Overview

Responsibilities

• Ensuring that all employees involved in developing and implementing new or updated Care Plans are appropriately trained and kept up to date with government policies, guidelines, legislation, relevant professional standards, organisational policy, and procedural requirements.
• The provision of adequate resources for appropriate staff to enable the timely and comprehensive assessment of the client’s needs
• Upholding and maintaining accountability to funding bodies and individuals for their contractual obligations for a client’s service, as documented in the Care Plan, including facilitation of the appropriate sharing of information
• The development, delivery and review of employee training of the Care Plans.
• Training of all CCMs in the development and review of Care Plans.
• The Care Plan will contain the client-specific information in a language and style appropriate for use by carers, enabling care provision in the nominated environment where assistance is required.

• The accuracy of the information supplied to HWH CCMs concerning their health and support needs for developing their Care Plan.
• Ensuring that the Care Plan is read, understood and agreed 
• Advise changes and/or alterations to their health.
• HWH will ensure that services documented in the client-specific Care Plan are planned and delivered promptly to meet the client’s physical, emotional, spiritual and social needs, optimising the client’s independence and participation.

• Maintaining a high level of client knowledge to ensure the timely and accurate development and review, in collaboration with clients and other relevant stakeholders, of a Client Support Plan.
• Upon commencement of services, the timely completion of the Care Plan and supporting documents [in hard and electronic versions].
• Providing, as required, Allied Health Professional’s Health Care Plan[s].
• Ensuring documented evidence of communications with the HWH client and/or their representative, HWH staff and the client’s Funding body[s] if any.
• Ensuring the Care Plan from other Agencies can be utilised and implemented within reasonable timeframes and with timely consent by the HWH Clinical Manager.
• Determining the appropriateness of Carer knowledge and skills required to meet the HWH client’s support needs per the Care Plan.
• Developing appropriate HWH documentation/records for HWH clients when appropriate.
• Acting upon reported changes and/or alterations to the client's health or service results in facilitating an immediate or ongoing review [s] of the client’s Care Plan in a practicable, reasonable and timely manner.
• Undertaking a comprehensive assessment of the client’s health care needs before the commencement of service.
• Ensuring the provision of Allied Health Professional’s required Health Care Plan [s] for the client’s Care Plan.
• Assist in determining the Carer competencies required to meet the client's specific health needs per the individualised Care Plan.
• Ensuring Carers have been trained, assessed, and deemed competent to undertake client-specific health care procedures, Following the client’s Care Plan.
• Acting upon reported changes and/or alterations to the client’s health that result in immediate or ongoing review [s] of the client’s Care Plan in a practicable, reasonable and timely manner.

• Reading and following Care Plan instructions on the CMS.
• Contacting CCM's to report the absence of a client’s Care Plan
• Reporting, verbally and in writing (CMS Shift Notes) to the CCM if there are concerns, issues or uncertainties concerning the information and instructions contained within the Care Plan
• Seeking assistance from CCMs, if unsure about any duties or tasks they must undertake to meet the individual client’s support needs as documented in the Care Plan.
• Adhering to all the advice and instructions given by HWH.

1. Initial assessments will occur for each newly referred client. The Assessment Form will be used for initial assessments before formally developing the client’s Individual Care Plan.
2. When a client or their representative nominates HWH as their provider, the client and/or their representative will enter into collaborative and cooperative communication to develop an agreed Care Plan.
3. HWH will utilise a consultative process to meet each client's specific individualised support needs, based on an assessment carried out by the HWH CCM/Registered Nurse – along with any or all Health Care Plans contributed by Medical / Allied Health Professionals. 
   • The consultative process will include collecting client-specific information: including but not exclusive to the specific client’s strengths, support needs, special needs and preferences.  This will ensure that the Care Plan remains consistent with the client’s individual support needs and lifestyle choices and reflects the services provided by HWH.
   • Within this consultative process, privacy and confidentiality will be respected and discussed with the client and/or their representative, and the Care Plan Agreement Form will be signed accordingly.
   • The formulation of the Care Plan will vary according to the level of care required but may, but not limited to the inclusion of:-
     • Client Details 
       • Family/Social Supports, 
       • Living Arrangements and access, 
       • Medical/Allied Health
       • Disability/Health Information including relevant health/medical history, Allergies
     • Medication 
     • Diabetes Care 
     • Asthma Care 
     • Seizure Care 
     • Behaviour Care 
     • Anaphylaxis Care 
     • Communication 
     • Mobility 
     • Transfers 
     • WHS Guidelines
     • Falls Guidelines 
     • Personal Hygiene and Skin Care Plan, Dressing and Grooming
     • Nutrition 
     • Oral Intake 
     • Bladder Plan
     • Bowel Care
     • Shopping/Bulk Cooking Plan
     • Meal management
     • Shift Routine
     • Respite Plan
     • Accommodation Plan
     • Palliative Plan
     • Recreation Plan
     • Independent Living Skills Plan
     • Mentoring Plan
   • HWH will respect and reflect the client's cultural and spiritual needs and will access translating services and culturally specific advocacy agencies when appropriate or required. 
   • The Care Plan will include Workplace Health and Safety issues and specific manual handling needs. It will also reflect hazards and risks and any safety/control measures that have been put in place. As far as practicable, these will be determined with input from the client and/or their representative, the support workers, and the CCM.
   • The Care Plan will be reviewed at twelve [12] month intervals for adults and children or whenever the Client’s support needs change.
   • The authorised Care Plan [with amendments and/or accompanying documents] remains the property of HWH. Intended for use by HWH carers for the specific client for whom it is developed
   • Must remain in the environment in which HWH carers provide support.
   • Hard and electronic copies remain in the HWH office.
   • If other agencies are involved with the client, HWH may negotiate with management approval and share relevant information to provide optimum care.
   • All care plans must be endorsed (signature and date)

• Care Plan Template 
• Initial Assessment Template
• Incident Report Form
• Hazard Report Form
• Care Plan Agreement forms
• Confidentiality and Privacy form
• Client Home WHS Assessment Form Procedures