CARE AND CASE MANAGEMENT PLAN 04 Community Aged & Disabilty Service LANDS END Steps: 1. Client referral and consent 2. Assessment 3.Eligibility 4.Care & Case Management Plan 5.Daily Client Plan Name Bessie Nangala Roberts Date of plan 10/08/14 HRN 147 258 369 DOB 17/01/1954 Diagnosis or Main Illness(es) ALERTS: e.g. client may be cytotoxic Concerns e.g. Purpose Statement Consumer level of involvement & control Arthritis Type II Diabetes (NIDDM) Explain /provide example of other relevant medical concerns N/A The purpose of care provision for Bessie is to encourage independent living and assist her to remain an active member of her family and the community Bessie would like to meet with the case manager on a quarterly basis to discuss how the service is being delivered. Her preference is for Cultural Aged Care to employ and manage the staff required for the delivery of care support according to her care plan. Monthly Budget to be: Emailed Posted Case Manager and Brokerage (Note if different from Coordinator, eg NT Disability Case Manager, Palliative Care team.) Caitlin Denning Brokerage Yes No Contact details Lands End Aged Care landsendagedcare@cac.org.au Organisations and people Involved in Case Management Planning Name Position &/or Organisation Notes / Contact Details Patricia James Daughter 08 8912 3456 04E_CARE & CASE MANAGEMENT PLAN_EXAMPLE_CAC AGED & DISABILITY_V1.1_05.09.2014 1
Goals and Management / Action Plan Identified Needs: MEALS / Delivery times &/or day Cost To support the family caring role through the provision of basic meal service Lunch only Lunch will be delivered Monday to Friday, a description of meals can be found in client information pack The client and family will prepare all other meals Aged Care Monday to Friday Client and family to provide all other meals $80.00 On days of public holidays or centre closure when meals are not prepared the client will receive a ration pack to cover meals for the day and the carer / family will cook or prepare this for him as required. Identified Needs: Domestic Assistance To provide Bessie with a tidy and pest free environment and ensure clutter and other hazards are minimised or eliminated to prevent falls To support good skin health and hygiene and support social acceptance Aged Care to clean Bessie's bedroom on a fortnightly basis. Family responsible for the cleaning of all other areas of the home. Aged care to wash Bessie's blankets on a fortnightly basis. Family to wash clothes and other items Aged Care Cleaning of bedroom and blanket washing Family for all other aspects of cleaning and laundry 120 mins (2.0) When Cleaning and laundry on a Tuesday fortnightly Identified Needs: Shopping To promote independence and allow Bessie the dignity of choice in purchases Family carer to take Bessie to the store and assist in all aspects of shopping When As required 04E_CARE & CASE MANAGEMENT PLAN_EXAMPLE_CAC AGED & DISABILITY_V1.1_05.09.2014 2
Identified Needs: Medication To assist Bessie to maintain good health status and minimise the risk of acute health episodes Family carer to assist Bessie to get to appointment and to collect and assist client to medicate where required When As required Identified Needs: Mobility To support Bessie in feeling comfortable and safe in moving around independently Client to utilise walking stick as required and alert aged care if there are any issues identified with mobilisation Aged Care to submit any requests for assistance for mobility aid, rails or assessments to ACAT ACAT When Identified Needs: Transport To allow Bessie to access places beyond walking distance to meet social and physical needs To assist Bessie to connect with others in the community and allow her to express herself creatively. will provide all transport services for Bessie for shopping and social activities Aged Care will pick up and drop Bessie off at the art centre on Monday to Thursday when the art centre is open. to pick up Bessie after work. Aged Care to support access to art centre 15 mins (.25) When Monday to Thursday 9.30am Identified Needs: - SELECT - - SELECT - - How Long - When 04E_CARE & CASE MANAGEMENT PLAN_EXAMPLE_CAC AGED & DISABILITY_V1.1_05.09.2014 3
Approval I agree to the help described in this Case Management Plan and I understand that I will be reviewed / reassessed by the Lands End Aged & Disability team at least every 12 months or when my needs change. When a new assessment is completed - if there are any changes in my care needs (my needs increase or decrease), a new care & case management plan will be completed. If there are no changes to my care needs the Re-assessment Review /No Changes table will be filled in on the next page and the above plan will remain current. A copy of this Care & Case Management plan will be kept on my client file at the Lands End Aged & Disability Service centre and I can access this document at any time. (If English is not the clients first language please ensure the person interpreting signs below) CLIENT Client Signature (if able to) B. ROBERTS Date 10/08/14 The client should sign this form. Only in exceptional circumstances should someone else sign. If someone else signed, complete the following Why was the Client unable to sign Name of the person who did sign Relationship to client CARER / FAMILY MEMBER Name of / Family Rep present Patricia James Relationship to client Daughter Signature P. James Date 10/08/14 INTERPRETER (FILL IN ONLY IF DIFFERENT FROM ABOVE) Name & Contact Interpreter Interpreter Signature Date AGED & DISABILITY COORDINATOR Name & Contact A&D Coordinator Manager A & D Signature Caitlin Denning, Lands End Aged Care, landsendagedcare@cac.org.au C Denning Date 10/08/14 04E_CARE & CASE MANAGEMENT PLAN_EXAMPLE_CAC AGED & DISABILITY_V1.1_05.09.2014 4
RE ASSESSMENT (No Changes to Care Needs) Where the client has been re-assessed and no changes are required to their care & case management plan - the below should be completed. Name Interpreter / / Advocate: Signed Interpreter / / Advocate: Name Interpreter / / Advocate: Signed Interpreter / / Advocate: Name Interpreter / / Advocate: Signed Interpreter / / Advocate: 04E_CARE & CASE MANAGEMENT PLAN_EXAMPLE_CAC AGED & DISABILITY_V1.1_05.09.2014 5