Quick Reference Guide Completing the Support Plan (ACAT)

February 2018

7. Quick Reference GuideCompleting the support plan (ACAT)

1.What is the support plan?

The client’s support plan is developed with the assessor during the face-to-face assessment to record and identify the client’s areas of concern, goals to address these concerns, and any recommendations for services or actions to achieve the identified goals.

The client s support plan is developed with the assessor during the face to face assessment to record and identify the client s areas of concern goals to address these concerns and any recommendations for services or actions to achieve the identified goals

2.Entering information into the support plan

The support plan is made up of a number of tabs discussed below.

2.1Identified needs

The ‘Identified needs’ tab contains a summary of the needs identified as part of the assessment, that require addressing in the support plan.

Assessors can add an ‘Assessment Summary’in the ‘Identified needs’ tab. This summary mayassist the Delegate in their decision making process. It will also appear on the printedsupport plan for the client, and be visible to service providers who have receiveda referral for the client.

Step 1: To add or edit an Assessment Summary, select the edit button.

Step 2: In the free text box, enter the assessment summary and select Save.

Step 2 In the free text box enter the assessment summary and select Save

2.2Client motivations

The ‘Client Motivations’ tab asks you to consider the client’s strengths and abilities, and areas of difficultly. You can also record other care considerations in this tab, such as cultural or religious beliefs that are important to the client, and may be important for service delivery.

The Client Motivations tab asks you to consider the client s strengths and abilities and areas of difficultly You can also record other care considerations in this tab such as cultural or religious beliefs that are important to the client and may be important for service delivery

It is not mandatory for an ACAT assessor to enter information in to ‘Client Motivations’. However, should you wish to provide this information, the question set will become mandatory once information has been entered.

2.3Goals and recommendations

The ‘Goals recommendations’ tab is where you will record the client’s areas of concerns, goals to address their concerns, any services or general recommendations, and any care type recommendations. You may choose to link recommended services to the client’s area of concern and goals, or you can recommend services that are not linked to concerns and goals.

There are five types of recommendations that can be added to a support plan following a comprehensive assessment:

General recommendations are non-Commonwealth funded supports that are identified by the assessor and the client and will beactioned by the client or the assessor rather than aservice provider, e.g. that the client sees a health practitioner, or that they join a local support group.

Service recommendations are for adding recommendations for services to a client’s support plan, e.g. CHSP services or Multi-purpose services.

Recommended long-term living arrangementis only applicable to comprehensive assessments. Itisthe most appropriatelongterm living situationidentified during a comprehensive assessment that can be selected from a list of accommodation settings after discussing the goals with the client and/or their representative.

Care type recommendations are applicable only to comprehensive assessments. These recommendations relate to care types under the Act which require approval by an ACAT Delegate.

‘No care type under the Act’ is only applicable to circumstances where a client withdraws their application for care or is not applying for care under the Act, and still requires CHSP services and/or general recommendations.

2.3.1 Adding an area of concernand goals

Step 1: Select ‘Add area of concern’.

Step 2: In the pop up box, record the area of concern, and select ‘Save to plan’. The area of concern will appear under the Client goals section.

Step 2 In the pop up box record the area of concern and select Save to plan The area of concern will appear under the Client goals section

Step 3: To add a goal to the concern, select ‘Add a goal’.

Goals and concerns on a client’s support plan that may no longer be relevant to the client’s situation can be removed by selecting ‘Remove’.

Step 4: In the pop up box, enter the goal,record the client’s motivation to achieve the goal (with 1 being least motivated to 10 being highly motivated) and the status of the goal, and select ‘Save to plan’.

Step 4 In the pop up box enter the goal record the client s motivation to achieve the goal with 1 being least motivated to 10 being highly motivated and the status of the goal and select Save to plan

This information will appear under the associated concern.

This information will appear under the associated concern

Step 5: Continue to add concerns and goals as appropriate.

When multiple concern or goals have been added, you are able to change the display order by using the drop down box at the right hand side of the record.

2.3.2 Adding recommendations

Recommendations can be linked to concerns and goals, or they can be added as an ‘Other recommendation’. To add a recommendation, follow the steps below.

Recommendations can be associated to more than one goal. When adding your recommendations you can:

Select one or more goals to associate a recommendation to
Unlink the recommendation from all goals.

Step 1: To add a recommendation,select the appropriate recommendation from the links below ‘Other Recommendations’.Alternatively, you can add a recommendation directly to an area of concern and goal by selecting the arrow next to ‘Goal’ and below ‘Add to this goal’ on the right hand of the record.

You can choose to link general recommendations, service recommendations, and care types for delegate decision to relevant areas of concern and goals.

To add a general recommendation, go to Step 2a.

To add a service recommendation, go to Step 2b.
To add a long term living arrangement, go to Step 2c.
To add a care type for delegate decision, go to Step 2d.
To recommend that a client receive ‘No care type under the Act’, go to Step 2e.

Step 2a: Select ‘Add a general recommendation’. A pop-up box is displayed, enter information about the general recommendation, complete relevant fields, and select ‘Save to plan’.

Step 2b: Select ‘Add a service recommendation’. A pop-up box is displayed, select the recommended service, complete all mandatory fields and select ‘Save to plan’.

Where a client does not wish to access a particular service at that point in time, or only requires infrequent services, you should still create the service recommendation. The client will be able to access these services at a later date by calling the My Aged Care contact centre to facilitate the sending of electronic referrals from recommendations created in their support plan.

Step 2c: Select ‘Add recommended long term living arrangement’. A pop-up box will display, select the most appropriate long term living arrangement. Include comments where relevant to provide additional information regarding the most appropriate long term care needs for the client. Only one recommended living arrangement can be selected.

Step 2d: Select ‘Add a care type for delegate decision’. A pop-up box is displayed, select the care type recommended for approval. Additional information may be required, depending on the type of care selected (i.e.the end date if it is a time-limited approval, the priority of the referral, and whether it is emergency care).

Select ‘Save to plan’.

For Home Care Package recommendations, priority for care type will default to ‘Medium’. For all other care types that require delegate decision, this will default to the latest priority for assessment set in the referral for assessment. Assessors should continue to assess the priority and change the ratings as necessary.

For Home Care Packages, the ‘Priority of this care type’ determines the ‘Priority for home care service’ for the purposes of assigning a place in the national queue.
The agreed minimum interim package level must be entered after discussing if the client is willing to receive a package lower than the level that is being recommended.
If it is determined that a client has a high priority for a home care service, please ensure that you enter the reason for this determination in the ‘Reason or comments’ field. Note that while this is a requirement for the assessor, the system will not enforce this.

To receive notification of any home care correspondence a client receives, this notification can be enabled from any tab in the client’s support plan or on the ‘Approvals’ tab in the client record. Only one person from an outlet can be selected to receive this notification. This option is only visible if there is a recommendation for home care.

The notification link will only be enabled if the client has been marked as ‘Seeking services’ or a home care package recommendation has been made.

Step 2e: Select‘No care type under the Act’. A pop-up box is displayed, select the reason for the recommendation that the client receives no care type under the Act, enter a comment or reason if appropriate and select ‘Save to plan’.

If you recommend ‘No care type under the Act’, you will be able to match and refer for CHSP services without needing to submit to the Delegate for approval.

Step 3: If you add a recommendation from the ‘Add to this goal’ section, the recommendation will be displayed underneath the goal. Select the arrow to the left of the goal to display the recommendation details.

Alternatively, if you add a recommendation from the ‘Other recommendations’ section or are adding a ‘No care type under the Act’ recommendation, the recommendation will be displayed underneath that heading. The recommendation will not be linked to a goal.

You may edit or remove a recommendation once it has been added (but before completing the support plan and submitting it to the Delegate for approval), by selecting either ‘Edit’ or ‘Remove’ on the ‘Goals and Recommendations’ tab.
You may also remove ’General’ recommendations from previous assessments, for example,where they may no longer be relevant to the client’s situation.

2.3.3 Adding recommendations for prior approvals

Prior approvals that a client may havethat were not created in My Aged Care do not automatically populate in a client’s support plan.

To issue service referrals for a prior approval, the approval must be manually added as a recommendation of ‘care type for delegate approval’. They will not be submitted to the delegate for decision. To do this, follow the steps in section 2.3.2 (step 2d) and the details of the approval will be displayed.

Once you have added a prior approval, you are able to match and refer for services for these approvals.

Prior approvals do not appear in the ‘Decisions’ tab of the client’s Support Plan, and they do not require another Delegate decision. You must still submit the assessment to the delegate, with a ‘No Change to Existing Care Approvals’ recommendation, to finalise the support plan and match and refer for services.

2.4 Decisions

The ‘Decisions’ tab contains information about any care types you are recommending for the client. The status of the decision (e.g.recommended care requiring delegate decision) will be displayed. Existing prior care approvals will not appear in the ‘Decisions’ tab.

The ‘Decisions’ tab is where you can upload a client’s application for care form for care requiring approval under the Act. Select ‘Browse’ to choose the correct file, and then ‘Upload’ to upload the document to the assessor portal. You will be able to locate this document by viewing the ‘Attachments’ relating to a client record.

2.5 Manage services and referrals

The ‘Manage services referrals’ tab enables assessors to issue referrals for services and care types (after the delegate decision if the client is applying for care under the Act). Quick Reference Guide - Referring for services (ACAT)contains detailed information on this process.

For home care package recommendations, you will not be able to match and refer for service until the client has been assigned a package from the national queue. This may occur after the support plan has been finalised.
Referrals to CHSP providers:
To refer the client to any CHSP services (or other services that do not require delegate decision) alongside a care type requiring delegate approval, you need to include CHSP services as recommendations. You can then either match and refer electronically, or manually arrange via a referral code and send referrals before or after you select ‘Save and submit for Delegate decision’.
You are not able to send referrals during the decision process.
You are not able to add any other CHSP services after the delegate approves the care types. If you need to add CHSP services after delegate approval, you will need to call the My Aged Care Service Provider and Assessor Helpline to arrange the referral(s) to service(s) or conduct a Support Plan Review once your assessment has been finalised.

2.6 Associated people

The ‘Associated people’ tab allows assessors to record any people that were involved in the development of thesupport plan, or will assist the client with actions within the support plan.

Step 1: Select ‘Add people’.

Step 2: Select ‘Add a person’.

Step 3: Enter required information and select ‘Save’ to add the associated person to the client’s support plan.

Step 4:Select the person you want to associate to the client’s support plan and complete the other mandatory fields as required. Then select ‘Save’.

Step 5: The person will now display in the ‘Associated people’ tab in the client’s support plan.

2.7 Review

The ‘Review’ tab enables assessors to schedule a date for review of a client’s support plan.During a review, assessors can review and, where appropriate, amend a client’s support plan. If necessary, a new assessment can be initiated for a client following the review.

Step 1: To schedule a review of a client’s support plan, select the calendar icon to choose a review date.

Step 2: Once a date has been selected from the drop down calendar, and a reason for review has been entered, select ‘Save changes’ to set the review date.

The review date will be displayed in the support plan.

Once a review date has been added to the support plan, the referral will display in the Team Lead’s ‘Upcoming reviews’ tab.

For more information about conducting a review of a client’s support plan, see the Conducting a Review of a Client’s Support Plan fact sheet available on the Department’s website.

3.Completing the support plan

A client’s support plan must be completed in order to be able to submit a client’s assessment and support plan to a Delegate for approval of a care under the Act, or to be able to send referrals for CHSP services where ‘No care type under the Act’ is recommended.

To complete the support plan, follow the steps below.

Step 1: Confirm that you have made all service or general recommendations, and are satisfied with the client’s goals and concerns, as the support plan cannot be edited after it has been completed and/or submitted for delegate decision.

Step 2:Select ‘Complete support plan’ from any tab in the client’s support plan.

The option to ‘Complete support plan’ is available at the bottom of any tab within the client’s support plan. If you have recommended any care types under the Aged Care Act 1997 (the Act), or are opting to make no changes to the existing plan, you will then be able to submit for delegate approval.

Once you complete the support plan, you will not be able to make any changes to the assessment or support plan, unless you have recommended any care types under the Act and the delegate returns the assessment to you as part of their decision making process.

Step 3:If you have not answered all the mandatory questions in the assessment, a pop up box will be displayed. You will be required to provide a reason for not completing all the mandatory questions before you can ‘Completeassessment’

If your reason for ending an assessment without answering all mandatory quesdtions is ‘Client deceased’, this will change the client’s status to ‘Deceased’ and make the client record read only. Any unaccepted service referrals will be recalled and the client’s access to the client portal will be revoked.
Important: Where a client is active in the National queue or has been assigned a home care package, this will remove the client from the National queue and withdraw any assigned home care packages.

Step 4: If you are submitting the client’s assessment to a delegate for approval, you will be taken to the ‘Decisions’ tab, where a summary of the care types for delegate approval is displayed. You can also upload the client’s application for care form.

Select ‘Save and submit for Delegate decision’.

Step 5: Select ‘Submit’ to send the client’s assessment to the delegate.

Step 6: The status ofcare types you recommended as part of the support plan requiringdelegate approval will display as ‘Awaiting Delegate Decision’.

Step 7:The assessment will now display as ‘Awaiting Delegate Decision’ in your ‘Current work’ tab.

4.Finalising the support plan

When you have completed the assessment, completed the support plan and submitted to the Delegate for approval (where applying for care under the Act), you will receive a notification when the delegate decisionhas been made.