ELEMENT

PERFORMANCE CRITERIA

1. Undertake care planning to address identified client needs and goals

1.1 Work with client to identify realistic and relevant goals as a basis for care planning

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

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

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

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

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

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

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

1.9 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

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

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

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

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

2. Implement care plan in conjunction with relevant others

2.1 Seek and obtain person's consent before undertaking any referrals

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

2.3 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

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

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

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

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

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

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

3. Monitor implementation of client care plan

3.1 Regularly monitor planned services, support and resources against client-identified goals to ensure effective implementation of their care plan

3.2 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

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

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

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

4. Undertake review of care plan

4.1 Respond appropriately to informal monitoring of health and well being of the person and/or their carer by volunteers, carers or family

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

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

4.4 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

5. Respond appropriately to diversity

5.1 Ensure care planning for CALD and Aboriginal and Torres Strait Islander clients is culturally sensitive

5.2 Ensure appropriate interpreter support is provided in line with organisation protocols

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

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

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

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

6.1 Facilitate access to assessment for people with different levels of need including those in complex circumstances and identified as having high levels of need

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

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

7. Evaluate client outcomes

7.1 Undertake periodic evaluation of care planning based on analysis of outcomes

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

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

7.4 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

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

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

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

7.8 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