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reword – We have developed all of our policies and procedures in line with the Aged Care Quality Standards and follow them from receiving the referral to delivering our service, monitoring the effectiveness of care delivery, and implementing continuous quality improvement. All processes are detailed in the Aged Care Policies and Procedures Manual (the Manual) attached to this application and referred to below. The key stages of our service delivery model are as follows: Initial Contact Initial contact with prospective consumers will be through a My Aged Care Referral or direct enquiry from the care recipient or their representative. The main objective of this stage is to consider the care recipient’s situation and provide information. This stage involves the following key steps: Verifying My Aged Care eligibility, service approvals and package levels. Downloading the National Screening and Assessment Form (NSAF) and conducting an initial evaluation of the care recipient’s assessed needs and identified risks to confirm our ability to meet their needs and preferences, including cultural and any other special needs. Determine any communication support requirements ahead of further contact and arrange support such as interpreters or relay services if required. Providing initial information to the care recipient about the types of care and services that can be provided, funding, pricing, service agreement if requested, and other material to support initial informed choice and decision-making. Further details about the processes we follow during this stage are detailed in the following sections of the Manual: Section 1(3)(c) – details how information provision supports initial decision-making about care and services. Section 1(3)(e) – details how the information provided is current, accurate, and timely and enables choice and decision-making. Intake/Onboarding When a consumer has decided to accept a home care package and engage with our service, we assign a Case Manager and commence intake and onboarding processes. The main objective of this stage is further provision and consolidation of information to support choice and decision-making, empowerment in understanding rights, building trust, and setting up the care recipient in the information management system: Update the My Aged Care portal. Undertake further information provision to the care recipient, including explaining the home care agreement in detail, as well as fees and charges, to ensure there is sufficient time for comprehension and decision-making prior to care planning and budgeting. Explain the Charter of Aged Care Rights and provide a signed copy for the care recipient to consider and sign. Explain our responsibilities in relation to the Charter of Aged Care Rights, the Code of Conduct for Aged Care, and the Aged Care Quality Standards. Explain in detail any other rights and responsibilities of the care recipient. Explain privacy, confidentiality, consent, and information sharing, and provide a copy of the ‘Consumer Consent Form’ for consideration ahead of the initial assessment. Provide the care recipient with the ‘Consumer Welcome Pack’, which includes the ‘Consumer Handbook’. Enter the care recipient into operational and financial software systems. Schedule a home visit for the initial assessment and care planning process, including any representative and communication support required. Schedule nursing attendance at the initial assessment if indicated. Further details about the processes we follow during this stage are detailed in the following sections of the Manual: The preamble includes the Charter of Aged Care Rights, the Aged Care Code of Conduct, and the Aged Care Quality Standards. Section 1(3)(a)-(f) – all sections apply to and detail various aspects of this stage. Section 2(3)(a) – outlines the processes that precede and underpin Initial Assessment and Planning. Initial Assessment and Care Planning The initial assessment is conducted by the Case Manager in consultation with a member of the Health Care Management team, such as a Registered Nurse (where indicated by the care recipients assessed clinical needs), and in partnership with the care recipient and/or their representative, with previously identified cultural and communication support where required. The objective of the initial assessment is to gain a deeper understanding of the care recipient, their assessed needs and personal preferences, any risks to their health and safety, and their wellness goals, and to formulate a care plan to meet the needs, goals, values, and preferences of the care recipient. Follow up discussions about the initial information provided to the care recipient to confirm their understanding and to provide further clarifications if required. Establish the care recipient’s health and wellness goals. Identify if any other services are in place, including informal services being provided by the care recipient’s carer, family, or others, and confirm whether these will remain in place, considering any carer stresses that may impact ongoing involvement. Identify to what extent the care recipient wishes to manage their own care and, therefore, what support they may require to do so. Identify other individuals or organisations, including the care recipient’s general practitioner, who are involved in the care recipient’s care, and establish a plan to include care delivery, inputs and communication. Comprehensive clinical assessment to establish a baseline, evaluate current health and functional status, and assess clinical risks. Assessment of the care recipient’s home environment, using the ‘Consumer Home Safety Checklist’, to identify safety risks to the care recipient and workers, to inform the delivery of services, and to identify equipment or home modification requirements. Establish the care recipient’s personal preferences for service delivery, including preferred day and time, type of worker, and gender preferences or cultural matching if applicable and possible. Identify and assess risks and vulnerabilities. Discuss and document advance care planning and advance care directives. Establish what services are essential and how continuity of care will be maintained during an emergency such as severe weather events. Identify care recipient needs that may be supported by additional supplements such as Dementia, Oxygen, or Enteral Feeding. Identify Goods, Equipment, and Assistive Technology needs. Identify other goods required, such as wound care or continence consumables. Identify clinical care requirements and determine the required frequency and type of clinical services and reviews. Establish and document the care plan review cycle depending on assessed needs and risks. Develop and complete the care plan using the ‘Consumer Assessment and Planning Form (Care Plan)’. Develop and discuss the ‘Individualised Budget’. Complete the ‘Home Care Service Agreement’ to reflect the agreed care and services plan. Further details about the processes we follow during this stage are detailed in the following sections of the Manual: Section 2(3)(a) – details the initial assessment and planning processes. Section 2(3)(b) – details how the assessment and planning processes include the identification and consideration of the care recipient’s needs, goals, and preferences, including advance care planning. Section 2(3)(c) – details how assessment and planning are conducted in partnership with the care recipient and others. Service Delivery Planning and Implementation Service delivery planning will incorporate the needs, goals and preferences information learned, assessed and documented during the processes described above into the service scheduling and delivery system and the coordination of all other inputs required in readiness for service delivery: Care recipient service requirements will be communicated to the Operations and Human Resources teams to commence the set-up of the care recipient’s service schedule and to plan and allocate appropriately qualified workers. The Case Manager will arrange any referrals required, for example: Allied Health assessments to inform equipment purchases, Specialist clinical referrals for complex wound care, Ongoing 6-weekly Podiatry appointments. The Case Manager will also arrange any relevant external service provision where this meets the preferences of the care recipient or for services unable to be provided by our organisation, for example: Home modifications through a licenced builder, Taxi transport to Podiatry appointments, Weekly attendance at day respite centres, Appointments or ongoing scheduled services are logged and monitored through the scheduling system to facilitate coordination and verify service delivery. The Case Manager will place orders for any one-off or ongoing supply of equipment or goods, for example: Mobility aids, Weekly meal deliveries, Monthly supply of continence aids. Any further care and services arranged are documented in the care plan and accounted for in the individualised budget, and copies are provided to the care recipient. The care plan is also communicated to all care workers, nurses, contractors, and health professionals attending the care recipient’s home or involved in their care. Further details about the processes we follow during this stage are detailed in the following sections of the Manual: Section 2(3)(c) – details how assessment and planning are conducted in partnership with the care recipient and others. Section 3(3)(a) – details how we plan and deliver personal and clinical care. Section 4(3)(a) – details how we plan and deliver services and supports for daily living. Sections 3(3)(e) and 4(3)(d) – describe how the care recipient’s care plan is communicated internally and externally. Sections 3(3)(f) and 4(3)(e) – details how we arrange and monitor referrals to other individuals and organisations. Coordination and Delivery of Care and Services: The coordination of care and services to care recipients, including the allocation of workers, will be managed through a scheduling system, which is described in Section 3.2 (7) of this application form. At all times, the schedule will reflect who is receiving care and services, on what day, at what time, and by whom. The coordination and delivery of care and services will be managed and monitored in the following ways: The Case Manager will be responsible for coordinating the care recipient’s care and services, including monitoring the care recipient, making any necessary changes in response to requests from the care recipient (including leave) or changes in assessed needs, coordinating any changes with the Operations Team, and overall monitoring and verification that care and services are in accordance with the care plan. The Operations team is responsible for the day-to-day management and coordination of the master service delivery schedule to ensure that the service delivery schedules of individual care recipients meet their needs, goals, and preferences. This includes: Daily allocations of workers in consultation with the Human Resources Team, Adjustments to the service schedule in response to care recipient- or worker-initiated changes. Monitoring and verification of worker attendance and service delivery. Forward planning of human resources in consultation with the Human Resources Team. Direct supervision of workers. The Human Resources Team will be responsible for all aspects of recruitment, workforce planning (in consultation with Operations), training and development – including in response to emerging care recipient needs, for example, medication management or use of lifters, management of worker initial and ongoing credentialing, performance support and discipline, performance evaluations, etc. Ongoing monitoring The Case Manager is ultimately responsible for the ongoing monitoring of care and services delivered to each care recipient in collaboration with the Operations Team and the Health Care Team. This is facilitated by the following processes: Regular review of the service delivery schedule and verification of service delivery. Scheduled monitoring activities, including calls and home visits, to confirm with the care recipient that their care and services meet their needs, goals, and preferences. Monitoring of the care recipients’ individualised budget to ensure resources are adequate to meet their needs and that unspent funds are not accumulating. Conducting planned reassessments and reviews in accordance with documented frequencies. Conducting unplanned reassessments and reviews as needed. Proactively seeking feedback from care recipients about their care and services. Seek feedback from workers about care and service delivery. Monitoring the service delivery schedule to detect service refusals, staff exclusions, or missed services. Monitoring feedback and complaints. Monitoring incidents.

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