Assessment and planning

Standard 2 builds on the foundations of Standard 1 and includes requirements for organisations to work in partnership with consumers. This Standard describes what organisations need to do to plan care and services with consumers. The planned care and services should meet each consumer’s needs, goals and preferences and optimise their health and well-being. While a consumer might have some challenges with their health and abilities, they still have goals they want to achieve, roles that have meaning, and want to live as well as they can.

This means organisations need to listen to what the consumer wants and look at what they can do (their abilities). Organisations can then focus on planning care and services to ensure that consumers can still get to where they need to go, do what they need to do and have opportunities for participation and growth. The plan needs to be regularly reviewed so that changes in a consumer’s health or abilities are picked up and care and services are identified and put in place to minimise the impact of any loss of ability, and to support consumers to live their day-to-day lives with dignity.

The level of assessment and planning will depend on the level of care and services the organisation is providing and the risks of delivering care and services for the consumer. For example, an organisation providing weekly cleaning services to a consumer in their home would need less assessment and planning than an organisation providing residential aged care services.

It’s expected that an appropriately skilled and qualified workforce undertakes assessment and planning. Assessment and planning undertaken should be in addition to and complement any Aged Care Assessment Team or Regional Assessment Service assessments. Assessment and care planning is expected to provide access to advance care planning including the completion of legally binding advance care directives, and end of life planning if the consumer wants this.

Organisations need to document the outcomes of assessments and discussions with the consumer in a care and services plan and set an agreed review date. Care and services plans may include advance care planning, advance care directives, and end of life planning documents. The plan should be available to the consumer and to those providing care to the consumer. It also needs to be updated on an ongoing basis as the consumer’s needs, goals or preferences change, and after any transition between services.

In line with Standard 1, it’s expected when planning or making changes to care and services plans, consumers are given options and helped to make informed decisions about their options. This includes how much they want to be involved in managing these options themselves.

Standard 2 links to:

Standard 1 – All aspect of assessment and care and services planning needs to treat consumers with dignity and respect and support them to make choices. It’s also important that assessment and care planning occurs in a way that is culturally safe.

Standard 3 – Assessment and planning of the consumer’s needs, goals and preferences supports the delivery of tailored personal and clinical care. If care planning includes advance and end of life care planning this will be delivered in line with consumers wishes.

Standard 4 – Assessment and planning of the consumer’s needs, goals and preferences enables the delivery of safe and effective services and supports.

Standard 7 – Workforce interactions with consumers need to be kind, caring and respectful of each consumer’s identity, culture and diversity. In particular the workforce needs to have the competency, qualifications and knowledge to develop a care and services plan which meets the consumer’s needs, goals and preferences.

Standard 8 – The organisation’s governing body is accountable for the delivery of safe, effective and quality care and services as assessed and planned.

Intent of this requirement

This requirement is about making sure that assessment and planning are effective. These processes will support organisations to deliver safe and effective care and services.

Relevant risks to a consumer’s safety, health and well-being need to be assessed, discussed with the consumer, and included in planning a consumer’s care. This supports consumers to get the best possible care and services and makes sure their safety, health and well-being aren't compromised.

To assess, plan and deliver care and services that are safe and effective, members of the workforce need to have the relevant skills, qualifications and knowledge to assess individual consumers’ needs and to understand their needs, goals and preferences.

Where consumers have lost their decision making capacity and have an advance care directive in place, health professionals have obligations to access and enact the advance care directive. It should be available at the point of care and shared across service providers.

Where a consumer has requested care or services which may pose a risk to their safety, health or well-being, such as the use of a physical restraint for comfort, organisations are expected to discuss the risks and alternative solutions with the consumer, so the consumer can make an informed decision about their care and services. Arrangements to protect consumers require assessment, documentation in care and services plans, informed consent and regular monitoring and review, in line with best practice and legislation.

When two or more organisations share the care and services for a consumer, or where there are integrated care and services, there need to be arrangements in place to share and combine relevant information. This includes information about any risks to the consumer’s safety, health and well-being.

Reflective questions

• What assessment and planning processes enable consumers, their representatives, the workforce and others, to work together in developing a safe and effective care and services plan?
• How does the organisation use information from other sources, such as government assessment services, when developing assessment and planning methods?
• Do the workforce use validated risk assessment and planning tools? Do they ask for input from relevant, qualified practitioners about assessing and managing specific and common risks for older people? This may include diseases or conditions such as incontinence, hearing loss or cognitive impairment, high-impact or high-prevalence risks, or the use of restrictive practices.
  
   
• How does the organisation define advance care planning policy and ensure consumers are using quality and complete statutory advance care directive forms?
  
   
• How does the organisation know and measure whether assessment and planning processes are resulting in safe and effective care and services? How does the organisation monitor how effective the care and services plan is in meeting the consumer’s goals?

Examples of actions and evidence

Consumers

• Consumers say their care is well planned to meet all their needs.
• Consumers say they feel safe and confident because members of the workforce took the time to listen and understand how to support their health and well-being.
• Where it applies, consumers can give examples of how their care and services plan includes input from relevant practitioners to work out the help they need for day-to-day living activities.
• Where physical or chemical restraint is in use, consumers or their representatives say they have given informed consent, consistent with state and territory law.
• Consumers describe how the workforce took a problem-solving approach to managing or minimising risk or meeting their needs, goals and preferences where a solution wasn’t obvious.

Workforce and others

• The workforce can describe the assessment and care planning processes and how they inform how care and services are delivered.
  
   
• The workforce can describe how they assess risk, and how they work together with consumers to minimise risk.
• The workforce can describe how they can access appropriately skilled individuals or service providers to contribute to assessing and planning safe and effective care. (For example, input into planning for emotional health and well-being, clinical and personal care, continence management, dietary requirements, eating aids and assistance, mobility aids and assistance, and hearing, visual or communication assistance).
• The workforce can describe how consumers, and others who contribute more broadly to care and services (such as medical professionals), work together to deliver a tailored care and services plan, and monitor and review the plan as needed.
• Workforce orientation, training or other records that show how the organisation supported the workforce to meet this requirement.
• The workforce can describe advance care planning and advance care directives.
• Evidence of how the organisation makes sure the workforce has undertaken advance care planning training and has policy to inform advance care directive documentation; ensuring documentation is accurate, up-to-date, complete, shared and stored with relevant healthcare providers.
• Evidence that advance care directive documentation informs end-of-life care and decisions.

Organisation

• Evidence that shows members of the workforce are clear on who is accountable within the organisation for assessing, planning and reviewing the care and services needs of consumers.
• Records that show how members of the workforce consider risk with the consumer during assessment and planning to make sure care and services are safe and effective.
  
   
• Evidence of how the organisation makes sure workforce assessment and planning skills match the type and complexity of the consumer’s needs, such as specialised clinical skills or particular cultural skills.
• Evidence that when validated assessment tools are available (including risk assessments), they are used the workforce in assessment and planning for consumers’ care and services.
• Evidence of guidance for relevant members of the workforce on undertaking assessment and planning in a culturally safe way, tailored to the needs of each consumer.
• Evidence of how assessment and planning processes (and documents) inform safe and effective care and services, including where care and services are shared with other organisations.
• Evidence of the organisation monitoring assessment and planning tools and processes to make sure they are effective and are identifying and addressing the needs of consumers.
• Records that show how the organisation monitors, reports and continuously improves assessment and planning of care and services.

Intent of this requirement

For this requirement, organisations are expected to do everything they reasonably can to plan care and services that centre on the consumer’s needs and goals and reflect their personal preferences. This means:

• considering the consumer’s condition and functional abilities and identifying what help they need to live as well as they can
  
   
• listening to and understanding what is important to the consumer and working out how their goals and preferences can be met 
  
   
• tailoring an approach to fit the consumer’s cultural and personal preferences and how they want to have care and services delivered.

If an organisation can’t meet a consumer’s preferences for care and services, they will need to explain why, so the consumer can understand the reasons and look at other options. This allows the consumer to make an informed decision about their care and services.

Through this requirement, it’s expected that advance care planning, including completion of advance care directives and end of life planning happen in line with the consumer’s preference. These conversations are often left too late. It can cause distress for the consumer’s representatives, family and carers and members of the workforce when the consumer’s wishes are unknown. The consequence may be that the consumer does not have the end of life experience they would have wanted.

As part of advance care planning, consumers may wish to complete an advance care directive detailing their care preferences or appointment of a substitute decision-maker. Advance care directives are legally binding documents, which can only be completed by a competent consumer who still has decision-making capacity.

If a consumer is unable to document an advance care directive due to lack of decision making capacity, a medically driven document outlining the plan of care in relation to emergency treatment or severe clinical deterioration can be useful (e.g. acute resuscitation plan, do not resuscitate order). This document should be developed in consultation with the substitute decision-maker of a consumer without decision making capacity.

Where a consumer lacks the capacity to make decisions providers will need to check if they have previously appointed a substitute decision-maker (e.g. attorney, guardian). All states and territories have a default decision-maker (e.g. partner, eldest child, or carer) with the exception of the Northern Territory. If no substitute decision-maker can be identified, they will require a court or tribunal appointed guardian to make medical decisions.

Reflective questions

• What systems and processes does the organisation use to support a consumer-centred assessment of the needs, goals and preferences of each consumer?
• Does the organisation evaluate whether assessment processes are identifying consumer needs, goals and preferences? Are these documented in a care and services plan?
• How does the organisation access a skilled and qualified workforce to assess and plan care and services, including advance care planning and end of life care planning?
• How does the organisation make sure they give consumers culturally safe and supportive opportunities to talk about dying so they can make their wishes known? How is this done in a way that meets the needs of a diverse range of consumers?
  
   
• How does the organisation monitor that a consumer’s assessment and care planning includes the consumer’s social, cultural, language, religious, spiritual, psychological and medical needs?

Examples of actions and evidence

Consumers

• Consumers say they have been listened to and their care and services are planned around what is important to them, such as their intimate relationships, spirituality and culture.
• Consumers are happy with their care and services plan and feel it covers how they want their care and services delivered.
• Consumers say they didn’t feel judged or uncomfortable when talking about the care and services they need and how they want these delivered.
• Consumers have access to advance care planning and end-of-life planning.
• If a consumer chooses to complete an advance care directive, it is done while they still have decision making capacity.

Workforce and others

• The workforce involved in assessment and planning can describe how it’s undertaken to meet the consumer’s needs, goals and preferences.
  
   
• The workforce can provide examples of inclusive care planning which is tailored to meet the particular cultural preferences of consumers from diverse backgrounds.
  
   
• Members of the workforce know how to access people with the relevant knowledge or qualifications to provide information to consumers on end of life planning or palliative care if the consumer wishes to include these in their care and services plan.
  
   
• Workforce, orientation, training or other records that show how the organisation supports the workforce to identify consumer’s needs, goals and preferences through assessment and care planning and meet this requirement.
  
   
• The workforce can describe advance care planning and understand the substitute decision-maker should be consulted in medical decisions including consent, refusal and/or withdrawal of treatment.  
  
   
• Advance care directive documentation should be accurate, up-to-date, complete, shared and stored with relevant care and service providers.

Organisation

• Evidence of strategies, policies and procedures that support a consumer-centred approach to assessment and planning for care and services.
• Policies and processes that describe how assessment and care planning are to be undertaken and the matters to be taken into account, such as the consumer’s need for communication assistance.
• Records of appropriately skilled and qualified members of the workforce being involved in the assessment of a consumer’s needs, goals and preferences.
• Evidence that shows individual, tailored care and services plans are documented for each consumer.
• Policies and processes that provide consumers with opportunities to have safe and supported conversations about death and dying, to make their end of life and palliative care wishes known to the organisation.
• Evidence that there is clear guidance for members of the workforce on decision-making processes when a consumer’s wishes and preferences are not known. This includes wishes that were documented in the past, advance directives, and the role of representatives.

Requirement (3)(c) Assessment and planning

i) is based on ongoing partnership with the consumer and others that the consumer wishes to involve in assessment, planning and review of the consumer’s care and services; and

ii) includes other organisations and individuals and providers of other care and services, that are involved in the care of the consumer

Intent of this requirement

For this requirement, it’s expected that an organisation will carry out ongoing assessment and planning with the consumer their representatives and others who the consumer wants to involve in assessment and planning of their care and services.

Partnering involves ongoing sharing of information, asking for feedback from the consumer, and supporting and encouraging consumers to take part in assessing and planning their own care and services. This approach recognises that making decisions about their own life, and having those decisions respected, is an essential right of each consumer, improves their health and well-being and shows the organisation values the consumer.

The consumer can decide to be involved as much or as little as they want to be in the assessment and planning process. A consumer may choose to involve others as representatives in making their decisions. For example, the consumer may choose to have a relative, partner, or friend as a representative involved in decisions about their care. Where a consumer lacks the capacity to make decisions they may have a court or tribunal-appointed guardian to make decisions on their behalf.

Assessment and planning are also expected to include other organisations, individuals or service providers involved in caring for consumers. This requires effective communication with other service providers. Consumers may also be receiving care and support from unpaid carers, such as family and friends. These people may have been supporting the consumer over a period of time, before they accessed care and services. Involving them in assessment and planning (if the consumer wishes) can help the organisation to get to know the consumer’s needs, goals and preferences and help continuity of care and services for the consumer.

Organisations will need to comply with obligations relating to privacy of information when coordinating care with other organisations, individuals or service providers.

Reflective questions

• Do the organisation’s policies guide the workforce in how to involve, listen to, and respect the views of the consumer and how to include them as much as possible in planning their care and services?
  
   
• Does the organisation guide the workforce on how to involve others (such as family or other carers) in a consumer’s assessment and care planning if the consumer wants to assign some or all of, their care and services planning to others?
  
   
• How does the organisation support consumers who need help with communicating to take part in planning their care and services?
  
   
• How do the organisation’s practices encourage consumers to tell the organisation when their needs, goals and preferences have changed? How does the organisation respond when this happens?
  
   
• What systems does the organisation have in place to identify other organisations, individuals or service providers that are involved in the care of the consumer, or should be involved in their care? (To be able to meet the needs, goals and preferences of the consumer.)
  
   
• How does the workforce involve the consumer’s medical practitioner and other preferred service providers, such as those providing dental care, hearing aids or glasses?
  
   
• How does the organisation bring together those involved in a consumer’s care (including other organisations, individuals and specialist service providers) to talk about and coordinate care and service delivery and to make sure the consumer’s care and services are seamless and focused?
  
   
• If an organisation can’t meet all of the consumer’s expectations, how do they communicate this to the consumer? How does the organisation support a consumer’s access to other service providers?

Examples of actions and evidence

Consumers

• Consumers say they are actively involved in the assessment, planning and review of their care and services. They can describe their care and services plan and how it helps them to meet their goals.
  
   
• Consumer representatives (including carers) say they are actively involved, with the consumer’s consent, in the assessment, planning and review of care and services.
  
   
• Consumer representatives (including carers) say the organisation makes it easy for them to be involved in the assessment, planning and review of the consumer’s care and services.
  
   
• Where a number of organisations provide care and services, the consumer says the organisation has helped them to understand how they fit together. And they know which organisation is responsible for different aspects of their care and services, and who to contact in different situations.
  
   
• Consumers say their assessment and care planning is coordinated and they are satisfied the right people are involved.

Workforce and others

• Members of the workforce can describe what it means to partner with consumers to assess, plan and review care and services.
  
   
• The workforce and others delivering care and services describe how they work collaboratively. 
  
   
• Management can describe innovative and effective ways they have coordinated care and services for consumers where the organisation itself has been unable to meet a consumer’s needs, goals or preferences.
  
   
• Members of the workforce who share information about consumers with other organisations, individuals or service providers describe how they meet obligations relating to privacy of information when coordinating care.
  
   
• Workforce orientation, training or other records that show how the organisation supports the workforce to meet this requirement.

Organisation

• Evidence of consumer information and support to help consumers take part in assessing and planning their care and services.
  
   
• Evidence that information and resources are available in appropriate formats and language translations to help consumers partner in assessment and planning.
  
   
• Clear lines of workforce responsibility for the assessment, planning and review of care and services plans and what each element involves.
  
   
• Evidence the skills and qualifications of the workforce are appropriate for the type and complexity of the assessment and planning of care and services being undertaken.
  
   
• Resources and tools that support shared decision-making for care and services planning.
  
   
• Care and services plans for consumers show integrated and coordinated assessment and planning involving all relevant organisations, individuals and service providers.
  
   
• Evidence of arrangements or agreements with those outside the service involved in planning care and services, to meet the consumer’s needs, goals and preferences.

Intent of this requirement

A care and services plan is expected to be documented and reflect the outcomes of assessment and planning for each consumer. Accurate and up-to-date care and services plans are important for delivering safe and effective care and services, as well as positive outcomes for consumers.

A care and services plan, which includes a person’s needs, goals and preferences, should be available to the consumer in a way they can understand. This may involve support to have information in an accessible language and format, or to help consumers understand the content. It may include involving consumers in discussions, inviting them to meet and encouraging them to ask questions about their care and services plan. This will help consumers understand and have ownership of the care and services plan as they are entitled to have.

The care and services plan can take different forms. Care and services plans may include advance care planning, advance care directives, or end of life planning documents. It can be a single document or several documents that show an overview of the care and services to be delivered. It should be available to those providing care and services to the consumer. This doesn’t mean the care and services plan needs to be available at all times and to all members of the workforce, but the relevant information must be available when and where it is needed to support safe and effective care and services.

Relevant risks to a consumer’s safety, health and well-being need to be documented in the care and services plan to make sure their safety isn’t compromised. This includes things such as allergies and other risks relating to the consumer’s needs.

When two or more organisations, individuals or service providers share a consumer’s care and services, or where there are integrated services, the care and services plan and outcomes from assessment and planning need to be shared. Information sharing needs to happen promptly and comply with obligations relating to privacy of information.

Reflective questions

• How does the organisation communicate assessment and planning information in a way the consumer understands?
  
   
• When a consumer asks for a copy of their care and services plan, how promptly does the organisation provide it? Is it in a format they understand?
  
   
• When a consumer has trouble understanding outcomes of assessment and planning, how does the organisation support the consumer? Are interpreters available when explaining the plan? How are the consumer’s representatives involved?
  
   
• How does the organisation document care and services plans? Are they in plain English?
  
   
• What systems are in place to make sure relevant information for delivering a consumer’s care and services is available where the care or service is actually delivered?
  
   
• What processes are there to communicate critical information in a care and services plan to the workforce, including information alerts and risks?
  
   
• Is the level of detail in the care and services plans enough to enable the appropriate and correct delivery of care and services to the consumer to optimise consumer health and well-being? For example, the consumer’s preferences for personal hygiene, oral health care, taking medication, how to check a hearing device is working properly and where glasses are kept.

Examples of actions and evidence

Consumers

• Consumers say they know how to get a copy of their care and services plan if they want it. They say it will be in a format they can understand and they will get it in a timely manner.
  
   
• Consumers say they have been supported to understand their care and services plan and can describe how it meets their needs, goals and preferences.
  
   
• Consumers can describe the details of their care and services plan and who will provide the care and services.
  
   
• Consumers confirm they are involved if changes are made to their care and services plan, and they understand the changes.

Workforce and others

• The workforce can describe processes for documenting the outcomes of assessment and planning in a care and services plan.
  
   
• The workforce can describe how they access the care and services plan and how they use the information in it that is relevant to their role to deliver safe and effective care and services.
  
   
• The workforce can describe how changes to the care and services plan are communicated and say they receive updated information promptly.
  
   
• The workforce say care and services plans are current and contain enough detail to deliver appropriate and correct care and services for the consumer.
  
   
• Workforce orientation, training or other records that show how the organisation supports the workforce to document and communicate the results of assessment and planning and meet this requirement.

Organisation

• Policies and procedures explain the organisation’s systems, so that outcomes of assessment and planning are fully documented and are available where care and services are delivered.
  
   
• Evidence that care and services plans are accurate and reflect the outcomes of the most up-to-date assessments and reviews of consumer needs, goals or preferences.
  
   
• Evidence the consumer or their representative is involved in developing and reviewing the care and services plan.
  
   
• Evidence of how the organisation monitors the effectiveness of the care and services plan and documents assessment and planning process to improve outcomes for consumers.

Intent of this requirement

Through this requirement, organisations are expected to regularly review the care and services they provide to consumers. This is important to make sure that the:

• care and services plans are up-to-date and meet the consumer’s current needs, goals and preferences
• care and services the organisation provides meet the consumer’s needs safely and effectively
• care and services the organisation provides are updated to apply better practice when available.

All care and services plans are expected to include an agreed review date. How often a review is done depends on the needs of each consumer and on the nature and type of services the organisation is providing. However, in addition to the reviews that are scheduled, a consumer’s care and services plan should be reviewed when:

• the consumer’s condition changes (for example, physical or mental health) 
• situations change (for example, if the organisation’s arrangements for a service changes)
• incidents or accidents happen (for example, if a consumer has fallen). 

Reflective questions

• How does the organisation respond to adverse incidents and near misses? How does it learn from these events to update the way care is planned and delivered?
• What systems are in place to recognise and respond to changes in a consumer’s condition? What processes does the organisation then use to update care and services plans and make sure consumers are safe, and risks are minimised?
• How does the organisation identify when a consumer wishes to change the care and services that are provided, or the way the care and services are provided?
• What processes does the organisation use to include evidence of better practice when reviewing how effective care and services are?

Examples of actions and evidence

Consumers

• Consumers say the organisation regularly communicates with them about their care and services, seeks feedback and makes changes to meet their current needs, goals and preferences.
• Consumers say when something goes wrong, or things change, the organisation communicates with them about this and seeks their input to update their care and services plan to ensure safe and effective care and services can be delivered.

Workforce and others

• The workforce can describe when and how they reassess a consumer’s needs, goals and preferences, how they involve the consumer and how reassessment information is used to update care and services plans.
• The workforce can describe examples of reviewing care and service practices due to adverse incidents or near-miss events.
• The workforce can describe how these reviews capture all aspects of a consumer’s health and well-being, including emotional, spiritual and psychological.
• The workforce can describe how regular reviews of a consumer’s care and services can identify ways to respect the dignity of consumers, such as new dentures, hearing aid maintenance or an assistive device for eating.
• Workforce orientation, training or other records that show how the organisation supported the workforce to meet this requirement.

Organisation

• Documented care and services plans that show the organisation conducts regular reviews, including risk assessments.
• Evidence that members of the workforce with relevant skills and qualifications review the plans regularly.
• Policies and procedures that describe the need for regularly reviewing how effective the care and services plan is, and whether consumer outcomes are being achieved.
• Evidence of how the organisation monitors reports and keeps improving outcomes for consumers through effective assessment and planning.

• Aged Care Act 1997 (Cth), User Rights Amendment (Charter of Aged Care Rights) Principles 2019
• Privacy Act 1988 (Cth), Schedule 1, Australian Privacy Principles
• State and Territory privacy and health records legislation
• State and Territory work health and safety legislation
• State and Territory mental health, guardianship and administration, enduring power of attorney and medical directive/advance care planning legislation