Check out more information at: keepable.com.au 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. How to write support plans A part of the KeepAble ebook series 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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Check out more information at: Contents TheIntroductionpurpose of a support plan Who should be involved in the development of a support plan? Who needs a copy of a client’s support/care plan? How will I know if the plan is Mrs.working?A.Case Scenario Mrs A. Example Support Plan Good Practice - Support Planning Checklist Section12345678
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A support plan provides guidance to clients and support staff on how to work together in their pursuit to achieve the client’s goal/s. It builds on the information collected at the time of assessment by breaking down client goals into steps or actions using the strategies that will assist the client to reach their Developinggoals. an outcome focussed support plan requires you to work with your client and document how you and your support workers will action wellness and reablement strategies to assist the client to achieve their goals.
Clearly document what the client can do for themselves and what activities the support worker needs to do. WHO is going to do WHAT and WHEN to support the client will assist with the understanding of the roles those involve play. The support plan is to be used as a communication tool between the client and staff and is updated as the client progresses towards achieving their goal.
Document WHY you are working together (clients desired goals and outcome) and clear strategies on HOW you will ‘work with’ the client on activities that they have difficulty with, rather than ‘do for’ them.
Check out more information at: keepable.com.au 2. The purpose of a support plan
What would a consumer say?
• 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.
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• The plan has helped me to understand my role in becoming independent and to be able to do the things I want to do.
• It was clear from the outset that what I wanted to achieve was most important.
• The staff member really listened to me and understood what I wanted to get out of receiving the service.
• 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.
• It gives me confidence I can achieve my goal.
• My family were happy they were able to come to the meeting to discuss the support services and how they work.
• The plan is clear and steps out what I need to do and what the staff will do.
• I feel reassured if I have a setback, we can readjust my support to help me until I get back on track again.
Check out more information at: keepable.com.au 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 Followportal. 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. 3. Collaboration
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• It’s good to have a copy of the plan, it helps me to keep on track, I show any new staff if they haven’t already seen it.
What would a consumer say?
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’ “
• 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.
• 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.
• It was good having a family member with me at the planning meeting, now understand the role I play in getting back to do my daily activities.
• When I was asked my opinion about the steps we should take to achieve my goals, then it really felt like the plan belonged to me.
• Direct support staff who will be working with the client to achieve their goals should receive a copy prior to the commencement of services.
• When we had trouble coming up with suitable steps the staff member asked advice from others with expertise. Who needs a copy of a client’s support plan?
4.
• It was good to have a family member with me at the time of the planning meeting. They now understand that I want to get back to doing my chores how and when I want.
• The plan is so easy to follow, I know by whom, when and how I will be supported.
• Clients should receive a copy of their support /care plan prior to commencement of services or as soon as possible.
5.
Regular check ins with client and staff need to occur to confirm if the plan is still appropriate and the timelines remain realistic. Steps and strategies may need to be adjusted or the client may wish to review their goal/s. How will I know if the Support plan
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Everyone involved with the plan needs to understand the importance of communicating the progress or if the plan is not progressing and why. The support plan is to be updated when changes occur, and all involved need to be made aware of the changes.
“
Check out more information at: keepable.com.au 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 Whatequipmentwould 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. My plan is updated with the most recent changes and this is communicated to all involved.
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Both Mrs A. and her husband attend church weekly, and Mrs A. has a sister living close by who visits regularly.
MrsIntroductionA.hasbeen referred to your organisation for support to work with her and the physiotherapist to improve her strength and mobility so she can resume accompanying her husband when doing the shopping.
MrsBackgroundA.liveswith her husband in the family home, and her husband is her primary carer. They have two children who live a couple of suburbs away and assist when possible. They have their own families and work full-time.
6. Mrs A. - Case scenario
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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• She has experienced frequent falls, which has reduced her confidence when mobilising
• Is not able to sit or stand for extended periods of time I’d like to be able to walk around the shops so I can choose the groceries I want to buy. “
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. Meeting Strengths and abilities:
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
• Able to read and follow the exercise plan
• 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
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Initial
• Able to shower, dress and be ready to exercise
In-homeRecommendationsphysiotherapy
• Able to communicate if the pain is too much to complete exercises or a short walk
Difficulties:
• 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
• Experiences ongoing pain
Support details: (include day of week and time allowance and any specific instruction regarding the support)
• Able to read and follow exercise plan
Client name: Mrs A. Staff member name: Julia Roberts Date: 01/02/2021
• Able to take pain medication according schedule
Client abilities: • Able to shower, dress and be ready to exercise
• Able to mobilise with walker to area in the home where exercises are to be completed
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.
End date: 12/03/2021
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• Has experienced frequent falls which has reduced her confidence when mobilising
• Is not able to sit or stand for extended periods of time
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.
7.
• 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
Mrs A. support plan
• Reassure Mrs A. that if she is unable to complete exercises and walk due to pain, she is to let staff know.
• Discuss what days and times are the most suitable for her to be able to complete exercises and a short walk.
• Ensure a chair is nearby or placed halfway along the path to lessen the risk of falling and be able to rest while walking.
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 Mrsphysiotherapist.A.statedshe 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.
Support Plan Week 1 - include steps on how support staff are to work with client
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Mrs A. support plan
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• Review the Physiotherapist exercise plan with Mrs A. to ensure both understand what has been recommended.
• Encourage Mrs A. to take short breaks between exercises or when needed.
• Encourage Mrs A. to complete as much of her exercise plan as possible as per the physiotherapist’s instructions.
• Discuss with Mrs A. her confidence to complete exercises and walk. Check if she had any concerns.
• Follow up with Mrs A. guidance with these changeS
• As per week one but discuss with Mrs A. if she is able to complete both exercises and short walk.
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.
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.
• As week 1 Support Plan Week 4 - include steps on how support staff are to work with client
• Discuss with her about lengthening the walk.
• 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.
Mrs A. support plan
Support Plan Week 2 - include steps on how support staff are to work with client
Support Plan Week 3 - include steps on how support staff are to work with client
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Mrs A. support plan
• Accompany Mrs A. to the supermarket to build up confidence out of her home environment.
Support Plan Week 5 - include steps on how support staff are to work with client
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.
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• 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.
• Discuss with Mrs A. how she is feeling and if she is able to complete exercises and walk.
Support Plan Week 6 - include steps on how support staff are to work with client
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.
• Encourage Mrs A. to perform exercises at a slow pace and take breaks when needed.
• Encourage Mrs A. to continue to exercise daily and walk with her daughter or husband when feeling up to the task.
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.
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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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?
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.
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