REWORD The care plan is initially informed by our internal assessment processes, including clinical assessments conducted by a Registered Nurse where indicated and other information such as: The National Screening and Assessment Form (NSAF). Recent health summaries from the care recipient’s general practitioner. Any reports are available from specialists, including Geriatricians. Any other recent assessments, including those undertaken by Allied Health Professionals. Hospital discharge summaries where applicable. This supporting documentation, along with copies of any internal assessments conducted, will be incorporated into the care recipient’s record and their care plan. The care plan will then become the source of truth for the delivery of care and services to the care recipient, and it will be provided to the care recipient to keep in their home to direct frontline workers. Frontline workers will also have access to the care recipient’s care plan prior to their first visit so that they understand specific requirements before they attend the care recipient’s home, including any communication and cultural requirements, special needs, risks, and preferences. Workers attending the care recipient’s home will be trained and expected to read the care recipient’s care plan each time they visit to ensure they remain familiar with requirements and to apprise themselves of any changes. Ongoing information about the health status of a care recipient will also be documented through regular shift reports and progress notes, which are accessible by other members of the workforce based on their role-specific permissions. Frontline workers will alert the care recipient’s Case Manager or supervisor when they observe changes in the health status of the care recipient, including deterioration, that are not consistent with the current version of the care plan. These circumstances would trigger a review and update of the care plan. The care recipient’s care and services will be reviewed on a regular basis in accordance with the frequency established during the initial assessment and planning process. Reviews will also be conducted under other circumstances, including wherever there are changes in the care recipient’s condition, post-incident or hospitalisation, if the care recipient is approved for a higher-level package, or where the care recipient requests it. During reviews, and where indicated, clinical assessments will also be repeated and compared to the previous assessment to detect either improvement, maintenance, or deterioration. These results will inform updates to the care plan, and the completed assessments will be included in the care recipient’s central record. Care plan reviews will also consider and include other documentation obtained or received since the last assessment or review, including any service delivery reports from external service providers, other assessments, discharge summaries, health summaries, etc. As before, any such documentation is retained in the care recipient’s central record. Where there have been changes to the care recipient’s care plan, an updated copy will be provided to the care recipient to make available in their home, and workers will be advised of any changes prior to their next visit by their supervisor, either individually or during team meetings.
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