Standard 2 - Requirement (3) (b)
Assessment and planning identifies and addresses the consumer’s current needs, goals and preferences, including advance care planning and end of life planning if the consumer wishes.
Intent of this requirement
For this requirement, organisations are expected to do everything they reasonably can to plan care and services that centre on the consumer’s needs and goals and reflect their personal preferences. This means:
- considering the consumer’s condition and functional abilities and identifying what help they need to live as well as they can
- listening to and understanding what is important to the consumer and working out how their goals and preferences can be met
- tailoring an approach to fit the consumer’s cultural and personal preferences and how they want to have care and services delivered.
If an organisation can’t meet a consumer’s preferences for care and services, they will need to explain why, so the consumer can understand the reasons and look at other options. This allows the consumer to make an informed decision about their care and services.
Through this requirement, it’s expected that advance care planning and end of life planning happen in line with the consumer’s preference. These conversations are often left too late. It can cause distress for the consumer’s representatives, family and carers and members of the workforce when the consumer’s wishes are unknown. The consequence may be that the consumer does not have the end of life experience they would have wanted.
Where a consumer lacks the capacity to make decisions they may have a court or tribunal-appointed guardian to make decisions on their behalf. When this is the case an organisation needs to manage this according to relevant law and best practice guidance.
- What systems and processes does the organisation use to support a consumer-centred assessment of the needs, goals and preferences of each consumer?
- Does the organisation evaluate whether assessment processes are identifying consumer needs, goals and preferences? Are these documented in a care and services plan?
- How does the organisation access a skilled and qualified workforce to assess and plan care and services, including advance care planning and end of life care planning?
- How does the organisation make sure they give consumers culturally safe and supportive opportunities to talk about dying so they can make their wishes known? How is this done in a way that meets the needs of a diverse range of consumers?
- How does the organisation monitor that a consumer’s assessment and care planning includes the consumer’s social, cultural, language, religious, spiritual, psychological and medical needs?
Examples of actions and evidence
- Consumers say they have been listened to and their care and services are planned around what is important to them, such as their intimate relationships, spirituality and culture.
- Consumers are happy with their care and services plan and feel it covers how they want their care and services delivered.
- Consumers say they didn’t feel judged or uncomfortable when talking about the care and services they need and how they want these delivered.
Workforce and others
- The workforce involved in assessment and planning can describe how it’s undertaken to meet the consumer’s needs, goals and preferences.
- The workforce can provide examples of inclusive care planning which is tailored to meet the particular cultural preferences of consumers from diverse backgrounds.
- Members of the workforce know how to access people with the relevant knowledge or qualifications to provide information to consumers on end of life planning or palliative care if the consumer wishes to include these in their care and services plan.
- Workforce, orientation, training or other records that show how the organisation supports the workforce to identify consumer’s needs, goals and preferences through assessment and care planning and meet this requirement.
- Evidence of strategies, policies and procedures that support a consumer-centred approach to assessment and planning for care and services.
- Policies and processes that describe how assessment and care planning are to be undertaken and the matters to be taken into account, such as the consumer’s need for communication assistance.
- Records of appropriately skilled and qualified members of the workforce being involved in the assessment of a consumer’s needs, goals and preferences.
- Evidence that shows individual, tailored care and services plans are documented for each consumer.
- Policies and processes that provide consumers with opportunities to have safe and supported conversations about death and dying, to make their end of life and palliative care wishes known to the organisation.
- Evidence that there is clear guidance for members of the workforce on decision-making processes when a consumer’s wishes and preferences are not known. This includes wishes that were documented in the past, advance directives, and the role of representatives.