Goal-directed planning

CHCCSM001 Facilitate goal directed planning

This unit is about collaborating with clients to plan services to improve their independence and quality of life. It applies to a broad range of health and community service sector contexts and requiring a high level of collaborative skills to develop a plan based on needs that were identified in an assessment. These workers show autonomy, well-developed judgement, adaptability, and responsibility.

Students are typically already experienced in working intensively with clients with complex and diverse needs.

 

How you will be assessed

CA

You will be assessed on the job under the following conditions:

• use of suitable facilities, equipment and resources, including individualised case plans
• scenarios that reflect standard operating conditions and contingencies
• links to other local service agencies or organisations.

You will be assessed through:

• Assessor observation
• Supervisor reference (if the assessor is not the supervisor)
• Review of your workplace documents (e.g. procedures and case management notes)
• Interview/assignment based on the requirements below.

You will need to show that you have collaborated with at least three different clients to do goal-directed planning for providing services and resources to maximise and enhance their strengths, independence and quality of life.

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Interview/assignment questions

RK

1. What is the difference between complex and non-complex needs?
2. Describe the range of services, networks, resources and holistic solutions available to your clients with complex needs.
3. Describe the components of your service delivery system.
4. Where are the gaps in your service system?
5. Describe the characteristics and needs of your identified client population.
6. Describe the significance of the service setting, including working in the client's home?
7. What are your organisation policies and practices for case planning?
8. What are their strengths and weaknesses?
9. What legal and ethical considerations are relevant to developing plans? E.g.:
1. professional standards
2. code of ethics
3. duty of care
4. voluntary assumption of risk
5. informed consent.
10. How are these legal and ethical considerations applied in organisations? In individual practice?
11. Describe your organisation’s requirements and practices for documentation.
12. Describe the principles of:
1. beneficence
2. non-malfeasance
3. social justice
4. autonomy
5. advocacy.
13. Describe the natural supports of your organisation’s clients (e.g. family, friends, neighbours).
14. Describe current models and practices in goal-directed planning in your area of practice.

Note: Your assessor may also ask you a variety of what if questions.

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Detailed requirements

1. Develop a plan that addresses the client’s identified needs and goals.El 1/PC, RS. O,In, W

1. Collaborate with the client to:
1. Identify realistic, relevant goals and needs as a basis for planning.
2. Find out their preferred way to address their goals and needs
2. Document their goals, needs and preferences in line with your organisation’s requirements.
3. Build on their strengths and abilities to address their needs identified.
4. Clients have a right to make their own decisions (within legal parameters). You need to respect it.
5. Investigate the range of options available to address client-identified needs and achieve their goals.
6. Work with the client to plan a range of services that builds on their natural supports and strengthens them.
7. When specific services are not available, devise alternative strategies to meet identified client needs.
8. Inform the client of details of costs, and work with them to make sure the plan is sustainable in costs, access and availability.
9. Identify health and safety risks and plan for their management.
10. Support the client to make informed decisions about their plan. The plan needs to reflect their understanding of their current situation, their likely future situation and any future needs.
11. Write the plan in the client’s own words. Clearly identify all tasks and who is responsible for doing them.

2. Collaborate with others to develop and communicate the plan. El 2/PC, RS. O,In

1. Work with other professionals and organisations to provide services.
2. Explain roles, rights and responsibilities of client and service providers and make sure they are clearly written into the plan.
3. Involve the client and other relevant people as much as possible in planning and making decisions.
4. Consult other with the other service providers to plan for complex situations, and them coordinate with them.
5. Establish a communication strategy and process with all parties involved. Then communicate with everybody to make sure the plan is implemented effectively.
6. Share information between all organisations involved and keep them updated with current information.

3. Respond appropriately to diversity. El 3/PC, RS. O,In

If you are are working with clients from culturally and linguistically diverse (CALD) and Aboriginal / Torres Strait Islander backgrounds:

1. check that your plan is culturally sensitive and appropriate.
2. Involve representatives from ethnic organizations in the planning processes, according to clients' needs. (These might be ethno-specific and multicultural organisations or Aboriginal / Torres Strait Islander communities or organisations.)
3. Provide interpreter support in needed. (Follow your organisation’s protocols.)

4. Respond appropriately to clients with different levels of need. El 4/PC, RS. O,In

1. Many of your clients might have complex needs, or have complex situations in other ways (E.g. difficult family or social situations, or family or carer needs.
2. Help them get access to planning.
3. Maintain inter-organisation relationships and agreements, and promote them to address the client, their family and/or carer needs.
4. In the plan, include opportunities to build on the client's strengths and motivation to improve their quality of life.

5. Monitor implementation of client plans. El 5/PC, RS

1. Regularly monitor planned services, support and resources. Compare them with the client’s goals to make sure the plan is implemented effectively.
2. Maximise the client's potential for achieving their goals and meeting their needs.
3. Keep the client informed about delivery of services and resources in line with their plan.
4. Maintain collaborative relationships with clients, carers, their natural supports and other service providers.
5. Keep risks and needs under assessment. If there are any problems implementating the plan, identify them promptly and adjust the plan as necessary to best meet the client's needs and preferences.
6. Document and report any variations to the plan according to your organisation’s requirements and communication strategy.

6. Other.

1. Manage tasks and contingencies on the job
2. This unit follows Australian industry code of practice.

 

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Code for unit reqts: CA: Conditions of assessment El/PC: Element & criteria RE: Required evidence RK: Required knowledge RS: Required skills

Code for Foundation skills: L: Learning Id: Identify beliefs & thinking R: Reading W: Writing

N: Numeracy O: Oral communication N: Navigate world of work In: Interact with others G: Get work done