What is a care plan?

Care plan for aged care

Understanding care plans for home-based aged care

A care plan is a document that outlines a person's home care needs and the services they will receive to meet those needs. It’s an individualised plan, so it’s developed by assessing an older person’s unique needs. The care plan can be adjusted to include more or different services as an older person’s needs change over time. Care managers make sure an older person is receiving the right home care services for their needs.

An independent healthcare professional such as Empower Aged Care can provide guidance and care management from the initial contact and assessment onward, while a care manager would be assigned from a Home Care Package provider once a Home Care Package was approved.

What is a care plan?

A care plan outlines a person's assessed care needs and how healthcare and support services will meet those needs to keep them well at home.

It takes into account an older person’s physical, emotional, social, and mobility needs, as well as other lifestyle factors and is a written record of the agreed care, treatment and support for an individual’s well-being.

A care plan is a written document that identifies a client’s goals and then lists the types of services that will achieve this and how often such services are needed.

  • For example, if an older person recently had a fall and was worried about it occurring again, a goal may be to improve confidence, strength and balance through weekly in-home physiotherapy.

The importance of a care plan

When an older person relies on a number of different healthcare and support services, the care plan improves care coordination. It’s an essential reference for care providers on how to deliver services tailored to an individual's unique needs and preferences.

If your older loved one needs some help at home, the best step is to have their needs assessed by a healthcare professional who can identify their holistic needs and provide guidance about the services available to meet those needs, written up in a care plan.

Preparing an older person’s care plan

A care plan isn’t a standard list of services offered by a service provider. Each care plan is unique and based on the individual needs of an older person.

We create individual care plans in consultation with the older person’s family and healthcare professionals.

Drawing from a needs assessment, the care plan includes details and procedures for:

  • assistance with daily living activities
  • medication management
  • specialist care for ongoing medical conditions
  • mobility support
  • social engagement opportunities for mental and emotional health
  • and many more aspects of an individual’s care.

A care plan is prepared by a health professional who can consider a wide range of service options.

Who should be involved in a care plan?

Really good care plans involve important people. Usually there is someone like us or perhaps a care manager involved who takes the lead in developing a care plan.
Care plans are completed collaboratively with older people and their carers.

What happens if an older person’s care needs change?

If the needs of an older person have changed, then it may be time to review the care plan. It may be that an older person needs additional or different services.

  • For example, if an older person was no longer driving, then their care plan may be changed to include transport assistance so the individual can still get to important appointments and events.

When should a care plan be reviewed

  • After a hospital admission
  • Significant health events
  • Significant changes in care needs
  • Changes to carer or family supports
  • Routine intervals to be proactive!

With the right care plan in place, and adjusted to suit changing circumstances, older people can maintain their independence and remain in their homes while receiving the care and support they need.

For advice about establishing or reviewing your or your older loved one's care plan, contact us.

Empower Aged Care: This email address is being protected from spambots. You need JavaScript enabled to view it. 0404 444 985

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