What does care management include under Support at Home?
Care management includes developing and reviewing your care plan and budget, coordinating services, monitoring risks and outcomes, responding to changing needs, providing information and helping you navigate the aged care system. It must include meaningful direct contact at least once each month, even if you self-manage.
Key points
- Care management helps organise, monitor and adjust your care so services remain safe and suitable.
- The person's support plan and circumstances determine how the rule applies.
- Current official guidance should be checked before an important decision.
Care management includes the work your provider does to plan, coordinate, monitor and review your Support at Home services.
It is not limited to arranging workers. Its purpose is to make sure your approved services reflect your needs, preferences, goals, safety risks and cultural requirements.
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01Guide sectionDeveloping your care plan
Your care partner should work with you to develop an individual care plan before, or by the day, your services begin.
This includes:
understanding your needs, goals and preferences
reviewing your My Aged Care support plan and approved services
identifying help already provided by family, friends or other services
discussing cultural, language and communication requirements
completing relevant safety and home-risk assessments
developing your service schedule and quarterly budget
establishing and reviewing your service agreement
recording emergency and escalation arrangements.
The care plan should explain what support will be provided, how it will be delivered and what outcomes it is intended to achieve.
02Guide sectionPlanning and coordinating services
Care management can include:
deciding how approved services will be used
coordinating nursing, personal care, allied health and other supports
communicating relevant information to workers
involving family members, carers or registered supporters with your consent
incorporating cultural preferences into service delivery
ordering approved consumables
coordinating transitions between hospital, home, respite or other care settings
helping prevent gaps or duplication between different services.
Your care partner should help ensure that the different people involved in your care understand their roles.
03Practical actionManaging your quarterly budget
Your care partner should help develop and monitor your individualised quarterly budget.
This includes:
explaining how much funding is available
explaining provider prices and participant contributions
helping prioritise services
checking that planned spending is sustainable
monitoring spending to prevent an unexpected budget shortfall
reviewing the mix of services when needs or prices change
providing clear information so you can make informed choices.
Care management should not be used simply to control spending or deny suitable services. Budget decisions should still reflect your assessed needs and goals.
04Guide sectionMonitoring your care
Care management includes ongoing monitoring of whether services are:
being delivered as planned
safe and appropriate
meeting your needs
helping achieve your goals
responding to changes in your condition or circumstances.
The care partner may:
review workers’ care notes
speak with you about how services are going
discuss concerns with workers or clinicians
participate in case conferences
identify emerging health or safety risks
follow up after a fall, hospital admission or other incident
arrange an earlier care-plan review when necessary.
The provider must deliver at least one direct care management activity each month. This should generally involve at least 15 minutes of meaningful communication with the participant or their registered supporter. More frequent care management should be provided where the person has complex or changing needs.
A monthly care management activity may be a telephone call, video discussion or meeting. It should involve meaningful engagement, not merely an automated message or administrative contact.
05Guide sectionReviewing your care plan
The care plan should be reviewed:
at least once every 12 months
whenever your needs change
when services change
after a significant health event
when your goals or preferences change
when safety concerns arise.
A review may result in changes to your service mix, budget, worker instructions or risk-management arrangements.
Where your My Aged Care approval or classification is no longer sufficient, the care partner can help you request a Support Plan Review or reassessment.
06Guide sectionProviding information and support
Care management may include helping you:
understand your rights and responsibilities
understand your Support at Home approval
make informed decisions about services
navigate My Aged Care and other health or community systems
connect with GPs, hospitals, allied health or other relevant services
access interpreters or translated information
understand wellness and reablement approaches
prepare or review advance care planning documents
provide feedback or make a complaint.
A care partner can help you raise a complaint, but the provider cannot charge its complaint investigation and resolution work to the care management funding pool.
07Guide sectionSupporting families and carers
With the participant’s consent, care management may also involve:
communicating with family members or carers
explaining changes in care needs
including supporters in planning discussions
helping carers navigate aged care services
identifying risks of carer stress or burnout
linking families with respite or other support.
Family involvement should reflect the participant’s wishes and privacy rights.
08Guide sectionWhat does care management not include?
Some ordinary provider administration cannot be claimed as care management.
Excluded activities include:
creating staff rosters
scheduling routine visits
assigning or replacing workers
submitting government claims
staff travel
staff training
recruitment and performance management
ordinary financial and operational reporting
incident reporting administration
investigating and resolving complaints
routine care notes completed by support workers.
These are provider operating responsibilities and should not be presented as individual care management delivered to you.
09Guide sectionHow is care management funded?
For participants receiving ongoing Support at Home services, 10% of the quarterly classification budget is allocated to care management.
This amount is placed into the provider’s pooled care management account rather than remaining available for the participant’s direct services.
Because the funding is pooled:
you do not receive a fixed personal number of care-management hours
some participants may require more care management than others
the provider should allocate support according to complexity, changing needs and risk
every participant must still receive the required monthly direct activity.
The provider should be able to explain what care management it has delivered for you.
10Guide sectionDoes care management still apply if I self-manage?
Yes.
Self-management may give you more control over choosing workers, scheduling and managing parts of your budget, but the registered provider still retains responsibility for safety, quality, claiming and legal compliance.
A care partner must continue to:
maintain a care plan
monitor risks and service quality
review your needs and goals
explain your budget
provide at least one direct care management activity each month.
The 10% care-management allocation still applies to participants who self-manage ongoing services.
11Guide sectionWhat should good care management look like?
Good care management should be:
proactive rather than only responding when something goes wrong
personalised to your needs
clear about budgets and prices
responsive to changes
coordinated across workers and health professionals
culturally safe
respectful of your choices
properly documented.
Warning signs include:
no identifiable care partner
no meaningful monthly contact
unexplained budget changes
care plans not being reviewed
repeated service problems without follow-up
nobody responding to changes in health
family members being excluded or included against the participant’s wishes
routine rostering being described as personalised care management.
12Guide sectionWhat should I do next?
Check the person's Notice of Decision and support plan.
Ask the provider or My Aged Care to explain how the rule applies to this situation.
Keep the advice and any agreed changes in writing.
13Guide sectionHelpful Local Home Help resources
14Guide sectionCheck the official guidance
Check current official Support at Home guidance. Aged care rules, funding amounts and program guidance can change, so check the current official information before making an important care or financial decision.
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