How your care plan informs the services and support for in home care
When receiving co-ordinated 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 or dental conditions that need to be addressed? Can the package fund purchases that will help relieve these conditions? Think Obstructive Sleep Apnoea and a CPAP machine or dysphagia and purchasing thickening powder for fluids.
Any medical practitioner support that is not already subsidised by a Government program (think Medicare) or your private health insurance may qualify for expenditure from your home care package funding.
- Any cognitive impairment? Does a daily drive or outing help alleviate sundowning? 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. 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. Prescription for continence aids and wound care products.
- Physiotherapy for management of pain or massage therapy.
- Dietician for dietary intolerances or unintended weight loss or malnourishment. Suggest dietary supplements.
- Speech pathology for issues with communication or swallowing. Assistive devices for communication could be considered.
- An assessment with an Occupational Therapist to review the home and ensure any modifications are considered, such as grab rails, shower benches, an over toilet frame, bed stick, mobility aids and any devices to assist in the kitchen, such as a kettle tipper.
- Exercise physiology for a personalised program of strength and balance. Is group exercise or one on one appropriate?
- Any complimentary therapies including Reiki, reflexology, naturopathy or massage.
- Does the older person need social support or personal care?
- Is the older person able to drive, shop, prepare meals or manage finances independently?
- What services are needed in the maintenance of the house (cleaning, gardening, etc)? Cleaning the airconditioners, a Spring clean of the home, water blasting mouldy paving or mowing, mulching or pruning.
- Would the older person like to be involved in group social events?
- Consideration for a falls detecting alarm or a key lock box to enhance safety within the home.
- What other aspects specific to the older person should be considered?
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.
You can check out our overview of this service here, or send us a query via the form below.
Some useful links
We published a series by Coral Wilkinson on Carers’ Circle – Getting started with home care. The links to these useful articles are listed below:
How do I get started with aged care services? https://carerscircle.com.au/2022/01/12/how-do-i-get-started-with-aged-care-services/
How do you get your ageing parent to accept help? Turn resistance into acceptance https://carerscircle.com.au/2022/01/12/ageing-parent-accept-help/
What to think about before contacting My Aged Care – https://carerscircle.com.au/2022/01/12/what-to-think-about-before-contacting-my-aged-care/
Registering for aged care services with My Aged Care – https://carerscircle.com.au/2022/01/12/registering-for-aged-care-services/
Other useful links include:
See Me Aged Care Navigators – experts in navigating the home care space to make sure your loved one gets the optimal service and support tailored to their needs – https://www.seemeacn.com.au/
Australian Federal Government website to access all aged care services – My Aged Care – https://www.myagedcare.gov.au/ This is where you register for an assessment to access most government-subsidised aged care services. Please do your research and plan and prepare before you make your call to register your parent. Check out the site, the services available etc. Think about your parent’s situation, what they need etc.
Carers’ Circle article on accessing aged care services – with an ACAT assessment – https://carerscircle.com.au/2019/02/17/how-to-access-aged-care-services/
A version of this article “What is a care plan?” originally appeared on Coral Wilkinson’s See Me Aged Care Navigators website, written by Michelle Brown. Reproduced with permission.