Elements and Performance Criteria
- Elements define the essential outcomes
- Coordinate the delivery of the individualised plan
- Identify and prioritise the needs, goals and preferences of the older person outlined in the individualised plan
- Coordinate services and support activities in consultation with the older person and colleagues
- Outline and clarify all service providers’ understanding of the individualised plan and their roles and responsibilities
- Recognise signs consistent with financial, physical or emotional abuse or neglect of the older person and respond in line with organisation guidelines
- Liaise and negotiate with appropriate personnel and service providers
- Support the older person to access and negotiate resources in order to deliver identified services
- Support the older person to access community support agencies to facilitate the achievement of established goals
- Recognise when a service and/or support worker is no longer able to provide the level of service required and take action to minimise disruption to service delivery
- Support family and carers
- Coordinate feedback
- Explain to all service providers the mechanism/s for providing feedback on the effectiveness of the individualised plan
- Obtain feedback from service providers on the effectiveness of the individualised plan and report to supervising health professional
- Seek feedback from the older person and/or their advocate and report to supervising health professional
- Support the older person to seek advice and assistance from relevant health professionals when their goals are not being reached