Sometimes in aged care we look at what we are doing for someone and view that as the outcome for the individual.
The client is getting a shower and therefore improving their hygiene, or they are getting a good meal and thereby maintaining their nutritional health; but is this the right way to view service?
As part of our consultancy work, we sometimes see client care plans where the outcome or goal is actually a stated output, written most often by a busy coordinator. But we need to move beyond this service-directed output and really look at what the client wants to achieve from any provided service.
An assessment of a client might identify that the person requires some support to meet their dietary requirements. Let’s take a look at Molly, who is on dialysis support, but living at home on her community with family.
Molly might request a lunch meal at the Aged Care centre on Monday, Wednesday and Friday as part of her care supports. Perhaps in your discussions with Molly you identify that the reason she requests this is that:
- she is finding it hard to cook a meal that supports her dialysis regime;
- food security is an issue in the home she shares with eight other family members;
- she wants to be able to catch up with old friends at the centre, as being on dialysis three days a week is isolating;
- she likes to eat her meal in the friendly environment created by the staff.
Providing the meal to Molly achieves more than simply meeting her nutritional needs. Her goals are to be more connected with the community and to feel less isolated. While the delivered meals program can help meet an assessed need by catering for a renal-friendly diet, the meal is more than that – it provides an opportunity for her to meet a number of goals, and these should be reflected in Molly’s care plan.
The additional benefit in identifying the breadth of outcomes for your clients is that you are able to demonstrate your support of the concepts of wellness and reablement.
Molly’s example above demonstrates a wellness approach, meeting a client’s physical and emotional needs. The ‘outcomes’ approach to care planning, can also reflect a reablement mind-set within your service.
Let’s take another example.
Albert is a 55-year-old Aboriginal man who has recently returned to the community after suffering a stroke. The stroke was caused, in part, by the Rheumatic Heart Disease he has lived with for the past 30 years. As a result of the stroke, Albert is finding it difficult to walk far and maintain his home and yard, however, he doesn’t want on-going support from the aged care service. He wants to get well enough to do his own housework and shopping, although recognises he may need to use some help to recover fully.
In this scenario, Albert’s care plan will reflect his goal or outcome to improve his walking capacity and ability to look after his own home. His care plan will be time-limited and may include rehabilitation supports or aids and equipment that help him to regain independence and improve his capacity.
So take another look over your care plans. Do they reflect the outcomes sought by the individual or the outputs you are delivering?
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In her spare time, while she ages gracefully, she helps out with kids theatre, rides an electric bike and drags her husband off to explore the world as often as possible.
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