Guide to writing support plans

How to write support plans A part of the KeepAble ebook series

An eBook for staff engaged with support planning Are you involved in developing or working with support plans?

Then this resource has been designed to help you.

Check out more information at: keepable.com.au Funded by the Australian Government Department of Health, Commonwealth Home Support Program (CHSP) through Indigo Australasia Inc. The material contained herein does not necessarily represent the views or policies of the Australian Government. ©2022 Independent Living Assessment Inc.

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Making every opportunity matter

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Contents Section

1

Introduction

2

The purpose of a support plan

3

Who should be involved in the development of a support plan?

4

Who needs a copy of a client’s support/care plan?

5

How will I know if the plan is working?

6

Mrs. A. Case Scenario

7

Mrs A. Example Support Plan

8

Good Practice - Support Planning Checklist

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Creating more good days

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1. Introduction KeepAble are a team of people who are redefining what it means to age well. Their goal is to empower everyone to live more independent and healthy lives using smart, practical and engaging content that will help to deliver Wellness and Reablement approaches across the Australian Aged Care Sector.

We are dedicated to providing evidenced-based and trusted information on important topics around Wellness & Reablement.

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2. The purpose of a support plan

A support plan provides guidance to clients

Document WHY you are working together

and support staff on how to work together

(clients desired goals and outcome) and clear

in their pursuit to achieve the client’s goal/s.

strategies on HOW you will ‘work with’ the client

It builds on the information collected at

on activities that they have difficulty with, rather

the time of assessment by breaking down

than ‘do for’ them.

client goals into steps or actions using the strategies that will assist the client to reach

Clearly document what the client can do for

their goals.

themselves and what activities the support worker needs to do. WHO is going to do WHAT

Developing an outcome focussed support

and WHEN to support the client will assist

plan requires you to work with your client

with the understanding of the roles those

and document how you and your support

involve play. The support plan is to be used as a

workers will action wellness and reablement

communication tool between the client and staff

strategies to assist the client to achieve their

and is updated as the client progresses towards

goals.

achieving their goal.

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What would a consumer say?

• I welcomed the opportunity to talk and plan with the staff member, as I had many questions about someone coming to my home to help me.

• The plan has helped me to understand my role in becoming independent and to be able to do the things I want to do.

• Seeing my goal in writing and the steps I will take to achieve it, helps me to keep on track.

Sometimes different staff come to help me, having a plan helps me explain what I’m trying to achieve.

• The staff member really listened to me and understood what I wanted to get out of receiving the service.

• It was clear from the outset that what I wanted to achieve was most important.

• The plan is clear and steps out what I need to do and what the staff will do.

• It gives me confidence I can achieve my goal.

• I feel reassured if I have a setback, we can readjust my support to help me until I get back on track again.

• My family were happy they were able to come to the meeting to discuss the support services and how they work.

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3. Collaboration Who should be involved in the development of a support plan?

It is essential for the client be involved in the support planning process, and when appropriate others who provide informal support, such as a carer. Before meeting with a client for the first time it is important you read and understand the assessment report and support plan from the My Aged Care Service Provider portal.

Follow up with assessor if you require further clarification or health professionals and other service providers identified as having a role in the support of the client to achieve their goals.

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4. Who needs a copy of a client’s support plan?

• Clients should receive a copy of their support /care plan prior to commencement of services or as soon as possible.

• Where appropriate and with the client’s consent, carers and or others supporting the client to achieve their goals should receive a copy of the support/care plan.

• Direct support staff who will be working with the client to achieve their goals should receive a copy prior to the commencement of services.

“

The staff member didn’t ask me the same questions over and over again, they just wanted to check the information they had received was correct’

What would a consumer say?

• It’s good to have a copy of the plan, it helps

• It was good having a family member

me to keep on track, I show any new staff if

with me at the planning meeting, now

they haven’t already seen it.

understand the role I play in getting back

• The plan is so easy to follow, I know by

to do my daily activities.

whom, when and how I will be supported.

• When I was asked my opinion about the

• The staff member didn’t ask me the same

steps we should take to achieve my goals,

questions over and over again, they just

then it really felt like the plan belonged to

wanted to check the information they had

me.

received was correct.

• When we had trouble coming up with

• It was good to have a family member with me at the time of the planning meeting.

suitable steps the staff member asked advice from others with expertise.

They now understand that I want to get back to doing my chores how and when I want.

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5. How will I know if the Support p

Regular check ins with client and staff need to

Everyone involved with the plan needs

occur to confirm if the plan is still appropriate

to understand the importance of

and the timelines remain realistic.

communicating the progress or if the plan is not progressing and why.

Steps and strategies may need to be adjusted or the client may wish to review their goal/s.

The support plan is to be updated when changes occur, and all involved need to be made aware of the changes.

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plan is working?

What other information is required in a support plan?

• The support plan should display the start date of the service and when possible the staff who will be supporting the client.

• Days of the week support to be provided • Time of support service to be agreed with the client • Length of support service (End date of service/s.)

• Any additional information pertaining to the support of the client e.g.: use of assistive aids or equipment

“

My plan is updated with the most recent changes and this is communicated to all involved.

What would a consumer say?

• The support staff always report back to their supervisor when we have to make changes to the plan, even if it is for one day.

• Someone from the organisation gives me a call to chat about how I’m tracking along and see if we need to make changes to the plan.

• My plan is updated with the most recent changes and this is communicated to all involved.

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6. Mrs A. - Case scenario

Background

Introduction

Mrs A. lives with her husband in the family

Mrs A. has been referred to your organisation

home, and her husband is her primary carer.

for support to work with her and the

They have two children who live a couple of

physiotherapist to improve her strength and

suburbs away and assist when possible. They

mobility so she can resume accompanying her

have their own families and work full-time.

husband when doing the shopping.

Both Mrs A. and her husband attend church weekly, and Mrs A. has a sister living close by who visits regularly.

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Mrs A. Situation NSAF documentation identifies Mrs A. experiences chronic pain due to nerve damage and has very poor sensation in her right leg due to past spinal surgeries.

Her hip is also painful, and she is currently considering advice to have a replacement.

Mrs A. experiences continuous pain which she takes medication for, but the pain impacts most aspects of her daily life. She has experienced frequent falls and has increasingly been isolated due to declining mobility.

Active Assessment Mrs A. was observed furniture walking slowly around her home. She lives in a large twostory house and now finds the staircase very difficult to walk up and down. She uses a 4 wheeled walker when accessing the community but has started to spend most of her time at home due to poor mobility.

Mrs A. is independent in showering and dressing, she uses a stool in the shower and has rails to assist transfers, although it takes her a long time, she is keen to continue to do this independently. Mr A. drives locally to the shopping centre and the doctor, although, Mrs A. will remain in the car while her husband does the shopping as she now finds it too difficult to walk around the shop.

Her husband is now completing most of the household activities such as preparing and cooking of meals and some of the cleaning, they have a private cleaner once a fortnight to complete the rest of the domestic activities.

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Recommendations In-home physiotherapy assessment and exercise plan with the aim to regain some strength and balance. Support worker to visit twice weekly under a social support visit to assist with encouraging completing of exercises and walking short distances to assist Mrs A. to build up her strength and balance with the aim for Mrs A. to resume shopping with her husband and be able to feel confident to visit her sister’s home again.

“ Initial Meeting

I’d like to be able to walk around the shops so I can choose the groceries I want to buy.

Strengths and abilities: • Able to shower, dress and be ready to exercise • Able to take pain medication according to schedule • Able to mobilise with a walker to an area in the home where exercises are to be completed • Able to read and follow the exercise plan • Able to communicate if the pain is too much to complete exercises or a short walk • Able to provide options of where to walk and for how far, e.g., around the bottom floor of the home, out to garden or letterbox Difficulties: •

Experiences ongoing pain

•

She has experienced frequent falls, which has reduced her confidence when mobilising

•

Is not able to sit or stand for extended periods of time

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7.

Mrs A. support plan Client name: Mrs A. Staff member name: Julia Roberts Date: 01/02/2021 Client concern: Mrs A experiences back and hip pain which impacts on her daily life. She has become increasingly isolated due to her declining mobility.

Goal: I would like to feel confident to walk around the shop and accompany my husband while we do the food shop and visit my sister.

Client abilities: • Able to shower, dress and be ready to exercise • Able to take pain medication according schedule • Able to mobilise with walker to area in the home where exercises are to be completed • Able to read and follow exercise plan • Able to communicate if pain is too much to complete exercises or short walk • Able to provide options of where to walk and for how far e.g.: around bottom floor of home, out to garden or letterbox Client difficulties: • Experiences ongoing pain • Has experienced frequent falls which has reduced her confidence when mobilising • Is not able to sit or stand for extended periods of time Support details: (include day of week and time allowance and any specific instruction regarding the support)

End date: 12/03/2021

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Mrs A. support plan Support Plan Week 1 - include steps on how support staff are to work with client • Review the Physiotherapist exercise plan with Mrs A. to ensure both understand what has been recommended.

• Discuss with Mrs A. her confidence to complete exercises and walk. Check if she had any concerns.

• Discuss what days and times are the most suitable for her to be able to complete exercises and a short walk.

• Reassure Mrs A. that if she is unable to complete exercises and walk due to pain, she is to let staff know.

• Encourage Mrs A. to take short breaks between exercises or when needed.

• Ensure a chair is nearby or placed halfway along the path to lessen the risk of falling and be able to rest while walking.

• Encourage Mrs A. to complete as much of her exercise plan as possible as per the physiotherapist’s instructions.

Follow Up Week 1 - include notes on discussion with client Mrs A. stated she was experiencing some pain after completing her exercises on the first visit; therefore, she did not go for a walk.

Mrs A. stated she had been trying to complete the exercises every day as per instructions by the physiotherapist.

Mrs A. stated she was going to suggest to try and walk first when the support worker visited next time and, if tired or in pain, would do the exercises later or not on that day.

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Mrs A. support plan Support Plan Week 2 - include steps on how support staff are to work with client • As week 1

Follow Up Week 2 - include notes on discussion with client Mrs A. stated she had managed a walk and exercises on one of the visits with the support worker, but felt she was starting to feel stronger and more confident knowing there was a chair to rest on halfway up the hallway.

Support Plan Week 3 - include steps on how support staff are to work with client • As per week one but discuss with Mrs A. if she is able to complete both exercises and short walk.

• Discuss with her about lengthening the walk.

• Follow up with Mrs A. guidance with these changeS.

Follow Up Week 3 - include notes on discussion with client Mrs A. stated she is starting to feel more confident with her walking and completed exercises and walk on both visit days with the support worker. She also stated she has been completing the exercise every other day on her own.

Support Plan Week 4 - include steps on how support staff are to work with client • As per week three and incorporating longer walks into program including walking outdoors or around the garden.

Follow Up Week 4 - include notes on discussion with client Mrs A. stated this week she had not been feeling well and was experiencing pain more than normal, so had managed one walk and her exercises on a couple of days. Mrs A. stated physiotherapist had completed a home visit to review Mrs A’s progress, she was happy with progress which has been made and wants her to continue with the same plan.

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Mrs A. support plan Support Plan Week 5 - include steps on how support staff are to work with client • Discuss with Mrs A. how she is feeling and if she is able to complete exercises and walk.

• Encourage Mrs A. to perform exercises at a slow pace and take breaks when needed.

• Accompany Mrs A. to the supermarket to build up confidence out of her home environment.

Follow Up Week 5 - include notes on discussion with client Mrs A. has been feeling much better and completed exercises each day and walks with support worker. She stated she went for an additional walk with her daughter when she visited her during the week.

Mrs A. stated she was going to try and walk to the shopping centre next week with her husband and sit and wait for him inside the centre if she is unable to walk any further.

Support Plan Week 6 - include steps on how support staff are to work with client • Cut down to one visit and continue exercises and walks with guidance from Mrs A. on her pain and energy levels, encourage Mrs A. to take breaks and rests when required.

• Encourage Mrs A. to continue to exercise daily and walk with her daughter or husband when feeling up to the task.

Follow Up Week 6 - include notes on discussion with client Mrs A. stated her confidence has increased and she is aware when she needs to take a break or rest instead of pushing herself, this helps to lessen the pain in her joints. She also reported she had walked from the car park into the shopping centre and waited in a coffee shop while her husband completed the shopping.

She stated it was so good to be amongst the people in the centre, and almost felt like her old self. She is happy to continue her program without the support of the support worker; the physiotherapist is scheduled for another review in two weeks time.

Mrs A. is aware that if her situation changes, she can contact the organisation to discuss the best way forward and service can be reinstated if and when required.

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8. Good Practice Support Planning Check List It cannot be overstated how important a support plan is to guide all involved with assisting an individual to achieve their goal/s. Plans need to provide and communicate all the necessary information to ensure a client has every opportunity to be successful and like any good plan there are essential elements at the development and execution phases that will support a positive outcome for both the client and those involved.

Below is a checklist which covers these essential elements to guide staff who are developing support plans and ensure as an aged care provider you are making every opportunity matter for those who you support.

Have you read the client’s assessment, support plan and any other relevant information that has been provided?

Have you involved the client in every step of the planning process and any other people relevant and important to the success of the client achieving their goal/s?

Have you listened intently to what is important to the client, is this incorporated within the plan?

Are you aware of the clients strengths and abilities?

Are you aware of where the client needs assistance or encouragement?

Does the client, staff and others involved have access to a copy of the support plan?

Has the staff involved with the client’s support been provided with all the information they need?

Have you got a communication process in place to provide updates on progress while the plan is being carried out?

Have you got a process to update the support plan as changes occur?

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Funded by the Australian Government Department of Health, Commonwealth Home Support Program (CHSP) through Indigo Australasia Inc. The material contained herein does not necessarily represent the views or policies of the Australian Government. ©2021 Indigo Australasia Inc/Independent Living Assessment Inc.

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