Req 3a - Assessment & Planning

Will Holmes à Court
Will Holmes à Court
Last updated 
Assessment and planning informs the delivery of safe and effective care and services.

Context 
  • This requirement is about making sure that assessment and planning are effective.
  • These processes will support HWH in delivering safe and effective care and services.
  • Relevant risks to a client’s safety, health and well-being must be assessed, discussed with the client, and included in planning a client’s care. 
  • This supports clients in getting the best possible care and services and ensures their safety, health and well-being aren’t compromised.
  • To assess, plan and deliver care and services that are safe and effective, our Clinical Care Managers need to have the relevant skills, qualifications and knowledge to assess individual clients’ needs and to understand their needs, goals and preferences.
  • Where clients have lost their decision making capacity and have an advance care directive in place, we have obligations to access and enact the advance care directive. It should be available at the point of care and shared across service providers.
  • Where a client has requested care or services which may pose a risk to their safety, health or well-being, such as the use of a physical restraint for comfort, HWH are expected to discuss the risks and alternative solutions with the client, so the client can make an informed decision about their care and services. 
  • Arrangements to protect clients require assessment, documentation in care and services plans, informed consent and regular monitoring and review in line with best practice and legislation.
  • When two or more organisations share the care and services for a client, or where there are integrated care and services, arrangements are made to share and combine relevant information. This includes information about any risks to the client’s safety, health and well-being. 
Success Measures
  • The assessment and planning processes to enable clients, their representatives, the workforce and others to work together in developing a safe and effective care and services plan.
  • Use of information from other sources, such as government assessment services, when developing assessment and planning methods.
  • Use of validated risk assessment and planning tools.
  • Inputs from relevant, qualified practitioners about assessing and managing specific and common risks for older people.
  • Inclusion of diseases or conditions such as incontinence, hearing loss or cognitive impairment, high-impact or high-prevalence risks, or the use of restrictive practices.
  • HWH's advanced care planning policy ensures clients use quality and complete statutory advance care directive forms.
  • Efficacy of the assessment and planning processes to result in safe and effective care and services.
  • Monitoring of how effective the care and services plan is in meeting the client’s goals.
Success Indicators
Clients
  • Clients say their care is well-planned to meet all their needs.
  • Clients feel safe and confident because workforce members take the time to listen and understand how to support their health and well-being.
  • Where it applies, clients can give examples of how their care and services plan includes input from relevant practitioners to work out the help they need for day-to-day living activities.
  • Where physical or chemical restraint is in use, clients or their representatives say they have given informed consent, consistent with state and territory law.
  • Clients describe how the workforce took a problem-solving approach to managing or minimising risk or meeting their needs, goals and preferences where a solution wasn’t obvious.
Staff
  • Our staff can describe advance care planning and advance care directives.
  • Evidence that advance care directive documentation informs end-of-life care and decisions.
  • Our staff can describe the assessment and care planning processes and how they inform how care and services are delivered.
  • Our staff can describe how they assess risk and work with clients to minimise risk.
  • Our staff can describe how they can access appropriately skilled individuals or service providers to contribute to assessing and planning safe and effective care.  For example, input into planning for 
    • emotional health and well-being, 
    • clinical and personal care, 
    • continence management, 
    • dietary requirements, 
    • eating aids and assistance, 
    • mobility aids and assistance, and 
    • hearing, visual or communication assistance.
  • Our staff can describe how clients and others who contribute more broadly to care and services (such as medical professionals), work together to deliver a tailored care and services plan and monitor and review the plan as needed.
  • Staff orientation, training or other records that show how HWH supported the staff to meet this requirement.
Organisation
  • Evidence of how HWH ensures the workforce has undertaken advance care planning training and has a policy to inform advance care directive documentation, ensuring documentation is accurate, up-to-date, complete, shared and stored with relevant healthcare providers.
  • Evidence shows that staff members know who is accountable within HWH for assessing, planning and reviewing clients' care and service needs.
  • Records show how staff consider the risk with the client during assessment and planning to ensure safe and effective care and services.
  • Evidence of how HWH ensures workforce assessment and planning skills match the type and complexity of the client’s needs, such as specialised clinical skills or particular cultural skills.
  • Evidence that when validated assessment tools are available (including risk assessments), they are used by the workforce in assessment and planning for clients’ care and services.
  • Evidence of guidance for relevant staff members on undertaking assessment and planning in a culturally safe way, tailored to the needs of each client.
  • Evidence of how assessment and planning processes (and documents) inform safe and effective care and services, including where care and services are shared with other HWH.
  • Evidence of HWH monitoring assessment and planning tools and processes to ensure they are effective and identify and address clients' needs.
  • Records that show how HWH monitors, reports and continuously improves assessment and planning of care and services.