Course Title: Implement goal directed care planning

Part B: Course Detail

Teaching Period: Term1 2015

Course Code: HWSS5716C

Course Title: Implement goal directed care planning

School: 365T Global, Urban & Social Studies

Campus: City Campus

Program: C0045 - Vocational Graduate Certificate in Community Services Practice(Client assessment & case management)

Course Contact : Bronwyn Tanti

Course Contact Phone: +61 3 9925 9079

Course Contact

Name and Contact Details of All Other Relevant Staff

Nominal Hours: 75

Regardless of the mode of delivery, represent a guide to the relative teaching time and student effort required to successfully achieve a particular competency/module. This may include not only scheduled classes or workplace visits but also the amount of effort required to undertake, evaluate and complete all assessment requirements, including any non-classroom activities.

Pre-requisites and Co-requisites

None required.

Course Description

This course describes the knowledge and skills required to plan care for clients through provision of services and resources aimed at maximising and enhancing their independence and quality of life. This course may apply to work in a range of community sector contexts where high level care planning skills and knowledge are required.

National Codes, Titles, Elements and Performance Criteria

National Element Code & Title:

CHCCM702B Implement goal directed care planning


1. Undertake care planning to address identified client needs and goals

Performance Criteria:

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


2. Implement care plan in conjunction with relevant others

Performance Criteria:

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


3. Monitor implementation of client care plan

Performance Criteria:

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


4. Undertake review of care plan

Performance Criteria:

4.1 Respond appropriately to informal monitoring of health and well being of the person and/or their carer by volunteers, carers or family
4.2 Undertake regular and systematic reviews to ensure assessed needs of clients are being addressed effectively
4.3 Use regular reviews to re-prioritise client needs for service and to ensure equitable access based on ongoing appraisal of prioritised needs
4.4 Contribute 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


5. Respond appropriately to diversity

Performance Criteria:

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


6. Respond appropriately to people with different levels of need including those with complex needs

Performance Criteria:

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


7. Evaluate client outcomes

Performance Criteria:

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

Learning Outcomes

On successful completion of this course you will have developed and applied the skills and knowledge required to demonstrate competency in the above elements

Details of Learning Activities

Essential learning activities will take place during a series of 1 day workshops. You will also be required to undertake independent studies. Some of the learning activities that you will undertake are:
• Analysis of current case studies
• Self- reflection exercises
• Discussion groups relating to theoretical and practice-based topics
• Problem based activities

Reflecting on your own work content is a significant aspect of this course, and you will be given opportunities during the workshops to discuss and think about your practice.

All courses and learning activities will be supported and complemented by RMIT’s learning management tool “blackboard”. You will be required to participate in on line learning activities each month using the discussion board forum.

Teaching Schedule

There are 10 workshops scheduled for this program. This course is taught and assessed together with the following courses:  CHCCM701B: Undertake advanced client assessments and CHCCM703A: Apply effective case management practice

and will be covered in detail in workshops1, 2 and 3.

Feb 2015Assessment, care planning and case managementCHCCM701B: Undertake advanced client assessments

CHCCM702B: Implement goal directed care planning

CHCCM703A: Apply effective case management practice

March 2015
April 2015


While your teacher will cover all the material in this schedule, the order is subject to change depending on class needs and availability of guest speakers and resources

Learning Resources

Prescribed Texts

None required


Other Resources

Additional resources will also be available in the learning management tool ‘Blackboard’. A set of readings will be made available to you prior to each workshop. A list of Program Specific resources, including journals and texts that may support you in the program, can also be found on the link to the RMIT Library in ’Blackboard’.

Overview of Assessment

Assessment for this course is based on a written case plan for a client.

Assessment Tasks

This course has been clustered (grouped) for assessment with the following courses: CHCCM701B: Undertake advanced client assessments and CHCCM703A: Apply effective case management practice.

Assessment is a 3,000 page report focusing on a case study and identifying and critiquing the main areas of;
• assessment
• planning
• implementation
• evaluation
• review and
• case closure

Further details of how assessment tasks are mapped to individual courses are available from the Program Coordinator.

Assessment Matrix

The assessment matrix demonstrates alignment of assessment tasks with the relevant courses. These are available from the Program Co-ordinator.

Other Information

Assessment Tasks Submission Cover Sheet
You must complete a submission cover sheet for every piece of submitted work, including online submissions. This signed sheet acknowledges that you are aware of the plagiarism implications.

It is strongly advised that you attend all workshops in order to engage in the required learning activities, ensuring the maximum opportunity to gain the competency.

You will receive verbal and written feedback by teacher on your work. This feedback also includes suggestions on how you can proceed to the next stage of developing your competency. Information regarding student feedback can be found at:;ID=9pp3ic9obks7

Student Progress
Monitoring academic progress is an important enabling and proactive strategy to assist you to achieve your learning potential. The student progress policy can be found at:;ID=vj2g89cve4uj1

Special consideration Policy (Late Submission)
All assessment tasks are required to be completed to a satisfactory level. If you are unable to complete any piece of assessment by the due date, you will need to apply for an extension. Information regarding application for special consideration can be found at:;ID=g43abm17hc9w

Academic Integrity and Plagiarism
RMIT University has a strict policy on plagiarism and academic integrity. For more information on this policy go to Academic Integrity Web site:;ID=kw02ylsd8z3n

Course Overview: Access Course Overview