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Evidence Guide: CHCCM702A - Implement goal directed care planning

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

 

CHCCM702A - Implement goal directed care planning

What evidence can you provide to prove your understanding of each of the following citeria?

Undertake care planning to address identified client needs and goals

  1. Work with client to identify realistic and relevant goals as a basis for care planning
  2. Undertake care planning to address identified goals and in line with needs assessment and document in line with organisation requirements
  3. Undertake consultation with other organisation representatives to plan care in complex situations where multi-organisation involvement is required
  4. Ensure care plan recognises and supports person's strengths and abilities as well as addressing their needs
  5. Recognise and respect person's right to self-determination within legal parameters
  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
  7. Support person to make informed decisions about their care, reflecting understanding of their current situation, probable future situation and ensuing care needs
  8. Investigate range of options available to address client-identified needs and achieve their goals
  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
  10. Devise alternative strategies to meet identified client needs when specific services are not available
  11. Provide the person with cost details as required and work with them to ensure care plan is within their financial resources
  12. Identify occupational health and safety (OHS) risks and plan for their management
  13. Write care plan and clearly identify all work tasks and who is to perform them
Work with client to identify realistic and relevant goals as a basis for care planning

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Undertake care planning to address identified goals and in line with needs assessment and document in line with organisation requirements

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Undertake consultation with other organisation representatives to plan care in complex situations where multi-organisation involvement is required

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Ensure care plan recognises and supports person's strengths and abilities as well as addressing their needs

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Recognise and respect person's right to self-determination within legal parameters

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Plan care in consultation with the person, their carer/s and family, friends or others involved in advocacy or decision-making on their behalf

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Support person to make informed decisions about their care, reflecting understanding of their current situation, probable future situation and ensuing care needs

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Investigate range of options available to address client-identified needs and achieve their goals

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Devise alternative strategies to meet identified client needs when specific services are not available

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Provide the person with cost details as required and work with them to ensure care plan is within their financial resources

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Identify occupational health and safety (OHS) risks and plan for their management

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Write care plan and clearly identify all work tasks and who is to perform them

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Implement care plan in conjunction with relevant others

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Provide person with clear understanding of available services and choices, so they are an informed participant in all stages of care planning

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Ensure planning clearly articulates roles and responsibilities of each service provider, including coordination role/s

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Maximise involvement of client and carer/s in care planning processes and decision-making

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Ensure effective involvement of relevant health/ community services professionals in care planning where clients have chronic or complex needs

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Establish and maintain communication strategy and processes to ensure effective implementation of care plan

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Ensure mechanisms are in place to support sharing of information between organisations and maintenance of updated information to all involved organisations

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Support and develop person's ability to independently access alternative resources to ensure their needs are addressed in an appropriate manner

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Monitor implementation of client care plan

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Maintain collaborative relationships with clients, carers and other service providers to support people with complex needs

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Promptly identify problems with implementation of care plan and make adjustment as necessary to best meet person's needs

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Document and report any variations to care plan in line with organisation requirements and communication strategy

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Undertake review of care plan

  1. Respond appropriately to informal monitoring of health and well being of the person and/or their carer by volunteers, carers or family
  2. Undertake regular and systematic reviews to ensure assessed needs of clients are being addressed effectively
  3. Use regular reviews to re-prioritise client needs for service and to ensure equitable access based on ongoing appraisal of prioritised needs
  4. Contribute to adjustments in care plan in response to changes in client or carer health; review of risk management/OHS needs; or as specified in person's care plan or as required by personal circumstances
Respond appropriately to informal monitoring of health and well being of the person and/or their carer by volunteers, carers or family

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Undertake regular and systematic reviews to ensure assessed needs of clients are being addressed effectively

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Use regular reviews to re-prioritise client needs for service and to ensure equitable access based on ongoing appraisal of prioritised needs

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Contribute to adjustments in care plan in response to changes in client or carer health; review of risk management/OHS needs; or as specified in person's care plan or as required by personal circumstances

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Respond appropriately to diversity

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Ensure appropriate interpreter support is provided in line with organisation protocols

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Where appropriate, work in conjunction with ethno-specific and multicultural organisations and with Aboriginal and Torres Strait Islander communities and organisations

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Recognise and support the role of these organisations in linking their communities into the service system

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Where appropriate involve Aboriginal and Torres Strait Islander community and/or organisation representatives in the care planning process

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Maintain and promote inter-organisation relationships and agreements as appropriate to address client, family and carer needs

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Ensure care planning builds on person's strengths and motivation to improve their quality of life

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Evaluate client outcomes

  1. Undertake periodic evaluation of care planning based on analysis of outcomes
  2. Obtain information from clients, carers, families and other service providers to determine progress and evaluate against identified goals in care plan
  3. Take into account adjustments made to services and resources to better address person's ongoing situation and changing needs
  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
  5. Work with person to evaluate ongoing support needs to meet their goals, including review of parameters for disengagement, where applicable
  6. Demonstrate accountability for adjustments to the care plan and associated financial outcomes
  7. Identify opportunities for person to maintain or develop independence within any aspects of their overall care
  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
Undertake periodic evaluation of care planning based on analysis of outcomes

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Obtain information from clients, carers, families and other service providers to determine progress and evaluate against identified goals in care plan

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Take into account adjustments made to services and resources to better address person's ongoing situation and changing needs

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Work with person to evaluate ongoing support needs to meet their goals, including review of parameters for disengagement, where applicable

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Demonstrate accountability for adjustments to the care plan and associated financial outcomes

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Identify opportunities for person to maintain or develop independence within any aspects of their overall care

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

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

Completed
Date:

Teacher:
Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

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

Required Skills and Knowledge

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

Range Statement

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 OHS 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 OHS 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