Put in place a system for assessment and planning.

Assessment and planning is an important part of delivering quality care and services. In your system for assessment and planning, make sure you prioritise:

• the older person’s quality of life
• their reablement
• maintaining their physical, mental and cognitive functions.

Making these areas a priority will support you to:

• deliver quality care and services
• create care and services plans that meet the needs, goals and preferences of older people.

Make sure your system includes processes to:

• partner with the older person about who they want involved in their assessment and planning. Use your organisation’s system to identify and guide workers about how to involve the older person and others (such as supporters, family or carers) who the older person chooses to involve in assessment and planning (Outcome 1.3). If the older person lacks the capacity to make decisions, the provider has the responsibility to know and record:
  • who the substitute decision-maker is
  • the types of decisions they are authorised to make on behalf of the person.
• talk with the older person and other people the older person would like involved in their aged care services (Outcome 2.1). This will help workers to understand each older person’s goals of care. It will also help support their quality of life and reablement and to maintain their function. Make sure these discussions are in line with culturally and psychologically safe care principles. This will help to plan and deliver care that is culturally safe, trauma aware and healing informed (Outcome 3.2).
• document the older person’s needs, goals and preferences (Outcome 1.1) in their care and services plan. This includes their:
  • culture, diversity and religious beliefs
  • connection to Country and community. For example, for older people who identify as Aboriginal and/or Torres Strait Islander or live in regional and remote settings.
  • individual background and life experiences
  • language and communication needs and preferences
  • gender identity and sexual orientation
  • decision to share this information, who to share this information with, and their preferences to talk or not talk about their experiences.
• consider risks to the older person’s health, safety and wellbeing. Also include how you and workers can support the older person to manage these risks (Outcome 2.4) and how you will communicate critical information about these risks to workers, supporters and others involved in the older person’s care. This helps you demonstrate preventative care. Do this in partnership with the older person.
• provide the resources and support each older person needs when delivering aged care services. Make sure this information informs the supports what older people need to perform their activities of daily living. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.1 has more information on how you can support older people with activities of daily living. For older people receiving aged care services in a home setting, this could also involve identifying if referrals to other care services or providers may be needed.
• share information (Outcome 2.1). Workers need to inform older people that their own care and services plans are available and accessible to them. Use your information management (Outcome 2.7) and communication systems (Outcome 3.3) to do this.
• involve appropriate registered health practitioners and, allied health professionals and support services where you need to. For example, you may need to involve:
  • a mental health professional if the person has psychological deterioration
  • dementia support specialists if the person has cognitive deterioration
  • a dietician to provide nutrition care in response to identified weight loss (Outcome 5.5).
• make sure care and service plans are accessible and available to workers as well as older people. Workers need to access, refer to and understand care and service plans to guide how they deliver aged care services.
• enable reporting your Quality Indicator data about the quality of care.

Create care and services plans that:

• are individualised and person-centred. Care and service plans need to show the older person’s unique needs, goals and preferences (Outcomes 3.2 and 3.3). This will make sure aged care services are delivered safely and in line with the older person’s needs and preferences. When making care and services plans, consider each older person’s:
  • culture, diversity and religious beliefs
  • individual background and life experiences
  • language and communication needs and preferences
  • gender identity and sexual orientation (Outcome 1.1).
• are comprehensive (Outcome 5.4). Consider each older person’s:
  • individual needs and preferences (Outcome 1.1)
  • goals of care in collaboration with their supporters, registered health practitioners, allied health professionals and others they want to involve in their care (Outcome 5.4)
  • choices so that you can support them in optimising their quality of life, reablement and maintenance of function
  • clinical needs and risks. For example, individual nutrition, hydration and dining needs and preferences (Outcome 6.2).

• consider which registered health practitioners, allied health professionals and services are needed to meet the older person’s clinical needs, with their informed consent. For example, a person may need

  • medical
  • rehabilitation
  • allied health
  • oral health
  • specialist nursing
  • dementia support services. 

  This will help make sure older people receive coordinated, multidisciplinary care (Outcome 5.4)

• are available to older people and people they want involved in their aged care services. This may include the older person’s supporters, family and carers if requested by the older person. You need to share this information in a way each older person understands (Outcome 1.3). This should consider each older person's language and communication needs and preferences (Outcome 1.1). For example, if an older person has a cognitive impairment, workers should support them to understand the information. This needs to be based on each older person’s needs to support their understanding.
• are clear and accessible.

Care and services plans need to be up-to-date and informed by assessments. Review the plans regularly, including:

• if there are changes in the older person’s circumstances. This can include a change to:
  • their needs, goals or preferences (Outcome 1.1). For example, if an older person’s dietary preferences change.
  • their mental health, cognitive or physical function, capacity or condition. This includes if their function, capacity or condition deteriorates, improves or changes (Outcome 5.4). For example, if an older person’s mobility decreases after a fall.
  • their ability to perform activities of daily living. For example, if an older person is no longer able to walk without help.
  • the care that family or carers can provide to the older person
  • the care responsibilities of the people providing aged care services to the older person. This means, if any services or registered health practitioners or allied health professionals involved in the older person’s care and services change. For example, when an older person’s GP retires and they organise a new one, make sure you review and update the person’s care and services plan.
• after an incident (Outcome 2.5). After an incident, document any changes to the care and services plan that are needed.
• if the care and services plan is not reflecting the needs, goals and preferences of the older person. Older people, their supporters, family, carers or others may raise issues through feedback or complaints (Outcome 2.6). Workers may raise issues through established escalation pathways using the information management (Outcome 2.7) and communication systems (Outcome 3.3).
• if risks associated with the delivery of aged care services are identified (Outcome 2.4). Document the risks, any strategies to prevent or reduce risk in the future and how you plan to monitor and assess these strategies. For example, if an older person is identified as being at risk of choking or have difficulties swallowing (Outcomes 5.4 and 5.5), make sure assessments are undertaken to evaluate the risk and documented, and update their care and services plan. Recommendations and strategies to mitigate risk should be individualised to each older person in line with their assessed needs. The care and services plan should also outline when the older person needs to be reassessed and who should do this.
• at transitions of care. For example, when an older person is discharged from hospital or changes from aged care services delivered in a home or community setting to aged care services delivered in a residential care home. The guidance for Outcome 3.4 has more information on coordinating transitions. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.2 has more information on how you can support older people during transitions.
   

Put in place processes for advance care planning.

These processes need to:

• provide information to older people about how they can plan for their future health care if they are not able to make their own decisions
• provide opportunities for the older person to talk about their future medical treatment and care needs, if they choose to. This may include their needs, goals and preferences for their future health care, and their beliefs, cultural and religious practices and traditions (Outcome 1.1).
• support the older person to complete and review advance care planning documents, if they choose to. This may include recording their choices in the required document (or documents). The process of recording choices for advance care planning varies between states and territories. It is important to understand and confirm the relevant state or territory information and forms needed for advance care planning. Workers and registered health practitioners and allied health professionals also need to understand these.
• support the older person to have choices and exercise dignity of risk (Outcomes 1.2 and 1.3). For example, an older person may make the informed decision to not have active treatment for specific illnesses in the future.
• support the older person to nominate and involve a substitute decision-maker for health and care decisions, if and when they choose. Make sure policies and processes for substitute decision-making are in line with your state or territory legislation. The guidance for Outcome 1.3 has more information on supported decision making and the role of substitute decision-makers.
• record occasions where an older person was provided with information about advance care planning, offered an opportunity to discuss advance care planning, or had a conversation about advance care planning
• include systems for storing, managing, using and sharing advance care planning documents securely (including appointments of a substitute decision-maker) with relevant people if needed, including at transitions of care. This makes sure they can be easily accessed and regularly reviewed, while maintaining privacy. Use your information management system (Outcome 2.7) and communication system (Outcome 3.3) to do this. Informed consent should be obtained from the older person to share their information and advance care planning documents (Outcome 1.3).
• explain to older people that, with their consent, their advance care planning documents can be uploaded to My Health Record.
• be integrated with your systems and easily accessible for quality clinical care (Outcome 5.1) where relevant.
   

Make sure workers who provide aged care services have the time, support, resources and skills to plan for and deliver care and services tailored to each older person’s needs and preferences.

Provide workers with guidance and training on how to plan for and deliver tailored aged care services for each older person (Outcome 2.9). This needs to be in line with:

• the organisation’s policies and procedures
• contemporary, evidence-based practice
• workers’ roles and responsibilities.

Make sure workers who deliver aged care services understand how to:

• undertake assessments
• develop care and services plans
• use this information to plan and deliver aged care services tailored to the older person’s needs, goals and preferences (Outcome 3.2).

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Make sure workers can assess and understand care and services plans when they need them. Care and services plans need to be stored in line with your information management system (Outcome 2.7). 
 

Monitor how well your processes for assessment and planning are working.

To check if your assessment and planning processes work well, you can review:

• older people’s aged care services documents (Outcome 3.1). For example, care and services plans, progress notes and advance care planning documents. Check that each older person’s care and services plans include their current needs, goals, and preferences.
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5).

To check how well you are supporting advance care planning in everyday practice, you can undertake advance care planning reviews and assess how you:

• receive, store and manage advance care planning documents
• review, follow and share advance care planning documents with registered health practitioners and allied health professionals
• manage and share advance care planning documents to make sure relevant registered health practitioners and allied health professionals and services have access when needed, such as during transitions of care.

Look for situations where:     

• incidents have happened where the wrong service or care has been provided
• a care and services plan was not reviewed and updated after a change in circumstances
• an older person’s needs, goals or preferences were not documented in their care and services plan or advance care planning documents.

Also, talk with older people, their supporters, families and carers about the aged care services they receive (Outcome 2.1). For example, ask them if they were involved in the assessment and planning process of their aged care services. Ask them if their needs, goals and preferences have been understood and considered in their care and services plan and advance care planning. These conversations can then inform continuous improvement actions and planning (Outcome 2.1).

Assess if workers are following your quality system (Outcome 2.9). You can do this through quality assurance and system reviews.

If you find any issues or ways you can improve, you need to address them. If things go wrong, you need to:

• practise open disclosure (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their supporters and others they may want to involve, such as family and carers.
• put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.