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