If you're building a training plan to meet Outcome 3.1 Assessment and Planning under the Strengthened Aged Care Quality Standards, you're working with one of the most operationally significant outcomes in the entire framework. Every other aspect of care -- how it's delivered, how risks are managed, how older people are communicated with -- flows from the quality of your assessment and planning processes. Getting workers trained in this area isn't a compliance exercise. It's what makes personalised, safe, effective care possible.
Outcome 3.1 sits within Standard 3: The Care and Services, which describes how providers must deliver funded aged care services for all service types. The government guidance for Outcome 3.1 is clear that assessment and planning systems exist to guide quality care and services that meet older people's needs, goals and preferences -- and to support their quality of life, reablement, and maintenance of physical, mental and cognitive function.
Bottom Line Up Front: Outcome 3.1 requires your workers to understand and participate in a systematic assessment and planning process -- one that is person-centred, ongoing, and built around active partnership with older people. Your training must equip workers to contribute to care and services plans that are comprehensive, current and accessible; handle advance care planning sensitively; manage and escalate risks identified through care delivery; and review plans when circumstances change. This applies across both residential and home and community care settings, with some important differences in emphasis.
What Outcome 3.1 Actually Requires
The outcome statement requires providers to actively engage with individuals, their supporters, and others involved in their care in developing and reviewing care and services plans through ongoing communication. Those plans must describe current needs, goals and preferences and include strategies for risk management and preventative care. They must be regularly reviewed and used by aged care workers to guide service delivery.
The six actions that underpin this outcome cover:
- Action 3.1.1: A system for assessment and planning that identifies needs, goals and preferences; identifies and manages risks; supports preventative care and reablement; and directs quality service delivery.
- Action 3.1.2: Assessment and planning based on ongoing communication and partnership with the individual and others they choose to involve.
- Action 3.1.3: Effective communication of assessment and planning outcomes to the individual (in a way they understand) and to supporters and others involved in their care, with informed consent.
- Action 3.1.4: Individualised, current care and services plans that describe needs, goals and preferences; include risk information; and are accessible to the individual and understood by workers.
- Action 3.1.5: Regular review of care and services plans -- including when needs or circumstances change, after incidents, at transitions of care, and when the plan is not working.
- Action 3.1.6: Processes for advance care planning that support individuals to discuss future care, complete documents, nominate substitute decision-makers, and ensure documents are stored and accessible.
The Three Core Training Areas
Training for Outcome 3.1 covers three interconnected areas: understanding and contributing to care and services plans; supporting advance care planning; and identifying when plans need to be reviewed and escalating accordingly.
| Training Area | Core Focus | Key Ausmed Modules |
|---|---|---|
| Area 1: Care and Services Planning | Person-centred assessment, care plan development, documentation, communication of plans to individuals and teams | Understanding Care Plans in Aged Care (26m), Documentation in Aged Care (25m), Communicating in Aged Care (24m), Person-Centred, Rights-Based Care for the Older Person (12m) |
| Area 2: Advance Care Planning | Voluntary process, individual support, document storage and accessibility, substitute decision-making | Dignity of Risk & Decision-Making in Aged Care (20m), Standard 3: The Care and Services (10m) |
| Area 3: Review Triggers and Risk Escalation | Recognising deterioration, changes in circumstances, post-incident review, communicating concerns | Recognising Deterioration: Care Workers (23m), Promoting Mental Health and Wellbeing in Aged Care (22m), Dementia and Understanding Behavioural Changes (30m) |
The Standard 3: The Care and Services module (10 minutes) is a strong foundational piece that gives all workers a clear picture of what the standard requires before they engage with more detailed training.
Area 1: Care and Services Planning
The government guidance sets out clearly what a care and services plan must do: it must be individualised, comprehensive, current and accessible. It must reflect the older person's unique needs, goals and preferences -- including their culture, diversity, religious beliefs, language needs, gender identity and connection to Country -- and must include strategies for managing identified risks.
Workers don't just need to know what goes into a plan. They need to understand how to use it. The standards explicitly require that workers access, refer to and understand care and services plans to guide how they deliver services. That means your training must address both the creation and the application of plans.
| Training Component | What Workers Need to Know | Relevant Module |
|---|---|---|
| What makes a care and services plan person-centred | How to identify and document needs, goals and preferences; how to avoid task-focused rather than person-focused planning | Understanding Care Plans in Aged Care (26m) |
| Comprehensive documentation | What information belongs in a plan, how to write clearly, how to keep records current and accurate | Documentation in Aged Care (25m) |
| Communicating the plan | How to share plan information with the individual in a way they understand; how to communicate critical information to the care team | Communicating in Aged Care (24m) |
| Rights-based approach to planning | Respecting autonomy, supporting informed consent, involving individuals as genuine partners in planning | Person-Centred, Rights-Based Care for the Older Person (12m) |
A key emphasis in the guidance is the role of registered health practitioners, allied health professionals and other services in comprehensive care planning. Workers need to understand when and how to involve other care providers, and how to document and act on their input.
For workers supporting people living with dementia, planning must also incorporate contemporary evidence-based strategies for recognising and responding to dementia, understanding the person's strengths and skills, and involving supporters appropriately. Dementia and Understanding Behavioural Changes (30 minutes) directly supports this.
Cultural and Diversity Considerations in Planning
The guidance is explicit that care and services plans must document each person's culture, diversity and religious beliefs; language and communication needs and preferences; connection to Country and community; individual background and life experiences; and gender identity and sexual orientation. Workers need to be equipped to have these conversations with sensitivity and to document them appropriately.
Culturally Safe, Trauma-Aware and Healing-Informed Care (25 minutes) supports this requirement alongside the planning-specific modules above.
Area 2: Advance Care Planning
Advance care planning is explicitly included in Outcome 3.1 as an important component of person-centred care (Action 3.1.6). The guidance is clear that it is a voluntary process -- one that workers must support without pressure, and that the organisation must have systems to document, store and share appropriately.
Workers need to understand three things: what advance care planning is and why it matters; how to support individuals to discuss and document their preferences if they choose to; and how advance care planning documents must be managed, including at transitions of care.
The guidance notes that the process of recording choices varies between states and territories, which means your training should include jurisdiction-specific information relevant to where you operate. Advance care planning documents must be stored securely and be accessible to relevant health practitioners and services when needed -- particularly during transitions of care.
Training in this area should ensure workers can:
- Explain what advance care planning is in plain language
- Offer information and opportunities to discuss future care without coercion
- Support individuals to nominate and involve a substitute decision-maker
- Know how and where advance care planning documents are stored within your organisation
- Understand who has access to these documents and when they should be shared
Dignity of Risk & Decision-Making in Aged Care (20 minutes) supports workers' understanding of autonomy, informed choice and substitute decision-making -- all essential foundations for supporting advance care planning conversations.
Area 3: Review Triggers and Risk Escalation
Care and services plans are not set-and-forget documents. The standards require that plans are reviewed regularly and, critically, that workers recognise when a review is needed and act on it. Action 3.1.5 lists specific triggers for review that workers must be able to identify.
| Review Trigger | What Workers Need to Recognise |
|---|---|
| Changes in needs, goals or preferences | Dietary preferences shifting; the individual expressing new or changed wishes |
| Deterioration or change in physical, cognitive or mental function | Reduced mobility after a fall; changes in behaviour; declining cognition |
| Changes in ability to perform activities of daily living | Inability to walk without assistance for the first time; increasing difficulty with self-care |
| Changes in what family or carers can provide | A family carer's availability or capacity changing |
| After an incident | Any incident should trigger a review of whether the care and services plan needs updating |
| At transitions of care | Hospital discharge; moving between residential and home care settings |
| If care responsibilities between providers change | A GP retirement; a change in allied health involvement |
Workers on the floor are often the first to notice these changes. Training must equip them not just to notice, but to document observations, use established escalation pathways, and understand that their reporting directly informs care plan reviews.
Recognising Deterioration: Care Workers (23 minutes) is essential here -- it gives workers a practical framework for identifying changes in condition and escalating concerns appropriately. For mental health-related changes, Promoting Mental Health and Wellbeing in Aged Care (22 minutes) complements this.
Home and Community Care: Additional Considerations
The government guidance identifies specific additional requirements for providers delivering services in home or community settings, reflecting the reality that workers in these settings operate with greater autonomy and often without direct oversight of the older person between visits.
Providers delivering home and community care must train workers to:
- Review each older person's aged care assessment to inform their own assessment and planning
- Assess needs, goals and preferences for older people who self-manage their services
- Consider how external services (from other providers, health practitioners or allied health professionals) may impact the care they provide -- and ensure this is reflected in the care and services plan
- Reassess care needs while individuals are on a waitlist and after they come off waitlists
- Identify, monitor and manage risks when there is no direct continuous oversight -- for example, by educating family members and carers on fall prevention strategies so they can provide safe support between visits
Strengthened Aged Care Quality Standards: Home Care (25 minutes) is recommended for home care workers alongside the core planning modules, and gives context on how these requirements apply specifically in a home care setting.
Role-Based Training Approach
While all workers need a foundational understanding of care and services plans and their role in review processes, training emphasis should reflect each worker's actual responsibilities.
| Role | Training Priority | Key Modules |
|---|---|---|
| Direct care workers | Recognising review triggers, escalating concerns, using plans to guide daily care delivery | Understanding Care Plans in Aged Care (26m), Recognising Deterioration: Care Workers (23m), Documentation in Aged Care (25m) |
| Care coordinators and planners | Person-centred assessment, comprehensive plan development, multidisciplinary coordination, advance care planning support | All Area 1 and 2 modules plus Dementia and Understanding Behavioural Changes (30m) |
| Management and leadership | Monitoring system effectiveness, quality improvement, ensuring review processes are followed | Standard 3: The Care and Services (10m), Strengthened Aged Care Quality Standards (30m) |
Monitoring and Continuous Improvement
The government guidance outlines how providers should monitor whether their assessment and planning processes are working effectively. This has implications for your training system too -- if your monitoring reveals gaps in how care and services plans are being completed or used, that is a training need.
Key monitoring activities include reviewing care and services plan documents to check they reflect current needs, goals and preferences; analysing complaints, feedback and incident data; and speaking with older people, their supporters and families about whether they feel involved in planning and whether their needs are understood.
The guidance also highlights specific situations to look for: incidents where wrong care was provided; plans not reviewed after a change in circumstances; needs, goals or preferences not documented. Each of these is a signal to revisit your training and your processes together.
When things go wrong, the guidance emphasises practising open disclosure -- being transparent with individuals, supporters and others about what happened. Holding Difficult Conversations at Work (30 minutes) can support workers and leaders in navigating these conversations with skill.
Evidence of Compliance
Assessors will look for evidence that your assessment and planning processes are systematic, person-centred and actually embedded in day-to-day practice. Key evidence includes:
| Evidence Type | What It Should Demonstrate |
|---|---|
| Training records | All workers have completed training relevant to their role in assessment and planning |
| Care and services plans | Plans are individualised, current, include risk strategies and are accessible |
| Review records | Plans are being reviewed at the right times and after triggering events |
| Advance care planning documentation | Records of conversations offered, documents stored, access arrangements in place |
| Consumer feedback | Individuals report being involved in their own planning and having their needs understood |
| Incident and review data | Incidents are followed by plan reviews; patterns are used to improve the system |
The Foundation of Everything Else
Assessment and planning isn't one task among many -- it's the system through which everything else is organised and delivered. When it works well, workers know who they're caring for, what matters to that person, what risks they face and how to manage them. The care and services plan becomes a living document that reflects the real person, not a form completed at admission and rarely revisited.
That's what Outcome 3.1 is asking for: assessment and planning as an ongoing, collaborative process -- one that every worker participates in, whether they're a care coordinator writing the initial plan or a personal care worker noticing a change in condition and knowing exactly what to do next.
For the full government guidance on Outcome 3.1, visit the Aged Care Quality and Safety Commission's Assessment and Planning page.
This Training Requirement was created with the assistance of Generative AI tools. Pretty cool, right? Do it yourself!
