Outcome statement
The provider demonstrates that the provider understands that the safety, health, wellbeing and quality of life of individuals is the primary consideration in the delivery of funded aged care services.
The provider demonstrates that the provider understands and values individuals, including their identity, culture, ability, diversity, beliefs and life experiences.
The provider demonstrates that the provider develops funded aged care service with, and tailored to, individuals, taking into account their needs, goals and preferences.
Actions
The way the provider and aged care workers engage with individuals supports them to feel safe, welcome, included and understood.
The provider implements strategies to:
a) identify the individual background, culture, diversity, beliefs and life experiences as part of assessment and planning and uses this to direct the way their funded aged care services are delivered
b) identify and understand the particular communication needs and preferences of the individual
c) ask and record if an individual identifies as an Aboriginal or Torres Strait Islander person
d) deliver funded aged care services that meet the needs of individuals with specific needs and diverse backgrounds, including Aboriginal or Torres Strait Islander persons and individuals living with dementia
e) deliver funded aged care services that are culturally safe, trauma aware and healing informed, in accordance with contemporary, evidence-based practice
f) support individuals to cultivate relationships and social connections, including for individuals who identify as Aboriginal or Torres Strait Islander persons, connection to community, culture, and Country and Island Home
g) continuously improve its approach to inclusion and diversity.
The provider and aged care workers recognise the rights, and respect the autonomy, of individuals, including their right to intimacy and sexual and gender expression.
Aged care workers have professional and trusting relationships with individuals and work in partnership with them to deliver funded aged care services.
Why is this outcome important?
Outcome 1.1 explains providers’ obligations to deliver person-centred care. Outcome 1.1 is relevant to, and supports, all other standards. To meet Outcome 1.1, providers and workers need to understand each older person so they can deliver person-centred care.
Person-centred care makes sure the care older people receive is tailored to their individual needs, goals, and preferences by placing them at the centre of all services and decisions made by providers. Person-centred care respects each older person as a unique individual and is a key part of what it means to value an older person. It makes them central to the planning and delivery of their care. Providers need to partner with older people and understand their needs to deliver quality care and services.
Supporting older people’s independence is incorporated in Outcome 1.1. It now means more than respecting older people’s rights to make decisions about their own care. This outcome focuses on the provider making sure they have systems and processes that support older people, their supporters and others they may want to involve, such as family and carers, to shape how their funded aged care services are delivered. This involvement is essential for person-centred care.
Partnerships and personal relationships are at the centre of Outcome 1.1. Partnering with older people means working closely with them to develop and review their aged care services plans. This makes sure that you deliver care in a way that meets their individual needs, goals and preferences. Partnerships help build trust and make sure that care is person centred.
Providers need to have processes to support culturally safe care. This acknowledges and respects the diverse backgrounds, identities and beliefs of older people. Aged care services should be tailored to each older person's cultural, spiritual, religious and social needs. This will help to make sure the care they receive is respectful and meaningful to them. Diversity is a key focus of Outcome 1.1. It highlights how important it is to recognise and support individual differences and needs.
A stronger focus on trauma aware and healing informed care, recognises that many older people have experienced trauma at some point in their lives. This can significantly affect their quality of life and wellbeing. Being aware of these experiences helps you to provide care that is trauma aware and healing informed. Outcome 1.1 makes sure aged care services meet the older person’s physical needs and also supports their emotional and psychological wellbeing.
Providers need to offer accessible, culturally safe, trauma aware and healing informed care and services based on the older person’s needs, goals and preferences, regardless of their location, background and life experiences. This may include older people who:
- are Aboriginal or Torres Strait Islander persons, including those from stolen generations
- are veterans or war widows
- are from culturally, ethnically and linguistically diverse backgrounds
- are financially or socially disadvantaged
- are experiencing homelessness or at risk of experiencing homelessness
- are parents and children who are separated by forced adoption or removal
- are adult survivors of institutional child sexual abuse
- are care-leavers, including Forgotten Australians and former child migrants placed in out of home care
- are lesbian, gay, bisexual, trans/transgender or intersex or other sexual orientations or are gender diverse or bodily diverse
- are an individual with disability or mental ill-health
- are neurodivergent
- are deaf, deafblind, vision impaired or hard of hearing
- live in rural, remote or very remote areas.
You need to give focus to:
- valuing the individual needs and preferences of older people
- supporting the safety and wellbeing of older people
- creating professional and trusting relationships with older people.
Providers need to have effective strategies to place each older person at the centre of their aged care services. For providers delivering aged care services in a home or community setting, this involves acknowledging each older person’s background, culture, diversity, beliefs and life experiences, and using this to guide the delivery of person-centred care specific to their unique home setting. Providers also need to make sure all workers (including associated provider workers sub-contracted to deliver services on the provider’s behalf) understand their roles and responsibilities in adapting a person-centred approach when engaging with older people.
What are needs?
Needs are the essential requirements or conditions that must be addressed to optimise the older person's health, safety and wellbeing. These may include medical treatment, assistance with activities of daily living, social support and specialist health services.
What are goals?
Goals, also known as goals of care, are the clinical and personal outcomes the older person wants to achieve when they receive aged care services. Goals are set collaboratively with the older person, their supporters and others they may want to involve such as family and carers, registered health practitioners and allied health professionals involved in their care, through a shared decision-making process. Shared decision-making involves discussion and collaboration between an older person and their health or aged care provider. It is about bringing together the older person’s values, goals and preferences with the best available evidence about benefits, risks and uncertainties of treatment, in order to reach the most appropriate care decisions for that person. Goals may focus on optimising the older person's quality of life, reablement and maintenance of function, or addressing personal preferences.
What are preferences?
Preferences are the things the older person chooses, likes or dislikes when it comes to their care, services and lifestyle. It’s the way they like or wish for their aged care services to be delivered. These may include preferred types of care (such as in a home, community setting or in a residential care home), treatment options, daily routines and activities they want to do.
Key tasks
Providers
Providers
Put in place strategies that support tailored care for each older person.
Partner with older people when developing and reviewing their care and services plan (Outcome 3.1). Include in the plan how your aged care and services are going to be tailored and safe for the older person. This includes identifying, documenting and accommodating each older person’s:
- background
- gender identity, such as gender diverse or transgender
- sexual orientation
- culture and beliefs
- language and communication needs and preferences
- life experiences. It’s important to try and understand each older person's life experiences and how this can affect them. A life experience can be a single event at a particular time or a long period in an older person's life. Life experiences can include family, friends, career, meaningful activities and trauma.
Keep in mind an older person’s diversity when considering daily activities like food preferences (Outcome 6.2) and community-based activities (Outcome 7.1). If the older person identifies as Aboriginal and/or Torres Strait Islander, you need to record this information with their consent (Outcome 2.7). If an older person has a diverse background, tailor their care and services plan to make sure that their aged care and services are respectful and safe:
- spiritually
- socially
- emotionally
- culturally
- physically.
It’s important to make sure you respect older people’s privacy through this process (Outcome 1.2).
Identify if the older person is vulnerable. For example, an older person may be more at risk if they:
- live on their own
- live in rural or remote areas without many service options
- are socially isolated or don’t have close relationships
- have few or no family or friends who ‘check in’ on them
- have a cognitive impairment and might have difficulty problem solving or advocating for themselves
- have difficulty communicating or expressing themselves
- have a history of complex trauma
- are not very mobile
- show clinical frailty
- are dependent on their carer or only have one carer.
Make sure their care and services plan explains how you will address these circumstances and needs. Do this in partnership with the older person, their supporters and others involved in their care and services with their permission.
Make sure older people receive quality care and services based on their care and services plan. This includes any clinical care, palliative care and end-of-life care (Outcomes 3.2, 5.4 and 5.7).
Deliver aged care and services that:
- meet older people’s needs, goals and preferences. For example, for older people living in a residential care home, make sure food, drinks and the dining experience meet their needs and preferences (Outcomes 6.2, 6.3 and 6.4).
- improve people’s quality of life
- help people to do what they want to do. For example, if an older person wants to go for a daily walk but is finding this difficult because of their health, look at how care and support can help them achieve their goals and move safely. This could include allocating a worker to assist or supervise the older person, providing mobility aids such as a four-wheel walker, or offering a wheelchair for part or all of the walk.
- help older people to maintain and improve their physical, mental and cognitive function by encouraging them to use their skills and strengths. In some cases where older people have experienced a loss or reduced function, getting function back may not be possible. If this is the case, aged care and services should help them to maintain their current function. The guidance for Outcomes 3.1, 3.2 and 5.4 has more information on how you can support older people’s reablement and maintenance of function.
- meet older people’s cultural needs and preferences, are culturally safe, responsive and suitable for older people with diverse backgrounds (Outcome 3.2).
- are trauma aware and healing informed. Make sure that workers understand different types of trauma and how this can affect older people. Older people may have past experiences of trauma that aren’t included in the care and services plan or that the older person doesn’t want to share. The older person may show signs that they have past experiences of trauma. Workers should be aware of these signs and deliver trauma aware and healing informed care. Make sure trauma aware and healing informed care is part of your systems and processes.
- recognise the rights and autonomy of older people. This includes their right to intimacy, sexual and gender expression.
- are informed by contemporary, evidence-based practices.
- help older people to develop relationships and social connections. Older people who identify as Aboriginal and/or Torres Strait Islander may need extra support to stay connected with community, culture, Country and Island Home. For providers delivering aged care services in a residential service providerscare home, the guidance for Outcome 7.1 has more information on how you can help support older people with their daily living.
- match what you have agreed to with the older person during assessment and planning. They also need to be included in their care and services plan (Outcome 3.1).
Partner with older people to deliver quality care and services (Outcome 2.1). Make sure they:
- receive critical information about their aged care services (Outcome 3.3). Find out the older person’s language and how they need and prefer to be communicated with. Provide them with information in their language and that meets their communication needs and preferences. Include critical information in care statements.
- receive planned and coordinated care and services (Outcome 3.4). This includes where there are multiple health and aged care providers, supporters, family and carers involved in delivering aged care services, such as during transitions of care. This may include hospital-in-the-home arrangements where an older person receives acute care in either their home or residential care home. During transitions of care, you are responsible for making sure there is effective communication processes, and the older person receives continuity of care. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.2 has more information on how you support older people with transitions.
There may be situations where an assessment of an older person’s care needs are beyond what you are required to deliver to them under your legislative obligations and registration conditions. You are at all times expected to partner with the older person, registered health practitioners and allied health professionals to support them to access the aged care and services they need. You should be clear in your communication about what can and cannot be provided as part of your agreement to provide care in line with your legislative obligations.
Outcome service context
Put in place strategies that support tailored care for each older person.
Deliver aged care services that:
- meet older people’s needs, goals and preferences. For example, for older people receiving aged care services delivered in a residential care home, make sure food, drinks and the dining experience meet their needs and preferences (Outcomes 6.2, 6.3 and 6.4).
- For older people receiving aged care services delivered in a home or community setting, activities of daily living should be tailored to their specific needs, goals and preferences associated with living at home. This supports the older person to remain independent and live in their own home for as long as possible. For example, a provider delivering aged care services in a home or community setting is required to provide an older person with allied health and other therapeutic services to assist the older person in regaining, maintaining or improving their mobility, if this is an assessed need. This could include interventions, mobility aids, treatment programs or home modifications as prescribed by appropriate allied health professionals to support the older person in remaining safe and independent at home.
Make sure workers have the time, support, resources and skills to plan for and deliver safe, quality and person-centred care
Provide your workers with guidance and training on how to deliver safe, quality and person-centred care for each older person (Outcome 2.9). This needs to be in line with:
- the workers’ abilities and qualification
- the organisation’s policies and procedures
- contemporary, evidence-based practice
- the workers’ roles and responsibilities.
Make sure workers understand how to:
- create professional and trusting ongoing relationships with older people
- tailor aged care services to each older person’s needs, goals and preferences
- deliver care that is culturally safe, trauma aware and healing informed.
The guidance for Outcome 2.8 and Outcome 2.9 has more information on workforce planning and worker training.
Outcome service context
Make sure workers have the time, support, resources and skills to plan for and deliver safe, quality and person-centred care.
Providers need to make sure workers have access to accurate and current information about each older person they are providing care to. This will help them to deliver safe, quality and tailored care. For providers delivering aged care services in a home or community, this could include information about the older person’s home environment, who lives with them, what outside family support they have, and what aged care services they receive.
Providers delivering aged care services in a home or community also need to have systems and processes to make sure workers, including associated provider workers, always have access to accurate and current information about the older person relevant to the service they’re delivering. This will support them to deliver tailored care and services in line with the older person’s care and services plan.
Monitor how you plan for and deliver aged care and services to make sure older people’s needs, goals and preferences are at the centre all services and decisions you make.
To check if you’re providing tailored care for each older person, you can review:
- each older person’s care and service documents. For example, care and services plans and progress notes (Outcome 3.1).
- complaints and feedback you’ve received (Outcome 2.6a and 2.6b)
- information about incidents and near misses in connection with the delivery of aged care services (Outcome 2.5).
Look for situations where:
- older people have not felt safe, welcome, included or understood
- you haven’t met an older person’s communication needs and preferences
- you have delivered aged care services in a way that isn’t culturally safe, trauma aware or healing informed
- you or your workers haven’t respected or recognised an older person’s rights or autonomy.
Also, talk with older people, their supporters, families and carers about the aged care services they receive. Ask them if there are any services that they’re not currently receiving that they would like to. 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 through your reviews and assessments, you need to address them. If things go wrong, you need to:
- practise open disclosure. 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 and open disclosure.
Further resources about this outcome can be found on the Commission's Quality Standards Resource Centre.
