HWH clients are partners with us in ongoing assessment and planning that helps them get the care and services they need for their health and well-being.
Assessment & Planning
Statement
HWH undertakes initial and ongoing assessment and planning for care and services in partnership with the client.
Assessment and planning focus on optimising health and well-being per the client’s needs, goals and preferences.
Legislative Requirement That HWH demonstrates the following:
Assessment and planning, including consideration of risks to the client’s health and well-being,
informs the delivery of safe and effective care and services;
identifies and addresses the client’s current needs, goals and preferences, including advance care planning and end-of-life planning if the client wishes;
is based on ongoing partnership with the client and others that the client wishes to involve in the assessment, planning and review of the client’s care and services; and
includes other organisations, individuals and providers of other care and services involved in the client's care.
The outcomes of assessment and planning are effectively communicated to the client and documented in a care and services plan that is readily available to the client and where care and services are provided;
Care and services are reviewed regularly for effectiveness and when circumstances change or when incidents impact the client's needs, goals or preferences.
Purpose & Scope
Standard 2 builds on the foundations of Standard 1 and includes the requirements for HWH to work in partnership with our clients.
This Standard describes what HWH needs to do to plan care and services with clients.
The planned care and services should meet each client’s needs, goals and preferences and optimise their health and well-being.
While a client might have some challenges with their health and abilities, they still have goals they want to achieve, roles that have meaning and want to live as well as they can.
This means HWH must listen to what the client wants and look at what we can do (their abilities).
HWH can then focus on planning care and services to ensure that our clients can still get to where they need to go, do what they need to do and have opportunities for participation and growth.
The plan needs to be regularly reviewed so that changes in a client’s health or abilities are picked up, and care and services are identified and put in place to minimise the impact of the loss of ability and support clients to live their day-to-day lives with dignity.
The level of assessment and planning will depend on the level of care and services HWH is providing and the risks of delivering care and services for the client.
For example, an HWH providing weekly cleaning services to a client in their home would need less assessment and planning than an HWH providing residential aged care services.
An appropriately skilled and qualified workforce is expected to undertake assessment and planning.
Assessment and planning undertaken should be in addition to and complement any Aged Care Assessment Team or Regional Assessment Service assessments.
Assessment and care planning is expected to provide access to advance care planning, including the completion of legally binding advance care directives and end-of-life planning if the client wants this.
We need to document the outcomes of assessments and discussions with the client in a care and services plan and set an agreed review date.
Care and services plans may include advance care planning, directives, and end-of-life planning documents.
The plan should be available to the client and those providing care to the client.
It also needs to be updated on an ongoing basis as the client’s needs, goals, or preferences change and after any transition between services.
In line with Standard 1, it’s expected that when planning or making changes to care and services plans, clients are given options and helped to make informed decisions.
This includes how much clients want to manage these options themselves.
Assessment/Audit For each of the requirements, HWH needs to demonstrate that we:
understand the requirement
apply the requirement, and this is clear in the way they provide care and services
monitor how we are applying the requirement and the outcomes we achieve
review outcomes and adjust their practices based on these reviews to keep improving.
Related Documents
Aged Care Act 1997 (Cth), User Rights Amendment (Charter of Aged Care Rights) Principles 2019
PrivacyAct1988(Cth),Schedule1, Australian Privacy Principles
State and Territory privacy and health records legislation
State and Territory work health and safety legislation
State and Territory mental health, guardianship and administration, enduring power of attorney and medical directive/advance care planning legislation Advance Care Planning Australia
Cognitive Decline Partnership Centre (2018). Supported decision-making in aged care: A policy development guideline for aged care providers in Australia. (2nd edition)
Council of the Ageing (2017). HomeCareTodayResources3
End-of-Life Directions for Aged Care Resources
Palliative Care Australia (2018). National Palliative Care Standards (5th edition)
Palliative Care Australia (2017). PrinciplesforPalliativeandEnd-of-LifeCare in Residential Aged Care
Victorian Government, Department of Health, Participating with clients' information sheets
World Health Organisation (2017). WHOIntegratedcareforolderpeople: guidelines on community-level interventions to manage declines in intrinsic capacity
