Standard 2 - Requirement (3) (C)
Assessment and planning:
i) is based on ongoing partnership with the consumer and others that the consumer wishes to involve in assessment, planning and review of the consumer’s care and services; and
ii) includes other organisations and individuals and providers of other care and services, that are involved in the care of the consumer
Intent of this requirement
For this requirement, it’s expected that an organisation will carry out ongoing assessment and planning with the consumer their representatives and others who the consumer wants to involve in assessment and planning of their care and services.
Partnering involves ongoing sharing of information, asking for feedback from the consumer, and supporting and encouraging consumers to take part in assessing and planning their own care and services. This approach recognises that making decisions about their own life, and having those decisions respected, is an essential right of each consumer, improves their health and well-being and shows the organisation values the consumer.
The consumer can decide to be involved as much or as little as they want to be in the assessment and planning process. A consumer may choose to involve others as representatives in making their decisions. For example, the consumer may choose to have a relative, partner, or friend as a representative involved in decisions about their care. Where a consumer lacks the capacity to make decisions they may have a court or tribunal-appointed guardian to make decisions on their behalf.
Assessment and planning are also expected to include other organisations, individuals or service providers involved in caring for consumers. This requires effective communication with other service providers. Consumers may also be receiving care and support from unpaid carers, such as family and friends. These people may have been supporting the consumer over a period of time, before they accessed care and services. Involving them in assessment and planning (if the consumer wishes) can help the organisation to get to know the consumer’s needs, goals and preferences and help continuity of care and services for the consumer.
Organisations will need to comply with obligations relating to privacy of information when coordinating care with other organisations, individuals or service providers.
- Do the organisation’s policies guide the workforce in how to involve, listen to, and respect the views of the consumer and how to include them as much as possible in planning their care and services?
- Does the organisation guide the workforce on how to involve others (such as family or other carers) in a consumer’s assessment and care planning if the consumer wants to assign some or all of, their care and services planning to others?
- How does the organisation support consumers who need help with communicating to take part in planning their care and services?
- How do the organisation’s practices encourage consumers to tell the organisation when their needs, goals and preferences have changed? How does the organisation respond when this happens?
- What systems does the organisation have in place to identify other organisations, individuals or service providers that are involved in the care of the consumer, or should be involved in their care? (To be able to meet the needs, goals and preferences of the consumer.)
- How does the workforce involve the consumer’s medical practitioner and other preferred service providers, such as those providing dental care, hearing aids or glasses?
- How does the organisation bring together those involved in a consumer’s care (including other organisations, individuals and specialist service providers) to talk about and coordinate care and service delivery and to make sure the consumer’s care and services are seamless and focused?
- If an organisation can’t meet all of the consumer’s expectations, how do they communicate this to the consumer? How does the organisation support a consumer’s access to other service providers?
Examples of actions and evidence
- Consumers say they are actively involved in the assessment, planning and review of their care and services. They can describe their care and services plan and how it helps them to meet their goals.
- Consumer representatives (including carers) say they are actively involved, with the consumer’s consent, in the assessment, planning and review of care and services.
- Consumer representatives (including carers) say the organisation makes it easy for them to be involved in the assessment, planning and review of the consumer’s care and services.
- Where a number of organisations provide care and services, the consumer says the organisation has helped them to understand how they fit together. And they know which organisation is responsible for different aspects of their care and services, and who to contact in different situations.
- Consumers say their assessment and care planning is coordinated and they are satisfied the right people are involved.
Workforce and others
- Members of the workforce can describe what it means to partner with consumers to assess, plan and review care and services.
- The workforce and others delivering care and services describe how they work collaboratively.
- Management can describe innovative and effective ways they have coordinated care and services for consumers where the organisation itself has been unable to meet a consumer’s needs, goals or preferences.
- Members of the workforce who share information about consumers with other organisations, individuals or service providers describe how they meet obligations relating to privacy of information when coordinating care.
- Workforce orientation, training or other records that show how the organisation supports the workforce to meet this requirement.
- Evidence of consumer information and support to help consumers take part in assessing and planning their care and services.
- Evidence that information and resources are available in appropriate formats and language translations to help consumers partner in assessment and planning.
- Clear lines of workforce responsibility for the assessment, planning and review of care and services plans and what each element involves.
- Evidence the skills and qualifications of the workforce are appropriate for the type and complexity of the assessment and planning of care and services being undertaken.
- Resources and tools that support shared decision-making for care and services planning.
- Care and services plans for consumers show integrated and coordinated assessment and planning involving all relevant organisations, individuals and service providers.
- Evidence of arrangements or agreements with those outside the service involved in planning care and services, to meet the consumer’s needs, goals and preferences.