Assessment and planning | Aged Care Quality and Safety Commission

What is the outcome you need to achieve?

The provider must actively engage with individuals to whom the provider delivers funded aged care services, supporters of individuals (if any) and any other persons involved in the care of individuals in developing and reviewing the individual’s care and services plans through ongoing communication.

Care and services plans must describe the current needs, goals and preferences of individuals and include strategies for risk management and preventative care.

The provider must ensure that care and services plans are regularly reviewed and are used by aged care workers to guide the delivery of funded aged care services.

Updates to guidance

An updated version of the strengthened Standards was published by the Department of Health and Aged Care on 18 February 2025. Please see here for more information Strengthened Aged Care Quality Standards – February 2025 | Australian Government Department of Health and Aged Care.

The Commission is currently updating our guidance content to reflect these changes. Please ensure you check back regularly.

Actions

3.1.1

The provider implements a system for assessment and planning that:

identifies and records the needs, goals and preferences of the individual
identifies risks to the individual’s health, safety and wellbeing and, with the individual, identifies strategies for managing these risks
supports preventative care and optimises quality of life, reablement and maintenance of function
involves relevant health professionals where required
directs the delivery of quality funded aged care services.

3.1.2

Assessment and planning is based on ongoing communication and partnership with the individual and others that the individual wishes to involve.

3.1.3

The outcomes of assessment and planning are effectively communicated to:

the individual, in a way they understand
the individual’s supporters and others involved in their care, with the individual’s informed consent.

3.1.4

Care and services plans are individualised and:

describe the individual’s needs, goals and preferences
are current and reflect the outcomes of assessments
include information about the risks associated with the delivery of funded aged care services and how aged care workers can support individuals to manage these risks
are offered to, and able to be accessed by, the individual
are used and understood by aged care workers to guide the delivery of funded aged care services.

3.1.5

Care and services plans are reviewed regularly, including when:

the individual’s needs, goals or preferences change, or the care and services plan is not effective
the individual’s ability to perform activities of daily living, mental health, cognitive or physical function, capacity or condition deteriorates or changes
the care that can be provided by an individual’s family or carer changes
transition occurs
risks emerge or there are changes or an incident that impacts the individual
care responsibility changes between others involved in the individual’s care.

3.1.6

The provider has processes for advance care planning that:

support the individual to discuss future medical treatment and care needs, in line with their needs, goals and preferences, including beliefs, cultural and religious practices and traditions
support the individual to complete and review advance care planning documents, if and when they choose
support the individual to nominate and involve a substitute decision maker for health and care decisions, if and when they choose
ensure that advance care planning documents are stored, managed, used and shared with relevant parties, including at transitions of care.

What are needs?

Needs are the essential requirements or conditions that must be addressed to optimise the older person's health, safety and wellbeing*. These may include medical treatment, assistance with activities of daily living*, social support and specialist health services.

What are goals?

Goals, also known as goals of care*, are the clinical and personal outcomes* the older person wants to achieve when they receive care and services. Goals are set collaboratively with the older person, their family, carers, representatives and health professionals* involved in their care through a shared decision making* process*. Goals may focus on optimising the older person's quality of life*, reablement* and maintenance of function, or addressing personal preferences.

What are preferences?

Preferences are the things the older person chooses, likes or dislikes when it comes to their care, services and lifestyle. It’s the way they like or wish for their care and services to be delivered. These may include preferred types of care (such as at home or in a residential care home), treatment options, daily routines and activities they want to do.

Why is this outcome important?

Outcome 3.1 explains providers’ obligations to make sure they have thorough assessment and planning* processes*. Systems* and processes* for assessment and planning* are essential for guiding how providers deliver quality care* and services that meet older people’s needs, goals and preferences*. These systems* and processes* should support older people’s quality of life* and reablement*. They should also help older people to maintain their physical, mental and cognitive functions.

Assessment and planning* processes* are important guidance for developing care and services plans* that meet the needs, goals and preferences* of each older person. You need to do your assessment and planning* should be done using a person-centred care* approach and in line with the providers* policies and procedures. This means ongoing communication and partnership with:

older people
their families and carers*
their representatives
health professionals* involved in their care.

Identifying and assessing risks to the older person’s health, safety and wellbeing* is also an important part of assessment and planning*. You need to identify and assess these risks in partnership* with older people, their families, carers*, representatives and health professionals* involved in their care. This includes completing clinical assessments where required by qualified health professionals* to identify, document and plan for clinical risks (Outcome 5.4). Outcome 3.1 highlights the need to have strategies to manage the identified risks. These strategies should focus on supporting each person’s quality of life*, reablement*, right to make choices and maintaining their function.

Regular reviews of care and services plans* are essential to updating an older person’s care and services if there are any changes in their preferences, condition or circumstances. Outcome 3.1 also highlights how important it is to communicate any changes in their care and services to the older person and others involved in their care. This helps make sure care and services are suitable and effective. It also helps build trust between providers and the older people they care for.

Advance care planning* is an important component of person-centred care*. Providers are expected to have systems* and processes* to support older people in advance care planning*, if the older person wishes to develop an advance care plan. Advance care planning* is a voluntary process* and offers an opportunity to consider, discuss and document the older person’s preferences about their care. It’s important to provide information and support to older people about the benefits of advance care planning*, so they can make their own informed choices. Open and transparent communication about an older person’s future care needs can also help to make sure care and services are in line with their choices, values and preferences.

You need to give focus to:

considering quality of life*, reablement* and maintaining function
using strategies to manage risk to an older person’s health and wellbeing
outlining when care and services plans* need to be reviewed.

Updates to guidance

The Commission is currently updating our guidance content to reflect these changes. Please ensure you check back regularly.

Key tasks

Providers(active tab)

Providers

Put in place a system* for assessment and planning.

Assessment and planning is an important part of delivering quality care* and services. In your system* for assessment and planning, make sure you prioritise:

the older person’s quality of life*
their reablement*
maintaining their physical, mental and cognitive functions.

Making these areas a priority will support you to:

deliver quality care* and services
create care and services plans* that meet the needs, goals and preferences* of older people.

Make sure your system* includes processes* to:

partner with the older person about who they want involved in their assessment and planning. Use your organisation’s system* to identify and guide workers about how to involve the older person and others (such as family or carers) who the older person chooses to involve in assessment and planning (Outcome 1.3). If the older person lacks the capacity to make decisions, the provider has the responsibility to know and record:
- who the substitute decision-maker* is
- the types of decisions they are authorised to make on behalf of the person.
talk with the older person and other people the older person would like involved in their care and services (Outcome 2.1). This will help workers to understand each older person’s goals of care*. It will also help support their quality of life* and reablement* and to maintain their function. Make sure these discussions are in line with culturally and psychologically safe* care principles. This will help to plan and deliver care that is culturally safe* , trauma aware and healing informed* (Outcome 3.2).
document the older person’s needs, goals and preferences* (Outcome 1.1) in their care and services plan*. This includes their:
- culture, diversity and religious beliefs
- connection to Country and community. For example, for older people who identify as Aboriginal and Torres Strait Islander or live in regional and remote settings.
- individual background and life experiences
- language and communication needs and preferences
- gender identity and sexual orientation
- decision to share this information, who to share this information with, and their preferences to talk or not talk about their experiences.
consider risks to the older person’s health, safety and wellbeing*. Also include how you will manage these risks (Outcome 2.4). Do this in partnership* with the older person.
provide the resources and support each older person needs when delivering care and services. Make sure this information informs the supports what older people need to perform their activities of daily living*. For residential care providers, the guidance for Outcome 7.1 has more information on how you can support older people with activities of daily living*. For older people receiving care and services in a home setting, this could also involve identifying if referrals to other care services or providers may be needed.
share information (Outcome 2.1). Workers need to inform older people that their own care and services plans* are available and accessible to them. Use your information management (Outcome 2.7) and communication systems* (Outcome 3.3) to do this.
involve appropriate health professionals* and support services where you need to. For example, you may need to involve:
- a mental health professional* if the person has psychological deterioration*
- dementia* support specialists if the person has cognitive deterioration*
- a dietician to provide nutrition care in response to identified weight loss (Outcome 5.5).
make sure care and service plans* are accessible and available to workers as well as older people. Workers need to access, refer to and understand care and service plans* to guide how they deliver care and services.
enable reporting your Quality Indicator data about the quality of care.

Create care and services plans* that:

are individualised and person-centred*. Care and service plans* need to show the older person’s unique needs, goals and preferences* (Outcomes 3.2 and 3.3). This will make sure care and services are delivered safely and in line with the older person’s needs and preferences. When making care and services plans*, consider each older person’s:
- culture, diversity and religious beliefs
- individual background and life experiences
- language and communication needs and preferences
- gender identity and sexual orientation (Outcome 1.1).
are comprehensive (Outcome 5.4). Consider each older person’s:
- individual needs and preferences (Outcome 1.1)
- goals of care* in collaboration with their family, carers, health professionals* and others they wish to involve in their care (Outcome 5.4)
- choices so that you can support them in optimising their quality of life*, reablement* and maintenance of function
- clinical needs and risks. For example, individual nutrition, hydration and dining needs and preferences (Outcome 6.2).
consider which health professionals* and services are needed to meet the older person’s clinical needs, with their informed consent*. For example, a person may need:
- medical
- rehabilitation
- allied health
- oral health
- specialist nursing
- dementia* support services.
  
  This will help make sure older people receive coordinated, multidisciplinary care* (Outcome 5.4).
are available to older people and people they want involved in their care and services. This may include the older person’s family and carers if requested by the older person. You need to share this information in a way each older person understands (Outcome 1.3). This should consider each older person's language and communication needs and preferences (Outcome 1.1). For example, if an older person has a cognitive impairment*, workers should support them to understand the information. This needs to be based on each older person’s needs to support their understanding.
are clear and accessible.

Care and services plans* need to be up-to-date and informed by assessments. Review the plans regularly*, including:

if there are changes in the older person’s circumstances. This can include a change to:
- their needs, goals or preferences (Outcome 1.1). For example, if an older person’s dietary preferences change.
- their mental health*, cognitive or physical function, capacity or condition. This includes if their function, capacity or condition deteriorates*, improves or changes (Outcome 5.4). For example, if an older person’s mobility decreases after a fall.
- their ability to perform activities of daily living*. For example, if an older person is no longer able to walk without help
- the care that family or carers can provide to the older person
the care responsibilities of the people providing care and services to the older person. This means, if any services or allied health* and health professionals* involved in the older person’s care and services change. For example, when an older person’s GP retires and they organise a new one, make sure you review and update the person’s care and services plan*.
after an incident* (Outcome 2.5). After an incident*, document any changes to the care and services plan* that are needed.
if the care and services plan* is not reflecting the needs, goals and preferences of the older person. Older people, their family, carers or others may raise issues through feedback* or complaints* (Outcome 2.6). Workers may raise issues through established escalation pathways using the information management* (Outcome 2.7) and communication systems* (Outcome 3.3).
if risks are identified (Outcome 2.4). Document the risks, any strategies to prevent or reduce risk in the future and how you plan to monitor and assess these strategies. For example, if an older person is identified as being at risk of choking or have difficulties swallowing (Outcomes 5.4 and 5.5), make sure assessments are undertaken to evaluate the risk and documented, and update their care and services plan*. Recommendations and strategies to mitigate risk should be individualised to each older person in line with their assessed needs. The care and services plan* should also outline when the older person needs to be reassessed and who should do this.
at transitions of care*. For example, when an older person is discharged from hospital or changes from home care to residential care services. The guidance for Outcome 3.4 has more information on coordinating transitions. For residential care providers, the guidance for Outcome 7.2 has more information on how you can support older people during transitions.

Put in place processes* for advance care planning*.

These processes* need to:

support the older person to talk about their future medical treatment and care needs. Talk with the older person about their needs, goals and preferences*. This includes their beliefs, cultural and religious practices and traditions (Outcome 1.1)
support the older person to complete and review advance care planning* documents, if they choose to
support the older person to have choices and exercise dignity of risk* (Outcomes 1.2 and 1.3). For example, if an older person makes the informed decision to not use recommended pressure relieving devices or walking aids (as prescribed by a relevant health professional*).
support the older person to nominate and involve a substitute decision-maker* for health and care decisions, if and when they choose. The guidance for Outcome 1.3 has more information on supported decision making* and the role of substitute decision-makers*.
make sure you store, manage, use and share advance care planning* documents with relevant people if needed, including at transitions of care*. Use your information management system* (Outcome 2.7) and communication system* (Outcome 3.3) to do this. Informed consent* should be obtained from the older person to share their information and advance care plan (Outcome 1.3).
be integrated with your systems* and easily accessible for quality clinical care* (Outcome 5.1) where relevant.

Make sure workers who provide care and services have the time, support, resources and skills to plan for and deliver care and services tailored to each older person’s needs and preferences.

Provide workers with guidance and training on how to plan for and deliver tailored care and services for each older person (Outcome 2.9). This needs to be in line with:

the organisation’s policies* and procedures*
contemporary, evidence-based practice*
workers’ roles and responsibilities*.

Make sure workers who deliver care and services understand how to:

undertake assessments
develop care and services plans*
use this information to plan and deliver care and services tailored to the older person’s needs, goals and preferences* (Outcome 3.2).

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and worker training.

Make sure workers can assess and understand care and services plans* when they need them. Care and services plans* need to be stored in line with your information management system* (Outcome 2.7).

Monitor how well your processes* for assessment and planning are working.

To check if your assessment and planning processes* work well, you can review:

older people’s care and services documents (Outcome 3.1). For example, care and services plans*, progress notes and advance care planning documents*. Check that each older person’s care and services plans* include their current needs, goals, and preferences*.
complaints* and feedback* (Outcome 2.6)
incident* information (Outcome 2.5).

Look for situations where:

incidents* have happened where the wrong service or care has been provided
a care and services plan* was not reviewed and updated after a change in circumstances
an older person’s needs, goals or preferences were not documented in their care and services plan* or advance care planning documents*.

Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). For example, ask them if they were involved in the assessment and planning process* of their care and services. Ask them if their needs, goals and preferences* have been understood and considered in their care and services plan* and advance care planning* . These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).

Assess if workers are following your quality system* (Outcome 2.9). You can do this through quality assurance and system* reviews.

If you find any issues or ways you can improve, you need to address them. If things go wrong, you need to:

practise open disclosure* (Outcome 2.3). This means being open about what has gone wrong. Share what went wrong with older people, their family and carers.
put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.