Standard 2. Ongoing assessment and planning with consumers
(1) I am a partner in ongoing assessment and planning that helps me get the care and services I need for my health and well-being.
(2) The organisation undertakes initial and ongoing assessment and planning for care and services in partnership with the consumer. Assessment and planning has a focus on optimising health and well-being in accordance with the consumer’s needs, goals and preferences.
Click on the links below each Requirement to view the Guidance material, including:
- Intent of the Requirement
- Reflective questions
- Examples of actions and evidence
(3) The organisation demonstrates the following:
(a) Assessment and planning, including consideration of risks to the consumer’s health and well-being, informs the delivery of safe and effective care and services.
(b) Assessment and planning identifies and addresses the consumer’s current needs, goals and preferences, including advance care planning and end of life planning if the consumer wishes.
(c) Assessment and planning:
(i) is based on ongoing partnership with the consumer and others that the consumer wishes to involve in assessment, planning and review of the consumer’s care and services; and
(d) The outcomes of assessment and planning are effectively communicated to the consumer and documented in a care and services plan that is readily available to the consumer, and where care and services are provided.
(e) Care and services are reviewed regularly for effectiveness, and when circumstances change or when incidents impact on the needs, goals or preferences of the consumer.
Purpose and scope of the Standard
This Standard describes what organisations need to do to plan care and services with consumers. The planned care and services should meet each consumer’s needs, goals and preferences and optimise their health and well-being. While a consumer 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.
It’s expected that organisations work in partnership with the consumer to understand what is important to them. This means organisations need to listen to what the consumer wants and look at what they can do (their abilities). Organisations can then focus on planning care and services to ensure that consumers 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 consumer’s health or abilities are picked up and care and services are identified and put in place to minimise the impact of any loss of ability, and to support consumers to live their day-to-day lives with dignity.
The level of assessment and planning will depend on the level of care and services the organisation is providing and the risks of delivering care and services for the consumer. For example, an organisation providing weekly cleaning services to a consumer in their home, would need less assessment and planning than an organisation providing residential aged care services.
It’s expected that an appropriately skilled and qualified workforce undertakes assessment and planning. Assessment and planning undertaken should be in addition to and compliment any Aged Care Assessment Team or Regional Assessment Service assessments. Assessment and care planning is expected to provide access to advance care planning and end of life planning if the consumer wants this.
Organisations need to document the outcomes of assessments and discussions with the consumer in a care and services plan and set an agreed review date. The plan should be available to the consumer and to those providing care to the consumer. It also needs to be updated on an ongoing basis as the consumer’s needs, goals or preferences change, and after any transition between services.
In line with Standard 1, it’s expected when planning or making changes to care and services plans, consumers are given options and helped to make informed decisions about their options. This includes how much they want to be involved in managing these options themselves.
Assessment against this Standard
For each of the requirements, organisations need to demonstrate that they:
understand the requirement
apply the requirement, and this is clear in the way they provide care and services
monitor how they are applying the requirement and the outcomes they achieve
review outcomes and adjust their practices based on these reviews to keep improving
Standard 2 links to:
Standard 1 – All aspect of assessment and care and services planning needs to treat consumers with dignity and respect and support them to make choices. It’s also important that assessment and care planning occurs in a way that is culturally safe.
Standard 3 – Assessment and planning of the consumer’s needs, goals and preferences supports the delivery of tailored personal and clinical care. If care planning includes advance and end of life care planning this will be delivered in line with consumers wishes.
Standard 4 – Assessment and planning of the consumer’s needs, goals and preferences enables the delivery of safe and effective services and supports.
Standard 7 – Workforce interactions with consumers need to be kind, caring and respectful of each consumer’s identity, culture and diversity. In particular the workforce needs to have the competency, qualifications and knowledge to develop a care and services plan which meets the consumer’s needs, goals and preferences.
Standard 8 – The organisation’s governing body is accountable for the delivery of safe, effective and quality care and services as assessed and planned.
- Aged Care Act 1997 (Cth), Schedule 1 User Rights Principles 2014. Charter of Rights and Responsibilities-Residential Care
- Aged Care Act 1997 (Cth), Schedule 2 User Rights Principles 2014. Charter of Rights and Responsibilities – Home Care
- Aged Care Act 1997 (Cth), Schedule 3 User Rights Principles 2014. Charter of Rights and Responsibilities – Short-term restorative Care
- Privacy Act 1988 (Cth), Schedule 1, 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
Resources and references
- Advance Care Planning Australia
- National Palliative Care Standards: 5th Edition (2018)
- Principles for Palliative and End-of-Life Care in Residential Aged Care
- Supported Decision-Making in Aged Care: A Policy Development Guideline for Aged Care Providers in Australia
- WHO Integrated care for older people guidelines on community level interventions