Planning With Consumers

Being able to make decisions about their own lives, and having those decisions respected, is a fundamental right of people receiving care (ACQSC 2019).

Therefore, residents, clients and patients alike should be adequately supported to participate in the planning of care and services provided to them.

What is Planning With Consumers?

Providers are expected to work alongside clients in order to plan care and services that meet their clients’ needs, goals and preferences (ACQSC 2019).

Even if the client is experiencing challenges in their life, providers should support them to achieve their goals and live meaningfully while maximising their quality of life (ACQSC 2019).

Planning with consumers involves communicating with the client about their preferences, assessing their abilities and then delivering care that allows them to fulfil their goals. Plans should be regularly reviewed in order to identify changes in the client’s circumstances and adjust care and services accordingly (ACQSC 2019).

As an essential component of consumer-directed care, planning is expected to involve the client, encourage their input and provide them with the required information to make informed decisions (Larter 2020).

Clients should be supported to actively participate in the planning of their care. If they wish to do so, they should be involved in all decision-making, planning and goal setting (ACSQHC 2019).

Planning with consumers is a component of the Aged Care Quality Standards Standard 2: Ongoing Assessment and Planning with Consumers.

What Should Planning With Consumers Involve?

Providers should:

• Assess the client’s functional abilities and determine what assistance they may need to optimise their quality of life;
• Listen to the client’s goals and preferences and determine how these can be fulfilled;
• Take the client’s personal and cultural preferences into account in order to appropriately personalise the care and services delivered;
• Support the client to participate in planning as little or as much as they would like;
• Provide adequate information to the client so that they can make informed decisions;
• Ask for feedback from the client; and
• Communicate and liaise effectively with other providers involved in the client’s care.

(ACQSC 2019)

Getting to Know the Client

Taking a consumer-focused approach means being a good listener and understanding what your clients want to gain from their own lives. Your role is to explore options and solutions that will guide them towards their goals rather than enforcing what you think is best for them (CDCS 2019).

Consider the following about your clients:

• Experiences;
• Interests;
• Employment;
• Religion;
• Cultural background;
• Likes and dislikes;
• Values;
• Sources of happiness;
• Hobbies; and
• World views.

(CDCS 2019)

Care Plans

The outcomes of assessment and planning are expected to be documented in a care and services plan, which should be kept accurate and current. A care and services plan may comprise one or several documents and should be available to both the provider and client when needed (ACQSC 2019).

The plan should include the client’s needs, goals and preferences and may also include advance care planning (ACQSC 2019).

The goal of care plans is to:

• Ensure the client always receives the same care, regardless of which staff member is providing it;
• Ensure the care provided is recorded; and
• Help the client identify, manage and solve problems.

(RCN 2011)

The provider and client should agree on a review date for the care plan depending on the client’s needs and the services being provided (ACQSC 2019).

Long-term Planning

Part of planning with consumers means providing clients with resources and support to complete end-of-life planning and advance care directives, if they wish to do so. This will allow the client to inform their end-of-life experience, saving carers, staff and loved ones from unnecessary distress if the discussion is left too late (ACQSC 2019).

If the client does not have decision-making capacity, their designated substitute decision-maker can assist in the development of an emergency care plan (ACQSC 2019).

Once completed, this documentation is expected to be accurate, up-to-date and properly stored (ACQSC 2019).

Emergency Planning

Providers should work together with clients receiving care and services at home to develop an emergency plan. As the carer may not always be present, it is essential that the client knows what to do in such a situation.

• Encourage the client to consider advance care planning.
• Ensure advance care documentation can be retrieved quickly and easily.
• Ensure any advance care documentation accompanies the client if they need to be transferred to a different care setting.
• Liaise with the client’s general practitioner if you have concerns about their health.
• Inform carers about the Carer Gateway emergency plan. In the event of an emergency that incapacities the carer, this document will help somebody else quickly take over to care for the client.
• Encourage the client or their loved ones to compile a list of emergency contacts and leave it in an easily-accessible location.

(PalliAGED 2020)

Setting Goals

A key component of planning care with clients is identifying and setting goals that reflect the client’s personal and clinical needs, preferences, expectations and aspirations. Goal-setting is shown to improve clients’ satisfaction, quality of life and self-efficacy (ACSQHC 2019).

While a conversation with the client about their values and preferences may suffice at a minimum, you may also utilise tools, frameworks, models or person-centred communication models in order to identify goals. These goals should then be used to inform the client’s care (ACSQHC 2019).

The following principles should be used when identifying and setting goals:

• Set aside time to discuss what is important to the client;
• Make decisions about goals together with the client;
• Identify several goals that are positive and achievable, but challenging;
• Clarify the roles and responsibilities involved in achieving these goals;
• Clearly communicate and document the goals that have been agreed upon;
• Track progress and measure achievement against the goals;
• Understand that the goals may require repetition in order to be achieved; and
• Integrate the goals into existing care systems and processes.

(ACSQHC 2019)

Reviewing Plans

Providers are expected to regularly review care plans to ensure:

• The plans are up-to-date and adequately meet the client’s needs, goals and preferences;
• Care and services are meeting the client’s needs safely and effectively; and
• Care and services are improved or updated when possible.

(ACQSC 2019)

Plans should be reviewed when:

• It is the agreed review date as documented on the plan;
• The client’s condition (e.g. physical or mental health) changes;
• Situations change (e.g. organisation’s arrangements); and
• An incident or accident occurs.

(ACQSC 2019)

Additional Resources

• ACQSHC, Guidance and Resources for Providers to support the Aged Care Quality Standards
• ACSQHC, Implementing the Comprehensive Care Standard: Identifying Goals of Care
• Advance Care Planning Australia
• Carer Gateway, Emergency Care Plan
• Ongoing Assessment
• An Explanation of Advance Care Directives

References

• Aged Care Quality and Safety Commission 2019, Guidance and Resources for Providers to Support the Aged Care Quality Standards, Aged Care Quality and Safety Commission, viewed 23 June 2020, https://www.agedcarequality.gov.au/sites/default/files/media/Guidance_%26_Resource_V9.pdf
• Australian Commission on Safety and Quality in Health Care 2019, Implementing the Comprehensive Care Standard: Identifying Goals of Care, Australian Commission on Safety and Quality in Health Care, viewed 24 June 2020, https://www.safetyandquality.gov.au/sites/default/files/2019-06/implementing-the-comprehensive-care-standard-identifying-goals-of-care-final-accessible-pdf-24-apr-2019.pdf
• Australian Commission on Safety and Quality in Health Care 2019, Person-centred Care, Australian Commission on Safety and Quality in Health Care, viewed 25 June 2020, https://www.safetyandquality.gov.au/our-work/partnering-consumers/person-centred-care
• Culturally Directed Care Solutions 2019, ‘We’re All In This Together’ – Ongoing Assessment and Planning | New Aged Care Standard #2, Culturally Directed Care Solutions, viewed 23 June 2020, https://cdcs.com.au/standard-two-new-aged-care-standards/
• Larter 2020, Introducing Consumer Directed Care Into Residential Aged Care Settings in Australia, Larter, viewed 23 June 2020, https://larter.com.au/introducing-consumer-directed-care-residential-aged-care-settings-australia/#:~:text=Consumer%20Directed%20Care%20(CDC)%20is,are%20delivered%2C%20when%20and%20where.
• PalliAGED 2020, Emergency Planning and Management, PalliAGED, viewed 23 June 2020, https://www.palliaged.com.au/tabid/4489/Default.aspx
• Royal College of Nursing 2011, Care Plans, Royal College of Nursing, viewed 25 June 2020, https://rcni.com/hosted-content/rcn/first-steps/care-plans