1. The Practice Standards for the Implementation of Care Planning in Victoria.
Presented by: Kate Boucher, Integrated Chronic Disease Management Team & Shelly Lavery, Partnerships Team.
Primary Health Branch

2. Care Planning in Victoria
What is Service Coordination?
Where does care planning fit into service coordination?
What is a care plan?
What is the role of the Key Worker?
Practical activity
Care Planning Project
What we hope to achieve today is to articulate Victoria’s Service Coordination vision and practice standards for Care Planning
Provide some clear expectations for service providers
Provide information about state-wide tools, resources and support available to implementing care planning
Guide the implementation of care planning practice at a service provider level

3. Service Coordination Tower of Babel
according to the Book of Genesis,[1] was an enormous tower built at the city of Babylon.
Some believe that a vengeful God, seeing what the people were doing, came down and confused their languages and scattered the people throughout the earth.
The purpose of the Service coordination Practice Manual is to assist service providers to implement SC in a consistent manner. The manual has been designed as a reference guide for leading and implementing the practices and standards that underpin SC

4. Better Access to Services BATS (2001)framework
Service coordination is underpinned by consumer focus, social model of health, partnership & collaboration, competent staff
Significant change required to embed all elements of service coordination
–Systems & processes, cultural-organizational & individual
Since Service Coordination was introduced in 2001, government funded health and community services have been progressively implementing service coordination to achieve better outcomes for clients.
Consumer focus- driven by the needs of consumers and the community rather than the needs of the system or those who practice in it.
Social model of health- this framework is concerned with addressing the social & environmental determinants of health & wellbeing, as well as biological and medical factors ( bio/psycho/social)
Partnership & Collaboration- service providers work together ad take responsibility for the interests of consumers, not only in their own service but across the service system as a whole.
Competent staff- service coordination ( care planning) is undertaken by staff who are appropriately skilled, qualified, experienced, supervised and supported
Recognition that significant work would be required across a diverse sector to embed the principles of service coordination

5. What does Service Coordination mean to our consumers?
Easy, visible ‘entry’ into the system
Their full range of needs are identified as early as possible
They are treated as a whole person
Information about all services are up to date and readily available
They don’t have to retell their story every-time they see a new service
They control who and what information is shared

6. Elements of Service Coordination

7. Service Coordination Progress
Acknowledgement of urgent referrals within 2 working days
Initial Needs Identification is conducted within 7 working days of initial contact
Key message: results of the 2008 service coordination survey indicate mature levels of service coordination implementation in most of the areas covered by the survey.
commencing in the depth and breadth of service coordination implementation has been measured.
a web based tool is completed by PCP member agencies
203 agencies responded to the 2008 service coordination survey this included a total of 636 programs.
The chart on the slide shows that more than 90% of agencies who completed the survey responded to urgent referrals within 2 days.
Similar results were found for:
- obtaining client consent for disclosure of client information
monitoring clients between referrals
proving referral feedback and
responding to routine referrals
Service Coordination Survey 2008

8. Care Planning Results
Service Coordination Plans have been documented for consumers with complex or multiple needs who are receiving services from more than one agency.
When there is a Service Coordination Plan, the consumer's GP has a copy of the agreed Service Coordination Plan (if appropriate).
Although care planning is an integral element of service coordination it has been one of the least progressed
Particularly a coordinated approach where there are multiple issues and multiple providers involved
Today’s Presentation
What we hope to achieve today is to articulate Victoria’s Service Coordination vision and practice standards for Care Planning
Provide some clear expectations for service providers
Provide information about state-wide tools, resources and support available to implementing care planning
Guide the implementation of care planning practice at a service provider level
Finally to achieve an outcome of improving the consumer journey and experience by implementing care planning as part of SC in a consistent, high quality manner.
This presentation should also generate some thought and discussion into monitoring, benchmarking and continuous improvement activities to help develop care planning processes within your organisation.
Service Coordination Survey 2008

9. Service Coordination Progress
Care planning is an integral element of service coordination
BUT …..still a complex area which generates many questions……
Although care planning is an integral element of service coordination it has been one of the least progressed
Particularly a coordinated approach where there are multiple issues and multiple providers involved
Today’s Presentation
What we hope to achieve today is to articulate Victoria’s Service Coordination vision and practice standards for Care Planning
Provide some clear expectations for service providers
Provide information about state-wide tools, resources and support available to implementing care planning
Guide the implementation of care planning practice at a service provider level
Finally to achieve an outcome of improving the consumer journey and experience by implementing care planning as part of SC in a consistent, high quality manner.
This presentation should also generate some thought and discussion into monitoring, benchmarking and continuous improvement activities to help develop care planning processes within your organisation.

10. What is Care Planning?
Care planning required whenever assessment occurs
Dynamic process that incorporates care coordination, case management, referral, feedback, review, re-assessment, monitoring and exiting
Care planning involves discussion, negotiation and decision making between service provider and consumer to define goals and strategies, then identify actions and service to meet those goals.
Can be at a number of levels- single service, or a number of services both within (intra-agency) & across agencies (inter-agency)
-creates structure in the client pathway and links the client journey for chronic disease management
-ensures consistent and planned care across the continuum
Single service – straightforward
Where more than one service and more than one practitioners can require a coordinated approach particularly for people with chronic & complex conditions who are moving in and out of the system

11. Where does Care Planning fit?
Service specific
Intra-agency care plan
Inter-agency care plan
Single service – straightforward one practitioner involved e.g. Individual Treatment Plan, Self Management plan, Individual support Plan ( Disability)
An Intra- agency care plan is used for clients who require multiple services from within a single organisation, in order to coordinate service delivery. Clients have service specific care plans and an overarching intra-agency care plan. An intra-agency care plan can be documented using the SCTT Care Coordination Plan to
Articulate shaerd goals
Outline roles and responsibilities of each practitioner
Coordinate internal service provision to support and achieve their goals
Facilitate communication of agreed strategies and interventions, to ensure all involved in the consumer’s plan are well-informed and working towards rthe same goals.
Identify the person responsible for care coordination, key worker, care coordinator or case manger as appropriate
Monitor and review service provision (including recall) and plan for d/c, transition or exit from service
E.g a care plan involving a range of workers ( such as counsellor, support worker, GP) who work in the same organsiation
Inter-agency care plan
An inter-agency care plan is used with clients who have complex or multiple needs and require services from more than one organisation ( for example a client with a chronic disease). An inter-agency care plan can be developed using the SCTT Care Coordination Plan for clients who
Are involved with more than one organisation
Have multiple issues or problems that need to be addressed concurrently, such as chronic or terminal conditions
Are likely to experience better outcomes if the care and services they receive are coordinated between organisation over time.

12. What are the Benefits of Care Planning?
Assists consumers in achieving goals
Encourages active participation
Manages long term care/continuity
Provides documentation
Encourages a team approach
Proactive rather than reactive
Increases consumer awareness of services
Effective monitoring
Goals are identified by the client- goal directed care planning- encourages the client to be involved in their care and incorporates self management support, where possible.
Provides an essential checklist to ensure continuity of care
Provides a way of documenting essential information to be shared by others, including life saving actions for emergencies.
Encourages a team based approach, with the client at the centre
Increases consumer and carer awareness of support services available, and how and when to access them
Ensures effective monitoring of the clients health & wellbeing.

13. Key Features of Care Planning in Vic.
Nominate single key worker who has a specific role and responsibilities
Incorporation of care planning activities
Provision of effective monitoring
Coordination of referrals & feedback
Maximise collaboration with GP
Use of SCTT Templates
Nomination of a single key worker to promote effective communication between the client & service providers. The key worker may have a specific role, such as a coordinator. They are responsible, within the scope of their role, for ensuring the care plan is delivered and monitored, review dates are set, re-assessment are initiated, and feedback is given to referring service providers
Incorporation of care planning activities (from a simple booking of services through to comprehensive case management) for clients, where a client requires multiple services, or has complex multiple needs
Acknowledgment of the potential contribution of education and self-management to effective care
Provision of effective monitoring (both formal/informal) of a consumers health and wellbeing, and the effectiveness of services being delivered, for example through regular reviews
Referral and other information is coordinated, planned and efficient, and specific feedback loops are in place for other service providers and the client
Maximising the opportunities inherent in the federal governments MBS items, to facilitate and support collaborative Care Planning with GPs
Using the care Coordination Template for clients with complex or multiple needs, who require more than one service provider

14. Care Planning in Context of Chronic Disease Management
Particularly important in facilitating appropriate care for consumers with chronic and complex needs who require multiple services.
Consumers with chronic conditions may require care planning at all levels – single service plan, intra-agency and inter-agency
Must have a coordinated response across services and communication between service providers
Effective inter-agency care planning enables proactive rather than reactive approach to care for people with multiple support needs.
It is the most complex form of care planning, requiring a person in a specific role to coordinate information and assist the consumer to access appropriate care.
An interagency care plan provides a document for the coordination and client centred approach to addressing client needs.
The SCTT Care Coordination Plan is useful for documenting essential information, including life-saving actions for emergencies. It has been designed to encourage a team approach with the client at the centre.
The development of a care coordination plan can increase client and carer awareness of the support services available to them.
Service providers can use secure electronic forms of the Care Coordination Plan for efficient information sharing and on-line case conferencing
Examples of inter-agency Care Plan ( between organisations)
A care plan for an older person with a chronic condition, who receives services from a GP, uses a range of HACC services and allied health services from a Community Health Centre

15. Person Centred Practice
Partnership approach to care
Holistic approach to practice
Value of the role of family/carers
Support consumer to identify own needs/goals
Encourage consumer decision making
Support autonomy and choice
A partnership approach to care where consumers and service providers share knowledge, values, experience and information, and collaborate to develop goals and plan actions
Holistic approach to practice
Open clear communication, which respects a consumers values, culture and beliefs, based on practice that sensitive to cultural, communication and cognitive needs of the consumer ( for example, use of interpreters, translated material)
Respect for privacy
Consider the role of family and carers
Support clients to identify their own needs and develop their own goals
Encourage consumers to choose outcomes they define as meaningful
Encourage clients to participate in decision making partnerships in treatment, program planning and policy formation
Base practice on client values, backgound and choice as much as possible
Support consumers to examine risks and consequences
Encourage clients to use their own strengths and natural supports
Provide information to involve clients in decision making choices and streamline access to services
Respect the clients own style of coping and bringing about change
Support autonomy and choice
Encourage clients and participants to take responsibility for their part in the plan
Be flexible and responsive in planning car5e within the parameters of safety and service guidelines

16. What is in a Care Plan? Date care plan developed Participants
Consumer stated agreed issues/problems
Consumer stated agreed goals
Agreed actions/responsibilities/timeframes
Planned review date
Consumer acknowledgement of care plan
Actual review date
A Care plan is the documentation of items agreed to in the care planning process. All care plans should include these items:

17. Key Worker Role is likely to involve:
Engaging and empowering the consumer and acting as an advocate as required
Consolidating assessment or care plans
Good knowledge of existing services
Developing/documenting agreed goals/actions in collaboration (SMART)
Facilitate the creation, documentation and communication of initial care plan
Monitoring and review
The key worker role in Care Planning should be fulfilled by a trained service provider with the skills and competence to undertake care coordination. Each program area and local service system will have different guidelines, which determine availability of staff to perform the key worker role. Service providers may elect to elect to create a specific key worker role to support the implementation of Service Coordination.
A range of staff may participate in Care Planning by communicating communicating outcomes and progress to the key worker. People who may perform key worker functions, within the scope of their role, include: family support case managers, aged care case managers, disability support workers, integrated cancer services professionals, mental health case managers, housing support workers, nurses, d/c planners, social workers, care coordinators, GPs, HACC, Aboriginal liaison staff, or assessment staff.
When determining the key worker, consider client preference, relationship to client, level of engagement, frequency of contact, skills and capacity of the worker. The key worker may change over time.

18. Key Worker contin………… Liaising and communicating with participants
Organising & facilitating the case conference
Working in virtual/multi/inter discipline team
Discussing exit options and procedures
Feedback to referrers, GP & support workers
Ensuring documentation meets requirements of privacy legislation
Discuss with participants what key worker models are currently being utilised- share examples regarding above elemenets

19. Monitoring
Care Planning includes monitoring to ensure service is delivered as intended and is fulfilling the agreed goals. The role of the key worker and monitoring processes will be developed in the future.

20. GP Involvement in Care Planning
Involvement by GPs is the care planning for people with chronic/complex needs is essential
Communicate with GP’s to determine if there is an existing care plan
A copy of any developed care plan should be provided to the GP
CDM items available to General Practice- Team Care Arrangement
The involvement of GPs in Care Planning for people with complex or multiple needs or chronic diseases is essential.
Importantly, GPs can be involved in care planning led by other service providers, or they can lead Care Planning, which involves other service providers.
When a multi-service care plan is needed, service providers should consider communicating with the consumers GP to establish if there is already an existing care plan and determine the roles and responsibilities of the participants in the care planning process.
When a care plan is developed a copy of the care plan should be sent to the GP, with the consumers consent.
The ways that GPs can be involved in Care Planning are guided by the MBS Guidelines and general practice tools, which have been developed to meet MBS rules.
As part of the Chronic Disease Management (CDM) items available to general practice is a service for GP-only care planning, which is the General Practice Management Plan (GPMP). This is for clients who have a chronic or terminal medical condition without multi-disciplinary care needs.
The Team Care arrangement (TCA) is for consumers who have complex care needs and require other service providers in their care. If eligible, the consumer can access multi-disciplinary services, such as subsidised access to allied health, through a TCA. GP’s can be assisted by practice nurses, Aboriginal health workers and other health professionals in providing these items.
Further information about how GP’s can be involved in Care Planning can be obtained from your local PCP, local division of general practice.

21. How Can Agencies Support the Process of Care Planning?
Documented protocols
Documented care pathways
Up-to-date resources for staff
Relevant staff training
Defined practices/processes/protocols/system
Agreements between services (+GP’s)
Defined processes for monitoring, review, recall
This section sets out the Victorian Practice Standards for Care Planning:
Service providers implementing service coordination are expected to have these systems and processes in place
Documented protocols to guide a person-centred approach, including multi and inter-disciplinary practices
Documented care pathways that include early identification for consumers with complex and multiple issues
Up to date evidence and resources for staff, including service directories
Relevant staff training, for example in goal setting nad case conferencing
Documentation for staff that defines practices, processes, protocols and systems for intra-agency and inter-agency care planning
Documentation for staff such as position descriptions and service delivery models that defines the role, functions and responsibilities of the key worker
Agreements between services, including GPs, for communication, sharing information, referral, feedback, and exciting processes with other services including GP’s
Clearly defined processes for monitoring, review and recall
Process Objectives – Care Planning
To ensure that consumers are offered and have access to care planning and service coordination that :
Takes into account social, emotional, and health needs ( not just the presenting issues)
Is based on documented needs, consumer-centred goals and actions
Is person centred
Provides health education and empowers consumers to self manage, where appropriate
Includes an agreed monitoring process and review dates
Is underpinned by communication between the consumers and service providers

22. Good Practice Indicators
VHA Indicators
Service Coordination Manual
Consumer Outcomes

23. Care Plan Elements Date care plan developed
Client stated/agreed issues/problems
Client stated/agreed objectives/goals,
Client stated/agreed strategies/action
Timeframe for attainment of objectives/goals
Responsibilities for implementing strategies/action
Participants in development of care plan
Consumer Acknowledgement (signed or verbal acknowledgement recorded)
Review date of care plan (planned and actual)
Goal attainment
In the absence of clear guidelines for care planning we came up with a definition based on a review of literature and current practice which includes the components to be included in a care plan irrespective of the type of care plan
To be complete it requires all the elements to be present
These elements are consistent with the care plan as outlined in the new service coordination practice manual with the exception that we have the additional elements of goal attained which is a measure of outcome

24. Activity
The answers you seek……
……are in this room

25. Steps to Develop A Care Plan Activity
Does this person need a Care Plan?
What other care plans could this person already have?
How would you explain to this person what a care plan is and why you think they will benefit?
How do you obtain consumer consent to the care planning process?
Who are the people that need to be involved?
How would you obtain and record consent to share information?
How would you organise a case conference and who would be involved?
How would you agree on who the key worker would be?
Record all participants in care, their role and contact details.
Identify key issues, agreed goals (SMART), actions, responsibilities/target dates for each goal.
How do you decide on the review date?
How would you be confident that the consumer understands and agrees on the plan?

26. Care Planning Project 2007-2009
Initially developed to progress inter-agency care planning through PCPs
Care planning seen as a complex area requiring experienced practitioners able to coordinate care using a comprehensive person centred approach
Basic elements & principles of person- centred coordinated care planning not well known
This was intended to build on SC work & ICDM work of the PCPs
Considerable progress in areas of intake and referral and developing systems to support communication
Service coordination work at systems level- cross agency communication, intake & referral protocols, shared consumer pathways,

27. Care Planning Project found:
Care planning practice inconsistent
at inter-agency and intra-agency level
Care planning seen as a complex area requiring experienced practitioners able to coordinate care using a comprehensive person centred approach
Basic elements & principles of person- centred coordinated care planning not well known
That is care planning both within and across agencies

28. Why has it been difficult?
Increasing complexity & diversity within the service system itself
Diverse range of workers with different skills, qualifications and value bases.
Varied & inconsistent practice & approaches resulting in different outcomes for consumers

29. Key Issues Identified Through Care Planning Project
CP project identified skills & knowledge gaps, need for change management, definitions, guidelines, tools
Gaps in knowledge and skills in care planning
Definitions, guidelines not consistent
Lack of a consistent approach at DHS program level- policy & operational guidelines

30. Need for DHS Response to the Sector
To improve care planning practice at all levels
Provide resources to support systems development
Opportunity to start process of integration of consistent principles and guidelines across programs where possible
Improve care planning practice – particularly a coordinated approach across & within agencies
Assist change management and systems approach
Discuss ways of integrating consistent guidelines & approach

31. Tools and Resources
Service provider or program Care Planning Guidelines and tools
Service Coordination Tool Templates (SCTT) Care Coordination Plan
SCTT 2009 User Guide
Service Provider policies: Eligibility, criteria, priority, access
The human Services Directory
MBS care planning items
Integrated Health Promotion Tool Kit
Training resources