‘We’re All In This Together’ – Ongoing Assessment and Planning | New Aged Care Standard #2

Okay, so maybe the theme song from the movie High School Musical is not that familiar to you and yes, it’s a bit over the top and cutsie. However, the key message is a good one and hits the right note when we look at Standard #2 – Ongoing Assessment and Planning with Consumers.

‘Together, together, come on, let's do this right.'

What do we mean when we talk about doing assessment and care planning ‘right’?

Effective assessment and planning happens when you understand where the person is coming from; their ‘backstory’ and the contributing factors that impact on their current health status. It happens when you recognise the person’s needs, goals and preferences, and understand what will optimise their health and wellbeing.

Doing it right means listening to the person, ensuring they are heard and that they play a leading role in their care planning. It is also about partnerships, working together on a plan that is real, achievable and makes a difference for them.

What is NOT good assessment and care planning?

Be careful about making assumptions about what a person needs and developing the care plan around basic referral information and other people's comments. Limiting the care plan to only the services your organisation provides is not good care planning either.

Sure, there is often a lot of useful information in the medical summaries that come from the local health service or the person’s General Practitioner; this information is important in forming a holistic care plan. Yes, the My Aged Care profile or other referral may outline identified needs, but this is just the beginning. Consumers and their carers must be actively involved as a partner in their own care.

‘Assessment’ is not deciding what you think the person needs.

The key player in this story is the consumer. Think of yourself as Gandalf from Lord of The Rings; your role as an assessor and planner is that of a ‘guide’, opening the consumer's eyes to possibilities, alerting them to risks along the way and guiding them to that place where they can be their best self.

‘Everyone is special in their own way.'

As our High School Musical students discovered, we might have differences, but everyone is special in their own way.

A good assessor digs deeper, seeking to understand the person’s story.

• What experiences shaped them?
• What are their interests?
• What did they do in their work life or as a homemaker?
• Were they a veteran, a refugee, a member of the stolen generation or care leaver?
• Have they been impacted by traumas such as war, assault, deaths of close family members?
• What are their religious and cultural backgrounds, and their identity?

All of these questions help paint a picture of the individual. They help us to understand where the person is coming from, their likes and dislikes, as well as strategies that may be needed to support them in living a fulfilled life for as long as they can.

We also need to discover what brings them joy and what’s important to them. We need to understand what enriches a person’s life.

It may be as simple as getting out to the shops or local store or community centre on a daily basis, because this is where they see other people and feel connected to the wider world.

Maybe they can no longer drive, but they want to be driven to the shops in their own car (if they still have it) and then come home and sit in the car (in the shade) and read the papers. Perhaps it’s listening to music, visiting old friends, attending religious services, going to a park to exercise their dog or taking up a new hobby.

‘We're not the same.'

We all have our own world view, desires and preferences, and it’s rarely helpful to project what we think another person wants based on these.

Just because you might like to shower every morning doesn’t mean that your client wants this – they may prefer to shower in the evening or only a couple times a week. Just because I might prefer an interior decorating style that minimises the effort of dusting and clutter doesn’t mean that my client will want to give up her collection of Royal Wedding cups – she might like someone to dust them though.

Good planning is about seeking solutions and exploring options.

A good care planner also seeks to understand what people can and still want to do and what resources they need to support this. For example:

• The person still wants to do their own laundry, they just can’t bend down low enough to unload the front-loading machine. They want to maintain their independence and don’t want someone to come in and do the washing as this is an otherwise gratifying activity for them. Solution – mount the washing machine on a stand so that the laundry is easily unloaded and placed in the trolley.

A good care planner also helps people explore options that they may not have realised existed. For example:

• If they have a Home Care Package, do they know what flexible supports their package may be able to fund? Remember, you are there as a guide, opening their eyes. Maybe they thought that all they were able to use their package funds for was meals and laundry – they hadn’t thought it could be used to pay for someone to take them to the local waterhole to spend an afternoon fishing, or just sitting under a tree with a billy can and a small campfire, passing the time yarning about the old times.

Part of being a good planner is really listening to what people want, what is currently missing from their life, what they really wish they could do again, meeting those social and emotional needs as well as their identified physical supports.

‘Together, together, together everyone.'

In meeting those supports and helping the person reach their goals the planner may need to share the care and services with other organisations. It is therefore critical for assessors and planners to obtain consent from the consumer to engage with other providers, such as health services or art centres, who also support the person. Coordinated supports are so much more effective for meeting the stated outcomes for the client, as well as minimising the problems arising from lack of communication which can result in poor service continuity and ineffective use of resources.

Work with the consumer and other stakeholders to make things happen. Remember, we are all in this together!

We hope you enjoyed this article on the second Standard. This blog post is part of a series on the New Aged Care Standards, where we investigate how and why they were developed and take an in depth look at each of the Standards to give you ideas for implementing these effectively within your organisation. If this is of relevance to you and you’re not signed up for our short email alerts, fill in the quick form at the bottom of the page and we will let you know when the next post is released. We also send a monthly round up of blog posts and videos.

Other posts in this series

Why Do We Need New Aged Care Standards?

What Difference will the New Aged Care Standards make to Consumers?

What Impact Will The New Aged Care Standards Have On Your Organisation?

‘What About Me?' – Consumer Dignity & Choice | New Aged Care Standard #1

‘Stand By You' – Personal Care & Clinical Care | New Aged Care Standard #3

‘Help me get my feet back on the ground' – Services & Supports for Daily Living | New Aged Care Standard #4

‘Wouldn't It Be Loverly?' – Organisation's Service Environment | New Aged Care Standard #5

‘Who Ya Gonna Call?' – Feedback & Complaints | New Aged Care Standard #6

‘Lean On Me' – Human Resources | New Aged Care Standard #7

‘The Greatest Show' – Organisational Governance | New Aged Care Standard #8

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