Undertake planning to address person’s identified needs and goals.

1. Collaborate with the person to confirm needs and goals as a basis for planning.
2. Investigate range of options available to address the person’s identified needs and achieve their goals, incorporating legal and ethical considerations.
3. Support the person to make informed decisions regarding their plan that reflect understanding of their current situation, likely future situation and ensuing needs.
4. Recognise and respect the person’s right to self-determination within legal parameters.
5. Identify risks and barriers to plan implementation and develop strategies to address them.
6. Develop a plan that builds on the person’s strengths and abilities and incorporates their identified goals, needs and preferences.
7. Collaborate with the person to structure a range of services in a manner that builds on and strengthens natural supports.
8. Devise alternative strategies to meet the person’s identified needs when specific services are not available.
9. Provide the person with cost details and work with them to ensure their plan is sustainable in relation to costs, access and availability.
10. Document plan in the person’s own words, clearly identifying all tasks and who is responsible for performing them.

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Collaborate with others to communicate the plan.

1. Work in collaboration with other professionals and organisations to provide services to maximise the person’s potential for achieving their goals and meeting their needs.
2. Explain roles, rights and responsibilities of person and service providers and ensure they are clearly documented in the plan.
3. Maximise involvement of the person and other people identified by the person in planning processes and decision making.
4. Consult and coordinate with other service providers to plan for complex situations.
5. Establish and maintain communication processes to ensure effective implementation of the plan.
6. Share information between organisations and support maintenance of information by all parties involved, according to organisational policies and procedures for privacy and confidentiality.

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Respond to people with different needs.

1. Collaborate with person to ensure planning process is culturally sensitive and appropriate.
2. Work in conjunction with other organisations and communities by involving representatives in the planning processes, according to the person’s needs.
3. Facilitate access to planning for people in complex situations and with different levels of need.

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Monitor implementation of plan.

1. Regularly monitor the planned services, support and resources against person’s identified goals to ensure effective implementation of plan.
2. Identify any gaps in planned services and make adjustments to address them.
3. Maintain collaborative relationships with the person, their carer, natural supports and other service providers.
4. Work with the person to adjust the plan as necessary following reassessment of risks and needs.
5. Document and report any variations to the plan in line with organisational policies and procedures.

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