With the introduction of the new Aged Care Quality Standards from 1 July 2019, which has a stronger focus on clinical governance of risks associated with care, home care providers are encouraged to review their consumer assessment, reassessment and care planning policies.

During the assessment or reassessment of a consumer’s needs, goals and preferences, the home care provider’s assessor works together with the consumer to establish a care plan that reflects their strengths and abilities, areas of difficulty and the support that will best meet their needs and goals. The assessment includes consideration of formal and informal services as well as reablement pathways where appropriate. (Standard 2 Requirement 3(a))

The assessor builds on information collected from the comprehensive assessment undertaken by ACAT, as well as information from others involved in the consumer’s care (Standard 2 Requirement 3(b)): The assessment and care plan provides information that could include the following domains, depending on need:

Family and other support networks

  • Social and community participation
  • Carer, caring responsibilities, sustainability of caring relationships
  • Level of function – ADLs IDLs
  • Physical and personal health
  • Healthcare connections and health conditions
  • Medication management
  • Allergies and/or sensitivities
  • Cognitive capacity, behavioural management issues, psychosocial circumstances
  • Home and personal safety
  • End of life or advanced care plans
  • Support considerations
  • Goals, motivations and preferences
  • Level of complexity and/or risk of vulnerability

The ACAT Guidance Framework for Home Care Package Level provides helpful information on what should be considered when assessing or reassessing a consumer’s needs and if a request for a higher level of package of support is required, see https://agedcare.health.gov.au/acat-guidance-framework

If the consumer’s healthcare needs have changed since their last comprehensive assessment, or six months has lapsed and they are receiving personal care and/or clinical care, another comprehensive assessment may be required to reassess the consumer’s physical capability, medical condition, psychosocial factors, cognitive and behaviour factors, physical environmental factors and restorative needs. For this purpose, the home care provider would arrange a comprehensive assessment that would inform the redevelopment of the consumer’s care plan. Consumers receiving personal care and clinical care reviews require clinical assessment undertaken by allied health clinicians (e.g., Registered Nurse), either employed directly by the Home Care Provider or via subcontracted or brokerage arrangements. (Standard 3 Requirement 3(e))

Consumers with high impact or high prevalence risks associated with their care require regular monitoring. Home Care providers are well advised to have risk management systems in place to monitor their performance. (Standard 3 Requirement 3(b)).

For questions regarding this article, or other home care issues, email homecare@lasa.asn.au