This unit may apply to work in a range of community sector contexts where high level care planning skills and knowledge are required
This unit 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
You may want to include more information here about the target group and the purpose of the assessments (eg formative, summative, recognition)
Prerequisites
Not Applicable
Employability Skills
This unit contains Employability Skills
Evidence Required
List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.
The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.
Critical aspects for assessment and evidence required to demonstrate this unit of competency:
The individual being assessed must provide evidence of specified essential knowledge as well as skills
This unit of competence will be most appropriately assessed in the workplace or in a simulated workplace and under the normal range of workplace conditions e.g. writing care plans based on case studies, writing case notes based on case studies
Assessment may be conducted over one or more occasions and should include both the development and promotion of best practice
Access and equity considerations:
All workers in community services should be aware of access, equity and human rights issues in relation to their own area of work
All workers should develop their ability to work in a culturally diverse environment
In recognition of particular issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on Aboriginal and/or Torres Strait Islander clients and communities
Context of and specific resources for assessment:
This unit can be assessed independently, however holistic assessment practice with other community services units of competency is encouraged
Resources required for assessment include access to:
an appropriate workplace where assessment can take place
simulation of realistic workplace setting
Method of assessment:
Assessment may include observation, questioning and evidence gathered from the workplace setting
Examination of written examples of care plans and written examples of case notes
Submission Requirements
List each assessment task's title, type (eg project, observation/demonstration, essay, assingnment, checklist) and due date here
Assessment task 1: [title] Due date:
(add new lines for each of the assessment tasks)
Assessment Tasks
Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.
This describes the essential skills and knowledge and their level required for this unit.
Essential knowledge:
The candidate must be able to demonstrate essential knowledge required to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role
These include knowledge of:
Literature on models and practices in goal-directed care planning
The range of services, resources and holistic solutions available to clients with complex needs
Components of service delivery system
Gaps in the service system
Characteristics and needs of identified client population
Significance of the service setting, such as working in the client's home
Organisation policies and practices relating to care planning
Professional standards/code of ethics and relevant legislative requirements
Government legislation, regulations, policies and standards
Documentation requirements and practices
Duty of care requirements when developing and implementing care plans
Current research in area of practice
Essential skills:
It is critical that the candidate demonstrate the ability to:
Work within professional standards and applicable government legislation, regulations, policies and standards
Use data drawn from a range of client needs assessment information as a basis for planning care services to address client needs
Review and apply outcomes data as a means to continually improve practice and make adjustments to care plan
Practise in an ethical manner noted by professional discipline or defined ethical standards
Work within guidelines for currently identified best practices
Minimise client dependency by developing their self management skills
Examine issues related to sustainability of care to address client's level of need
Demonstrate actions to support improvement/maintenance of quality of life for clients
Navigate the service delivery system to meet client needs and support encouragement of client independence where possible
Apply communication and leadership skills with providers to services and resources meet client needs
Maintain client confidentiality when engaging stakeholders
In addition, the candidate must be able to effectively do the task outlined in elements and performance criteria of this unit, manage the task and manage contingencies in the context of the identified work role
These include the ability to:
Demonstrate application of skills in:
consultation, liaison and negotiation
analysis of assessment and other data
report, case note and care plan writing
liaison with other organisations and service providers
facilitation
advocacy
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.
Care planningmay include, for example:
Identifying range and type of specific services to be provided
Planning details of each specific service to be provided, such as
domestic assistance
respite
nursing care
Consideration of WHS and risk management issues and strategies to address these
Referral strategies as required to address breadth of client needs
Information about services, resources or activities the client may follow up independently, such as:
Health promotion
Local social or active living opportunities
Self management strategies and activities
Self-referral to other services
Complex needs may refer to:
Client needs requiring multiple service types with heightened needs for collaboration between service providers
Clients with a range of needs that may not be met by available services and resources
Clients who have family and carer needs that require additional service inputs
People who have broad range of care needs related to chronic and/or multiple health issues and who require assistance to access the service system as well as a high level of ongoing advocacy
People in complex circumstances and identified as having high levels of need may refer, for example, to:
Families with children with disabilities where a number of different organisations are providing support
People with disabilities with a diverse range of needs arising from physical and behavioural causes
People with disabilities requiring the development of appropriate responses for personal and/or respite care
People with complex medical issues which may pose critical issues for assessment and care planning
Older people with chronic illness and unstable health conditions requiring coordinated management across acute, sub acute and community health sectors
Older people with dementia and/or other cognitive impairment
Older people who are extremely socially isolated and withdrawn
Circumstances involving difficult WHS issues for community sector workers
People with mental health issues, whose functional limitations may fluctuate substantially over time
People with psychiatric disabilities where inter-organisation agreements may be required to access specialist assessment expertise
People with family and carer needs that require additional service inputs
Inter-organisation relationships and agreementsmay relate to:
Access to specialist expertise for secondary consultations , advice or assessment
Extent and type of information provided on referral
Joint assessment
Case conferencing
Care planning and ongoing support
Use of specialist assessment tools
Involvement in assessment of family members and other organisations providing services
Receiving relevant information from health practitioners and/or support workers
Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.
Observation Checklist
Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice
Yes
No
Comments/feedback
Work with client to identify realistic and relevant goals as a basis for care planning
Undertake care planning to address identified goals and in line with needs assessment and document in line with organisation requirements
Undertake consultation with other organisation representatives to plan care in complex situations where multi-organisation involvement is required
Ensure care plan recognises and supports person's strengths and abilities as well as addressing their needs
Recognise and respect person's right to self-determination within legal parameters
Plan care in consultation with the person, their carer/s and family, friends or others involved in advocacy or decision-making on their behalf
Support person to make informed decisions about their care, reflecting understanding of their current situation, probable future situation and ensuing care needs
Investigate range of options available to address client-identified needs and achieve their goals
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
Devise alternative strategies to meet identified client needs when specific services are not available
Provide the person with cost details as required and work with them to ensure care plan is within their financial resources
Identify work health and safety (WHS) risks and plan for their management
Write care plan and clearly identify all work tasks and who is to perform them
Seek and obtain person's consent before undertaking any referrals
Provide person with clear understanding of available services and choices, so they are an informed participant in all stages of care planning
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
Ensure planning clearly articulates roles and responsibilities of each service provider, including coordination role/s
Maximise involvement of client and carer/s in care planning processes and decision-making
Ensure effective involvement of relevant health/ community services professionals in care planning where clients have chronic or complex needs
Establish and maintain communication strategy and processes to ensure effective implementation of care plan
Ensure mechanisms are in place to support sharing of information between organisations and maintenance of updated information to all involved organisations
Support and develop person's ability to independently access alternative resources to ensure their needs are addressed in an appropriate manner
Regularly monitor planned services, support and resources against client-identified goals to ensure effective implementation of their care plan
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
Maintain collaborative relationships with clients, carers and other service providers to support people with complex needs
Promptly identify problems with implementation of care plan and make adjustment as necessary to best meet person's needs
Document and report any variations to care plan in line with organisation requirements and communication strategy
Respond appropriately to informal monitoring of health and well being of the person and/or their carer by volunteers, carers or family
Undertake regular and systematic reviews to ensure assessed needs of clients are being addressed effectively
Use regular reviews to re-prioritise client needs for service and to ensure equitable access based on ongoing appraisal of prioritised needs
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
Ensure care planning for CALD and Aboriginal and Torres Strait Islander clients is culturally sensitive
Ensure appropriate interpreter support is provided in line with organisation protocols
Where appropriate, work in conjunction with ethno-specific and multicultural organisations and with Aboriginal and Torres Strait Islander communities and organisations
Recognise and support the role of these organisations in linking their communities into the service system
Where appropriate involve Aboriginal and Torres Strait Islander community and/or organisation representatives in the care planning process
Facilitate access to assessment for people with different levels of need including those in complex circumstances and identified as having high levels of need
Maintain and promote inter-organisation relationships and agreements as appropriate to address client, family and carer needs
Ensure care planning builds on person's strengths and motivation to improve their quality of life
Undertake periodic evaluation of care planning based on analysis of outcomes
Obtain information from clients, carers, families and other service providers to determine progress and evaluate against identified goals in care plan
Take into account adjustments made to services and resources to better address person's ongoing situation and changing needs
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
Work with person to evaluate ongoing support needs to meet their goals, including review of parameters for disengagement, where applicable
Demonstrate accountability for adjustments to the care plan and associated financial outcomes
Identify opportunities for person to maintain or develop independence within any aspects of their overall care
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
Forms
Assessment Cover Sheet
CHCCM702B - Implement goal directed care planning
Assessment task 1: [title]
Student name:
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I declare that the assessment tasks submitted for this unit are my own work.
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Result: Competent Not yet competent
Feedback to student
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Assessment Record Sheet
CHCCM702B - Implement goal directed care planning
Student name:
Student ID:
Assessment task 1: [title] Result: Competent Not yet competent
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Feedback to student:
Overall assessment result: Competent Not yet competent