Prepare for initial assessment.

1. Prepare for broad-based holistic assessment of the person’s needs based on referral or other documentation in line with organisational policies and procedures.
2. Establish rapport with person and obtain their consent to participate in the assessment process.
3. Identify additional stakeholders, including carers, natural supports and family members, whose input will assist the person in assessment process and outcomes.
4. Identify the range of information, products and resources to be utilised in the assessment process.
5. Work with the person to collaboratively identify opportunities to build on strengths, improve functional capacity, and participate in social and community activities.
6. Organise suitable time and place for assessment in conjunction with the person and their carers, support workers and family.
7. Identify and agree on suitable assessment tools and processes according to organisational policies and procedures.
8. Explain privacy and confidentiality principles, practices and procedures.
9. Provide suitable interpreter support according to person’s needs and brief interpreter and cultural specific workers.
10. Communicate with all people involved in the assessment using language and form to meet their needs.
11. Clearly explain the assessment process and how information is used, including legal requirements and organisational policies and procedures for mandatory reporting.
12. Implement risk assessment processes and stratify risks to determine interventions based on person’s circumstances, needs and interests.
13. Involve the person and their carers, families, and natural supports in the assessment process in a way that empowers the person and is in accordance with the person’s preferences.
14. Use suitable assessment tools and processes to identify, clarify and prioritise complex and multiple needs of the person, their carers and families.
15. Collect and document information about the person according to organisational policies and procedures.
16. Collaborate with stakeholders and service providers to avoid duplication experienced by the person and to share information and resources.
17. Assist those involved in the assessment to identify and prioritise the person’s goals, needs and any risk factors.
18. Where carers and families are involved, ensure the assessment focuses on, and strengthens the relationship.
19. Inform carers and families about their role and rights in the assessment and decision-making processes, including their right to an assessment of their own needs.
20. Identify and assess work health and safety (WHS) risks and issues associated with service and resource delivery.
21. Use assessment processes and practices designed to build trust and confidence to work with mainstream services.
22. Use assessment processes that are non-discriminatory and suitable for each distinct but potentially overlapping population.
23. Provide equitable access and culturally competent assessment processes for culturally and linguistically diverse (CALD) and Aboriginal and/or Torres Strait Islander people.
24. Build and maintain relationships with ethno-specific and multicultural organisations.
25. Build and maintain relationships with Aboriginal and/or Torres Strait Islander communities and organisations and involve representatives in the assessment processes.

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Respond to people with different levels of needs, including people with complex needs.

1. Support people with complex needs and circumstances and facilitate access to assessment.
2. Develop and maintain inter-organisation relationships and agreements to address the person, family and carer needs.
3. Recognise the need for secondary consultation, medication administration and monitoring and additional specialist assessment, including those undertaken by a specified health professional.
4. Identify when the person’s health is unstable and refer to ensure the appropriate multi-disciplinary approach is applied.
5. Identify and build on the person’s motivation to improve their functional capacity and set their own goals.

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Undertake ongoing assessment and review.

1. Respond appropriately to informal monitoring of health and wellbeing of all parties involved in the assessment processes.
2. Undertake regular and systematic reviews to ensure assessed needs of person are addressed effectively.
3. Use regular reviews to reprioritise person’s needs for service and to ensure equitable access based on ongoing appraisal of prioritised needs.
4. Reassess person’s needs as specified in their plan and as required by personal circumstances and changes in person or carer health and family support.
5. Maintain communication with all parties and document and report all processes, according to organisational policies and procedures.

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