How often are care plans reviewed and updated?

How often are care plans reviewed and updated?

Your Support at Home care plan should be reviewed with you at least once every 12 months.

However, this is only the minimum. Your care partner can review and update the plan earlier whenever it no longer reflects your needs, goals, preferences or current services.

What is the care partner’s role?

Every ongoing Support at Home participant should have a care partner responsible for helping plan, coordinate and review their care.

Care management activity must occur at least monthly, although this does not mean the entire written care plan must be formally rewritten every month.

Regular contact may be used to:

• check whether services are being delivered properly

• discuss changes in health or daily functioning

• monitor the person’s budget

• review whether the current mix of services remains suitable

• respond to problems with workers or schedules

• identify whether a formal plan review is needed.

Even people who self-manage their services must still receive care management from a care partner.

When should the care plan be reviewed early?

Ask for an earlier review after:

• a fall or near fall

• a hospital admission or discharge

• a new diagnosis

• worsening pain, mobility or fatigue

• changes in memory or behaviour

• difficulty with showering, dressing, meals or medication

• a change in the support provided by family or friends

• carer stress or burnout

• a move to a new home

• a new safety concern

• repeated missed or unsuitable services

• a change in personal goals or preferences.

The provider should not wait for the annual review when there has been a significant change.

What should be reviewed?

The review should consider:

• your current abilities and support needs

• your goals and preferences

• the services being delivered

• whether those services are achieving the intended outcomes

• worker suitability and continuity

• risks and safety arrangements

• your schedule and preferred routines

• your individualised budget

• participant contributions

• any equipment or home-modification needs

• whether family or unpaid carers require additional support.

The updated plan should be current, accessible to you and understood by the workers delivering your services. Providers are required to ensure care and services plans are regularly reviewed and accurately reflect the person’s needs, goals, preferences and risks.

Can the provider change services without another My Aged Care assessment?

Sometimes.

Your provider may be able to change the timing, frequency or mix of services where:

• the services are already approved in your My Aged Care support plan

• the change addresses your assessed needs and goals

• enough funding is available

• the arrangement remains safe and appropriate.

For example, you may be able to use less cleaning and more social support if both services are approved and the revised arrangement fits within your budget.

Your provider should review the care plan and individualised budget with you before making significant changes.

When is a formal Support Plan Review needed?

Your provider’s care plan is different from the support plan issued through My Aged Care.

A formal Support Plan Review or reassessment may be needed if:

• you require a service that is not currently approved

• your ongoing funding classification is no longer sufficient

• you need substantially more support

• your condition or living circumstances have significantly changed

• you may need residential respite or permanent residential care

• your current My Aged Care support plan no longer reflects your needs.

You can request a Support Plan Review at any time through My Aged Care on 1800 200 422. Your care partner can also help prepare and submit the request.

Do I have to wait for the provider to initiate a review?

No.

You can ask your care partner for a review whenever you believe the plan is no longer working.

You might say:

“My mobility has declined since my hospital admission, and the current care plan no longer provides enough help with showering and meals. I would like the plan reviewed.”

Ask for:

• a date for the review

• a copy of the updated care plan

• a revised service schedule

• an updated individualised budget

• an explanation of whether a My Aged Care review is required.

What if the provider does not review the plan?

Raise the issue with the provider’s care-management or complaints team.

Explain:

• what has changed

• why the current plan is no longer suitable

• any risks created by the delay

• what review or service change you are requesting.

You can also contact My Aged Care directly or seek free assistance from OPAN on 1800 700 600.

What should I do next?

Check when your care plan was last reviewed. Ask your provider for a review if your needs, goals, services or circumstances have changed, or if the current plan no longer reflects the support you need.

You do not need to wait for the annual review. Ask for any agreed changes to be added to your care plan and provided to you in writing.

Helpful Local Home Help resources

Use Ask Liz to understand your options, prepare questions for your provider and explore suitable local support.