Course Title: Implement goal directed care planning

National Element Code & Title:

CHCCM702B Implement goal directed care planning

Performance Criteria:

1.1Work with client to identify realistic and relevant goals as a basis for care planning
1.2Undertake care planning to address identified goals and in line with needs assessment and document in line with organisation requirements
1.3Undertake consultation with other organisation representatives to plan care in complex situations where multi-organisation involvement is required
1.4Ensure care plan recognises and supports person's strengths and abilities as well as addressing their needs
1.5Recognise and respect person's right to self-determination within legal parameters
1.6Plan care in consultation with the person, their carer/s and family, friends or others involved in advocacy or decision-making on their behalf
1.7Support person to make informed decisions about their care, reflecting understanding of their current situation, probable future situation and ensuing care needs
1.8Investigate range of options available to address client-identified needs and achieve their goals
1.9In conjunction with client, structure a range of services in a manner that supports informal care arrangements such as family support, and support of friends and/or neighbours
1.10Devise alternative strategies to meet identified client needs when specific services are not available
1.11Provide the person with cost details as required and work with them to ensure care plan is within their financial resources
1.12Identify work health and safety (WHS) risks and plan for their management
1.13Write care plan and clearly identify all work tasks and who is to perform them

Performance Criteria:

2.1Seek and obtain person's consent before undertaking any referrals
2.2Provide person with clear understanding of available services and choices, so they are an informed participant in all stages of care planning
2.3Work in collaboration with appropriate professionals and organisations to ensure services are provided in a manner that maximises person's potential for achieving their goals and addresses identified needs
2.4Ensure planning clearly articulates roles and responsibilities of each service provider, including coordination role/s
2.5Maximise involvement of client and carer/s in care planning processes and decision-making
2.6Ensure effective involvement of relevant health/ community services professionals in care planning where clients have chronic or complex needs
2.7Establish and maintain communication strategy and processes to ensure effective implementation of care plan
2.8Ensure mechanisms are in place to support sharing of information between organisations and maintenance of updated information to all involved organisations
2.9Support and develop person's ability to independently access alternative resources to ensure their needs are addressed in an appropriate manner

Performance Criteria:

3.1Regularly monitor planned services, support and resources against client-identified goals to ensure effective implementation of their care plan
3.2Ensure appropriate level of rapport and communication with client is maintained as required to support disclosure of information regarding delivery of services and resources in line with care plan
3.3Maintain collaborative relationships with clients, carers and other service providers to support people with complex needs
3.4Promptly identify problems with implementation of care plan and make adjustment as necessary to best meet person's needs
3.5Document and report any variations to care plan in line with organisation requirements and communication strategy

Performance Criteria:

4.1Respond appropriately to informal monitoring of health and well being of the person and/or their carer by volunteers, carers or family
4.2Undertake regular and systematic reviews to ensure assessed needs of clients are being addressed effectively
4.3Use regular reviews to re-prioritise client needs for service and to ensure equitable access based on ongoing appraisal of prioritised needs
4.4Contribute to adjustments in care plan in response to changes in client or carer health; review of risk management/WHS needs; or as specified in person's care plan or as required by personal circumstances

Performance Criteria:

5.1Ensure care planning for CALD and Aboriginal and Torres Strait Islander clients is culturally sensitive
5.2Ensure appropriate interpreter support is provided in line with organisation protocols
5.3Where appropriate, work in conjunction with ethno-specific and multicultural organisations and with Aboriginal and Torres Strait Islander communities and organisations
5.4Recognise and support the role of these organisations in linking their communities into the service system
5.5Where appropriate involve Aboriginal and Torres Strait Islander community and/or organisation representatives in the care planning process

Performance Criteria:

6.1Facilitate access to assessment for people with different levels of need including those in complex circumstances and identified as having high levels of need
6.2Maintain and promote inter-organisation relationships and agreements as appropriate to address client, family and carer needs
6.3Ensure care planning builds on person's strengths and motivation to improve their quality of life

Performance Criteria:

7.1Undertake periodic evaluation of care planning based on analysis of outcomes
7.2Obtain information from clients, carers, families and other service providers to determine progress and evaluate against identified goals in care plan
7.3Take into account adjustments made to services and resources to better address person's ongoing situation and changing needs
7.4Ensure evaluation includes determination of client satisfaction, comparison of costs against benefits received and assessment of quality and effectiveness of service delivery and case management components
7.5Work with person to evaluate ongoing support needs to meet their goals, including review of parameters for disengagement, where applicable
7.6Demonstrate accountability for adjustments to the care plan and associated financial outcomes
7.7Identify opportunities for person to maintain or develop independence within any aspects of their overall care
7.8Document and report quantifiable impacts experienced by person as a result of implementation of care plan and indicate how client-centred outcomes have been achieved

CHCCM702B: Implement goal directed care planning (E1, E2, E3, E4, E5, E6 and E7)

CHCCM703A: Apply effective case management practice. (E1, E2, E3, E4, E5, E6)

None required