CHCAGE003 - Study Guide PDF

RTO No.
31736 |CRICOS 03010G
COMMUNITY SERVICES
Learner Guide
CHCAGE003 Coordinate services for older people
Student Name: Student No.
OFFICE USE ONLY

Document CHCAGE003 Coordinate services for older Person
Head of Operations
name people Learner Guide responsible
Version 2.0 October
Issue date Status Released
2016
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QUEENSFORD COLLEGE COMMUNITY SERVICES
Copyright
Copyright © 2016 Malekhu Investments trading as Queensford College. All rights reserved.
Version control & document history

Date Summary of modifications made
Version 2.0 October Version 2.0 Courseware transferred into new templates
2016
Learner Guide| Version 2.0 October 2016 2 of 39

CONTENTS
Topic 1 – Coordinate the delivery of the individualised plan .......................................................................... 4
Identify and prioritise the needs, goals and preferences of the older person outlined in the
individualised plan and Coordinate services and support activities in consultation with the older person
and colleagues .......................................................................................................................................... 4
Outline and clarify all service providers’ understanding of the individualised plan and their roles and
responsibilities .......................................................................................................................................... 8
Recognise signs consistent with financial, physical or emotional abuse or neglect of the older person
and respond in line with organisation guidelines ................................................................................... 13
Topic 2 – Liaise and negotiate with appropriate personnel and service providers ....................................... 18
Support the older person to access and negotiate resources in order to deliver identified services ..... 18
Recognise when a service and/or support worker is no longer able to provide the level of service
required and take action to minimise disruption to service delivery ...................................................... 22
Topic 3 – Support family and carers............................................................................................................. 26
Recognise the impact of support issues on the carer/s and families and refer appropriately and Provide
support and respite for carer/s ............................................................................................................... 26
Topic 4 – Coordinate feedback .................................................................................................................... 28
Explain to all service providers the mechanism/s for providing feedback on the effectiveness of the
individualised plan and Obtain feedback from service providers on the effectiveness of the
individualised plan and report to supervising health professional.......................................................... 28
Seek feedback from the older person and/or their advocate and report to supervising health
professional ............................................................................................................................................ 29
Support the older person to seek advice and assistance from relevant health professionals when their
goals are not being reached.................................................................................................................... 30
Topic 5 - further knowledge......................................................................................................................... 33
The social model of disability .................................................................................................................. 33
Manifestations and presentation of common health problems associated with ageing, appropriate
actions in response to these problems and when to refer ..................................................................... 34
Summary ..................................................................................................................................................... 38
References .................................................................................................................................................. 39

TOPIC 1 – COORDINATE THE DELIVERY OF THE INDIVIDUALISED PLAN

Identify and prioritise the needs, goals and preferences of the older person outlined
in the individualised plan and Coordinate services and support activities in
consultation with the older person and colleagues
Individualised plans
People who are ageing or those who have a disability have a capacity for physical, emotional, social and
intellectual development. They are entitled to the same conditions of everyday living as anyone else in
the community.
Clients require an individualised approach to deal with their unique issues, needs, abilities and character
traits.
Asking questions to confirm the plans of the client enables you to find the best care options for your
client's particular needs.
Questions should be delivered in a way that will encourage clients to share relevant information with
you, that is, current and past history, including physical, intellectual or psychological health.
Providing the client with open-ended questions enables you to assess the reasons consequences and
evidence for their responses. It provides the worker with a perspective on the client’s view of the world.
When gathering information from clients, it is useful to:

• Use simple words and short sentences
• Speak with the client in a manner that is age appropriate
• Be respectful of all their concerns
• Provide a quiet and private environment, free of distractions
• Address the person by their preferred name
• Allow enough time for the client to respond to your questions
• If the client appears to be struggling for words, gently suggest words that may assist them according
to the context of the conversation, but do not assume that you know what they want to say
• Try to frame questions and instructions in a positive way
Your organisation should have well-designed systems and procedures for case/ care plans. The types of
information you will require from your clients will include:
• Client’s history
• Currents wants
• Preferences
• Expectations
• Future intentions

When working with a client, you must ensure you:

• Are aware of the varying levels of support that clients need at different times
• Take into consideration case histories and family or representative contributions
• Utilise inclusive assessments that are based on client needs, abilities and readiness for care
• Design and implement plans that will enable clients to live in a manner as closely aligned with their
previous comfort needs as possible
• Take into consideration the original diagnosis, appropriate and necessary medical treatments,
adherence to the treatment plan, and the presence of co-existing conditions
Identifying the types of needs a client may have from the plan
In the community care sector, your job is to assist the person with a disability or ageing client to identify
and meet their needs. Depending upon the needs of your client, you may need to seek the assistance of
involving other organisations to meet the needs of the client.
As part of your role within your organisation, you may be involved both the designing of their
individualised plan, along with accessing and linking the client with the services they require according to
their plan.
The services that you may use will be dependent on both the individual needs of the client, as well as
what is available according to your location. There may indeed be variations from one state to another.
In order to provide a complete and quality service, you may require assistance from specialists.
Many people require more than one service to manage their needs. For example, Jack is an 85-year-old
man, living alone in his own home. The services he requires are:
• Meals on wheels
• Home help
• Transport to and from appointments
• Assistance with dressing and hygiene
• Wound dressing
You might need to collaborate with other care organisations and specialist services. Specialists are people
with qualifications in a particular field that can provide specific assistance to meet the needs of the client.
Specialist services can provide the client with assistance in areas of their life such as:
• Medical treatment
• Psychological support and counselling
• Financial management
• Legal advice
• Housing
• Day-to-day living requirements

There may be other services available which can provide your client with valuable assistance beyond the
scope of your own organisation, and your own level of expertise. Linking your client with the relevant
services will mean that you will have to know the process involved in doing so. Your organisation may
have a list or database of the services available. Your supervisor, manager and other staff members might
also be able to provide you with information about the range of available services and the required steps
in engaging them.
Let’s look in more detail at some of the services that you might use in the care and support of your
clients.
Domiciliary Care is designed to support people to continue living independently in their own homes.
Through the provision of assistance in the home, the client is able to live in their home for longer,
without the need to be admitted to a residential care facility, nursing home or hospital. It also assists in
improving people's quality of life by improving their health and well-being outcomes. Being able to live in
their own home provides for the emotional well-being of the person by maintaining a sense of
independence and empowerment. Some of the types of support offered by domiciliary care include:
• Home support services
• Home assistance
• Respite services
• Physiotherapy
• Occupational therapy
• Social work
• Health advice
• Community care nursing
Home assistance and support programs
Home support services can provide the client with valuable assistance by helping them to maintain a
clean and comfortable environment in which to live. It may be that the client has difficulty in keeping
their house clean, or as they age they are finding it more difficult to prepare meals for themselves. Home
assistance makes it easier for the client to live in their home, ensuring that their standards of living are
not compromised as a result of their decreasing ability to perform everyday tasks.
Home assistance programs can provide practical assistance and support to clients/ carers by carrying out
essential household modifications and maintenance that the client might not otherwise be able to do on
their own. Examples might be, helping with the cost of installing bannister and handrails, ramps and the
widening of doorways.
Respite services
These provide assistance for the regular carers of the client to ‘take a break’. They include:
• Residential respite
• In-home respite
• Centre-based respite
• Alternative/ shared family care - respite in care provider's homes
• Recreation and community access
• Emergency respite

• Child care
• Holiday programs, preschools, occasional care and out-of-school care
Physiotherapy
The purpose of physiotherapy is to restore physical function through exercise, massage and other
techniques, thus promote and maintain the client’s quality of life.
The aims of physiotherapy are to:

• Maintain mobility
• Restore function
• Decrease pain
• Promote self-management of joint and postural problems
• Encourage maximum level of independence
Physiotherapists can provide an assessment of the activities of the client such as walking, movement
restrictions, postural problems and disabilities. A client's physiotherapy needs are determined via an
evaluation of their functional activity.
A physiotherapist can also educate clients and caregivers about injury and prevention, coping with
disability and maintaining good health.
Occupational therapy
Occupational therapists assess how well a person manages their activities of daily living. Their assessment
provides a guide to ways the person’s independence can be enhanced in all aspects of their life.
Occupational therapists can make assessments relating to:

• Home assessment
• Home modifications required
• Activities of daily living that may require assistance such as showering dressing or feeding
• The need for mobility assistance, like the use of wheelchairs, scooters or walking frames
• The need for the client to access domiciliary care
• Assessing the movement of the individual after accident or hospitalisation
Social work
Social workers can be of benefit to your client by ensuring that the social and emotional needs of the
individual are properly met. They can provide assistance in counselling issues such as:
• Social isolation
• Grief and loss
• Lifestyle and decision making
• Mental health issues
• Relationships the client has with family and significant others

Health advice
People who are ageing or who have a disability will often require specialist health advice. Specialists can
provide education to clients regarding health issues such as diabetes management, nutritional advice,
wound care and continence issues, just to name a few. There are often clinic and home-based services
available to provide the necessary information. In some communities, special information sessions are
held on a regular basis and are open to clients, their carers and families.
Community care nursing
Community care nurses are able to provide planned home nursing services to clients there are a wide
range of nursing services aimed at assisting people to maintain their health, wellbeing and
independence. This might be short term, for example, if the client requires dressing changes after a
surgical procedure, or they may be more extensive if the client is suffering from a chronic illness.
The above are just some of the services that you may use in the care of your clients. Your organisation
should be able to provide you with a list of the services that are available
Outline and clarify all service providers’ understanding of the individualised plan and
their roles and responsibilities
The health system is placing greater emphasis on promoting the health and wellbeing of older people in
order to maximise their ongoing independence. This approach is facilitated through government policy
directions and funding, resulting in growth of health and wellbeing services (such as the Well for Life
initiative) that are an integral part of a comprehensive aged care service system. Improving care for older
people: a policy for Health Services is one policy initiative which outlines a range of strategies for health
services that are focused on inpatient care, post-acute community support and transition processes for
people moving from the acute setting to an ongoing care arrangement.
These integrated service approaches across the health and aged care system provide effective person-
centred and comprehensive services for older people through:
• Physical and emotional health promotion
• Rehabilitation
• Assistance with management of functional decline
• Effective treatments for chronic conditions
• Support and assistance with complex care needs
• Greater emphasis on integrated, multidisciplinary service approaches across the health and aged
care system, including increasing emphasis on early intervention, and providing care where it will be
most effective.
In this dynamic context it is essential that public sector services continue

to review their roles and services to remain responsive to the changing needs of their communities and
align to changing policy and broader service system developments. The public sector will continue to play
an essential role in facilitating access to
aged care services; however, in some instances alternative service configurations
or approaches may be required to better meet the emerging needs of communities, better respond to
the service preferences of older people, enhance service access and promote continued improvements
to service quality and sustainability.

Preparing a care plan including WHS considerations
The information gathered about the client’s needs from referral and assessment is used to prepare a care
plan. Care plans are given to the support workers to inform them about the client, the services they are
to provide, any WHS risks identified and control measures in place.
Included on care Example WHS considerations
plan
Client details Are there cultural factors which may influence choice of worker? Are there
infection control issues? Is assessment from another professional, eg
occupational therapist, required due to the client's condition, special needs or
level of function?
Types of Do services / tasks to be performed require specific attributes of workers? Is a
services safe work procedure or training required? Is equipment required to minimise
Specific tasks risks associated with tasks due to factors such as client’s weight / physical
condition?
Equipment Do workers need training in use of equipment? Is equipment appropriate to task
required and in good condition? Are there issues around moving / storing equipment?
Number of Is one worker safe to undertake the service due to client or environmental
workers factors?
Time and days Are night services required? If so, this creates additional security risks for
of service workers.
Duration of Is service for an extended duration that may require breaks for workers?
service
Care Manager’s Allows urgent communication with supervisors.
contact details
Special notes These may highlight other risk factors.
Your clients have rights and responsibilities under WHS legislation. Principally, your work should not place
the client at risk. However, they are also required to not place your workers at risk. Clients should be
informed of their WHS rights and responsibilities. This can be included in documents such as:
• Client handbook
• Standard information sheets/brochures provided to clients at assessment (e.g. make your home safe
for you and your support workers and volunteers – foreign language versions are also available)
• service agreement - examples provided
• Care plan
Ensure you inform clients of your organisation’s policies regarding:

• Smoking
• Cleaning products
• Animals
• Equipment
• Dignity and respect
• Hazard and incident reporting

Equipment
During assessment, and at the planning stage, equipment needs are identified. It is important to ensure
all equipment is available, appropriate to the task and in good working order to ensure efficient service
delivery and the safety of support workers and the client.
Equipment may be required for:

• Personal care
• Mobility
• Home cleaning
• Maintenance
• Transporting clients
Use the Safe cleaning equipment - guidance in conjunction with the Home Safety Check to conduct a
thorough risk assessment of equipment used for cleaning tasks. Provide clients with the Safe cleaning
equipment for you and your support workers brochure so they can check their cleaning equipment is
suitable for your workers to use.
Some mobility and daily living equipment may require client assessment by an Occupational Therapist
and the trialling of several pieces of equipment over time. The process of assessment, trial and
acquisition of this kind of equipment may be lengthy and can impact on service delivery.
Interim options for personal care and mobility equipment may need to be considered to provide a
suitable and safe service. These include:
• Equipment loan pools from hospitals, community, disability and home care organisations
• Equipment hire from pharmacies and/or equipment supply companies
• Direct purchase of equipment by the client or through seeking financial support from family
members or charities
Mobility and personal care equipment may also need to be used around or in conjunction with existing
client furniture. You should consider how the client's furniture may impact on service delivery. If clients
and their carers are considering replacing or purchasing furniture they should read the Choosing
furniture guidelines to ensure WHS is considered in the purchasing decision.
Home modifications
The work environment also needs to be safe for providing services. This may require modifications to be
completed prior to commencement of service delivery. Interim options may need to be considered so a
suitable and safe service can be provided whilst home modifications are completed. Interim options may
include:
• Providing the parts of the service that can be done safely
• Providing the service in another area of the house that is safe
• Doing tasks in a different way until the modifications are completed
• Providing the service away from the home e.g. At school, day program, relative’s house, community
centre

If you are considering temporary arrangements for showering clients whilst their bathroom is modified
refer to the factsheet Managing water in the bathroom for information and advice. Home modifications
should only be undertaken after assessment by an occupational therapist.
Common examples of home modifications to improve safety include:

• Bathroom modification to allow support workers safe access to assist with bathing;
• Installation of railings at stairs to assist clients with mobility issues;
• Installation of ramps to assist support workers required to transport clients in wheelchairs.
Further information on equipment and home modifications is included under manual handling strategies.
Assignment of the support worker to the client
The matching of a suitable support worker to the client’s needs is a critical element of the care planning
process. A good match is the first step in creating an enjoyable working relationship between support
worker and client. It is also good risk management.
Consider client factors such as:

• Geographical location
• Physical and behavioural needs
• Social needs and background
• Cultural and religious background
• Service preferences
Consider support worker factors such as:

• Geographical location
• Workload
• Cultural and religious background
• Health requirements
• Skills, knowledge and experience
This process begins with good recruiting procedures. Worker selection should take into account the:
• Nature of the work
• Physical demands of the work
• Psycho-social demands of the work
• Skills and experience
• Training and qualifications
You should provide information to prospective workers about the requirements of the job to help them
decide if they are suited to the work. Position descriptions should include documented roles and
responsibilities for support workers, which should be communicated to workers and potential
applicants.1
1
http://www.haccohs.adhc.nsw.gov.au/service_planning_and_delivery/care_and_service_planning

In all cases each care worker should be informed as to their job role and the part they play in the care of
each client. These tasks must be detailed and should provide procedures to assist them in the care of the
client.
Providing assistance
Supporting and assisting the older person to meet their needs, will involve assisting them with their
activities of daily living as well as encouraging them to participate in activities provided by your
organisation and those provided by other sources. Some of the activities of daily living that you may be
required to assist the older client with might include:
• Bathing and showering
• Nail care
• Dressing
• Continence and toileting
• Shaving
• Oral hygiene
• Provision of meals and feeding if required
• Skin care
• Planning menus
• Handling food
• Physical activity
• Assisting with medication
Of course this is not an exhaustive list and there will be many other roles that you will perform in your
care for a client. During assistance, you will need to ensure you make observations so that you can
provide reports and further treatment or care as required.
That may include observations of:

• Nutritional status
• Changes in skin
• General condition
• The mouth
• The ears
• Behavioural changes
• Mobility and range of movement
There are many activities that you will need to perform however to do this you will need to prepare well.
Your preparation to support the client will involve activities will include tasks such as:
• Ensuring that you have the necessary equipment, tools, personnel and resources required for the
task prepared
• Making sure that the environment arranged is safe and accessible
• Preparing and engaging your client

• Prompting the client where necessary

• Conducting personal care tasks
• Cleaning up
• Report according the activities of the client according to organisational procedures and
requirements
All of these activities are important in ensuring that you provide the optimal standards of care for the
client.
All of the activities that you engage in with your client should be guided by their individualised plan. The
plan will provide you with details regarding the client’s abilities and the activities with which they will
require assistance in meeting their needs.
The individualised plan should also provide you with valuable information regarding the like and dislikes
of the client. This may be the type of foods they like to eat, how they prefer to be addressed, what types
of hobbies or activities they like to participate in or other services they wish to use. Encouraging the
client to participate in planned activities, assists in keeping them actively engaged and thus promoting
their physical, social and emotional well-being.
Recognise signs consistent with financial, physical or emotional abuse or neglect of

the older person and respond in line with organisation guidelines
Client abuse and/or neglect are fortunately rare in Australia. However it does occur. Consider the
following report on an investigation conducted in 2014 by the Australian Broadcasting Corporation and
Fairfax:
When it comes to people with disabilities, caregivers are supposed to be exactly that - carers,
protecting the most vulnerable in our community. But what if managers in a major institution ignored
warning signs that staff may have been abusing people in their care, effectively allowing the abuse,
including sexual assault, to continue?
This week, in a joint Four Corners/Fairfax investigation, reporter Nick McKenzie lifts the lid on a major
scandal involving one of the country's biggest disability providers. How did a respected provider fail in
its duty to the people it has sworn to protect and nurture?
Despite their horrific experiences, a number of disabled people and former staff speak about their
treatment. The allegations they make are deeply disturbing.
They detail shocking sexual assaults repeatedly inflicted upon numerous disabled clients… with the
victims left to fend for themselves, scarred and terrified. They tell how complaints were ignored and
whistleblowers targeted, their warnings not acted upon. As a result, two men employed by the
organisation - and now allegedly a third - went on to rape and sexually abused disabled clients.
Read the complete article here: http://www.abc.net.au/4corners/stories/2014/11/24/4132812.htm
It is important that you recognise possible indicators of client abuse and/or neglect. Consider the
following examples of indicators of different types of abuse and neglect (bearing in mind that these are
general examples):

Forms of elder abuse
Physical abuse Non-accidental acts that result in physical pain, injury or physical coercion.
Unwanted sexual acts, including sexual contact, rape, language or exploitative behaviours,
Sexual abuse where the older person’s consent is not obtained, or where consent was obtained through
coercion.
Financial Illegal use, improper use or mismanagement of a person’s money, property or financial
abuse resources by a person with whom they have a relationship implying trust.
Inflicting mental stress via actions and threats that cause fear or violence, isolation,
deprivation or feelings of shame and powerlessness. These behaviours – both verbal and
Psychological nonverbal – are designed to intimidate, are characterised by repeated patterns of behaviour
abuse over time, and are intended to maintain a hold of fear over a person. Examples include
treating an older person as if they were a child, preventing access to services and emotional
blackmail.
The forced isolation of older people, with the sometimes additional effect of hiding abuse
Social abuse from outside scrutiny and restricting or stopping social contact with others, including
attendance at social activities.
Failure of a carer or responsible person to provide life necessities, such as adequate food,
shelter, clothing, medical or dental care, as well as the refusal to permit others to provide
Neglect appropriate care (also known as abandonment). This definition excludes self-neglect by an
older person of their own needs.
Signs and symptoms of elder abuse and neglect in care
Signs and symptoms of elder abuse and neglect in care include but are not limited to:
• Dehydration, malnutrition (without illness-related cause), untreated bedsores, and poor
personal hygiene unattended or untreated health problems hazardous or unsafe living
conditions/arrangements (for example, improper wiring, no heat, or no running water)
• Unsanitary and unclean living conditions (for example, dirt, fleas, lice on person, soiled bedding,
faecal/urine smell, inadequate clothing)
• A nursing home resident’s report of being mistreated
• An injury that has not been cared for properly
• An injury that is inconsistent with explanation for its cause pain from touching
• Cuts, puncture wounds, burns, bruises, welts
• Poor coloration, sunken eyes or cheeks
• Inappropriate administration of medication
• Frequent use of hospital or health care/doctor-shopping
• Lack of necessities such as food, water, or utilities
• Lack of personal effects, pleasant living environment, personal items
• Forced isolation

Behavioural signs:
• Fear; Anxiety; Agitation; Anger
• Isolation, Withdrawal; Depression
• Non-responsiveness; Resignation; Ambivalence
• Contradictory statements; Implausible stories
• Hesitation to talk openly; Confusion or disorientation
Signs by caregiver:
• Prevents elder from speaking to or seeing visitors
• Anger, indifference, aggressive behaviour toward elder
• History of substance abuse, mental illness, criminal behaviour, or family violence
• Lack of affection towards elder
• Flirtation or coyness as possible indicator of inappropriate sexual relationships
• Conflicting accounts of incidents
• Withholds affection
• Talks of elder as a burden2
Policy
When initial contact and identification of service need is undertaken, the relevant worker should pay
attention to the suspicion or identification of abuse.
If there is suspicion of abuse – either of an older person or the primary carer – the relevant worker
should first consult their supervisor before discussing suspected abuse with an older person.
Confidentiality of information must be respected, and the wishes of an older person who may experience
abuse should take precedence.
Workers involved in a service response involving elder abuse should be supported by their employer to
develop appropriate self-care strategies. Agencies need to ensure the provision of adequate supervision,
monitoring and training for workers involved in cases of suspect or alleged abuse.
Procedures
Acting on suspicion:
Commonly, several types of abuse may occur at one time, with indications of different types of abuse
being present. However, the presence of one or more indicators does not necessarily mean that abuse
has occurred. In these circumstances, workers should remain vigilant to indicators of abuse.
Many forms of elder abuse also constitute family violence. ‘Family violence’ includes violent behaviour
that is repeated, controlling, threatening and coercive, and occurs between people who have had or are
having an intimate relationship or significant relationship.
2 http://www.advocare.org.au/help-with-aged-care-complaints/signs-and-symptoms-of-eld/

Family violence is recognised in Tasmania as a range of behaviours perpetrated against a spouse or

partner. The Family Violence Act 2004 does not extend family violence offences to other family members.
This does not preclude people being charged with assault or restraint orders being taken out under the
Justices Act 1959.
Family violence occurs across all cultural and socioeconomic groups.
Identify the instance of abuse
A worker should determine the different possible types of abuse through sensitive questioning of an
older person and the older person’s family and friends. This should be done with the permission of the
older person, to ascertain what signs or symptoms of abuse have been observed or suspected, their
severity and frequency.
A worker may need to deal with a potential lack of capacity of an older person to give permission.
When abuse is suspected:

• Discuss your concerns with your supervisor
• Vital considerations when addressing abuse include how suspicion is managed, who is spoken to and
when
• Ensure that actions do not cause more harm, and do not undermine the rights of an older person or
their carer
• Considering some basic questions and issues relating to abuse can assist with needs identification.
• Open-ended, non-judgmental questions about caring and family relationships and dependencies are
recommended
• Any safety concerns for staff should be addressed and managed
Be aware that abusive situations make it more difficult for an older person to stand up for their own
rights. Identifying the alleged perpetrator or perpetrators of abuse is integral to this stage.
An older person may or may not be cognitively impaired or mentally competent, nor be aware of the
abusive situation. They may not even refer to it as abuse. The older person may actively shield the
perpetrator for fear of losing their support or help.
Gathering and substantiating information about individual cases of abuse might need to be done over
time, proceeding slowly and carefully.
Involve other organisations, drawing on their perceptions, judgment and experience to assist in
identifying suspected instances. This process helps validate concerns and supports health and community
care workers to act on triggers of suspicion.

Assessment
The assessment process collects, weighs and interprets relevant information about the client situation
and service needs, including suspected or actual abuse. Assessment is an investigative process using
professional and interpersonal skills to uncover relevant issues and develop a care plan.
Assessment is not an end in itself, but part of a process of delivering care and treatment. Several
assessments may be required, because specific disciplines collect and interpret particular information to
inform the recommended care plan. Each agency should have assessment tools in place that meet
consumer, service, agency, reporting and program requirements.
If your agency does not provide an assessment service for older people, you will need to refer to an
appropriate funded assessment service (for example, ACAT or HACC assessment or allied health
assessment) for the older person concerned. An older person involved in a suspected abusive situation
will need to agree to have the assessment. An assessment worker should first consult their supervisor or
line manager before discussing suspected abuse with an older person or an older person’s carer or family
members.
Assessment workers should contact specialist services for information on elder abuse matters, or a
culturally specific service to gain greater understanding of cultural sensitivities, should the older person
come from a CALD background. Refer to Section 8: Resources for information on government and non-
government services that may enhance an assessment worker’s capacity to act on suspicion and
allegations of elder abuse.
Comprehensive assessments that involve more in-depth or service-specific information include other
health and community care workers involved with the situation. Permission should be obtained from an
older person to involve other workers before undertaking additional assessments. Issues of
confidentiality may arise if permission is refused.
A range of considerations should be explored when identifying the next appropriate action, taking into
account all the information, context and timing of the situation.
Service-specific assessments
In the case of suspected or alleged abuse, a service-specific assessment may be needed, depending on
the type and scale of abuse.
While workers from different disciplines (for example, nurses, social workers, occupational therapists,
direct care workers) have distinct expertise, it may be appropriate to draw on broader knowledge such as
drug treatment, sexual assault, legal services or family violence services.
Where the abusive situation requires it, expertise beyond the scope of a discrete discipline should be
sought and included in the care plan and assessment process.3
3 Responding to elder abuse -Tasmanian Government practice guidelines for government and non-government employees

TOPIC 2 – LIAISE AND NEGOTIATE WITH APPROPRIATE PERSONNEL AND

SERVICE PROVIDERS
Support the older person to access and negotiate resources in order to deliver
identified services
Encouraging independence
The older person’s willingness and ability to direct the processes relating to the provision of their care
may be attributed to both how well informed they are and a recognition that they have the right to
refuse services.
In order to exercise choice and maximise independence, people require access to accurate information
and resources that will help them manage their own lives, understand their options and engage with and
actively participate in their community.4
The client has the power to determine the direction that their care takes. Those providing support
services should not presume what direction their care will take. As it is the older person who makes the
ultimate decision regarding the provision of their care and services, they are the person who is providing
direction to the support worker.
Whilst the support person can provide the client with information and suggestions which they feel may
be beneficial to their care, the older person has the right to refuse these suggestions and choose the path
they wish to take. They may wish to determine their ongoing care on a daily basis or institute planning for
their needs in the future. In the case where the support worker identifies potential issues in the way the
care in being planned or instituted then they may wish to raise this with the client, but ultimately they
need to respect the client’s decision.
Providing information to the older client, may assist them in making decisions about how they may
improve their lifestyle. The information needs to be relevant to their needs and lifestyle, how
improvements might be made, and should identify the services which could be of assistance to them in
meeting their needs. This information may be in relation to issues such as the provision of health care
services, equipment which might be beneficial to them, financial services or perhaps referrals that might
provide them with the further information they need. Providing this information enable the individual to
gain a better sense of control over their life.
If the older person is not given the responsibility of directing their care then there is a risk that they will
become compliant with the direction of the person or organisation providing the services. Subsequently,
this can negatively impact upon their independence. In this situation the provision of care and services is
directed by the provider and the older person risks losing their sense of empowerment. Whilst the
support worker may be compliant with respect to the provision of care and services, the overall effect
may be detrimental to the older person in that they can become reliant on others making decisions for
them.
There may be compliance issues arise when the support worker who is in a position of influence
promotes what they see as being beneficial to the client. If the worker promotes their ideas in such a way
that they are perceived to be insistent of intimidating to the older person, then this may result in the
4 http://www.adhc.nsw.gov.au/individuals/support/directing_my_own_life

older person feeling disempowered and having to do what they are told.
A more appropriate way of approaching the client regarding the way in which they utilise a particular
service would be to explain not only what services are available to them but how they might be
beneficial. I.e. there should be reasoning behind the suggestions given.
If the support worker identifies the need for an intervention which will be of benefit to the client, and the
client subsequently refuses, then there should be supporting documentation outlining the refusal as well
as the reasoning behind the refusal. Instances of non-compliance without the appropriate supporting
reasoning can sometimes be viewed as the client being merely obstinate or irrational. Providing the
reasoning behind their choice to refuse the implementation of services can assist in validating their
decision.
The older person may wish to consult with an advocate before making a decision based on the
suggestions of a support worker.
Advocacy services support people to actively participate in decision-making processes and conversations
that impact on their lives.
Advocates will listen and act in the best interests of the individual and support people with the aim to
increase independence and confidence to represent their own interests, and help them to be aware of
the different ways they can have a say.5
Higher care needs
Service users with high or complex care needs may require assistive aids such as hoists, pressure-relieving
mattresses and ambulation aids. If these are provided by the service provider, it is essential that they are
properly maintained and cleaned to ensure appropriate use.
Maintaining the temperature of medical supplies such as dressings, medications and other products may
also need to be considered to ensure their effectiveness.
If assistive aids such as hoists, pressure-relieving mattresses and ambulation aids are provided by the
service provider, it is essential that they are properly maintained and cleaned to ensure appropriate use.
NRCP services that prepare and/or provide meals need to be able to demonstrate that consideration has
been given to ensuring that food preparation buildings and infrastructure are safe and suitable for meal
preparation.
Overnight respite service providers are required to ensure that the physical environment provided for
service users is suitably maintained and safe with consideration given to the specific needs of the service
users. As service users may sleep at the facility, it is essential that the environment is suitably furnished,
maintained.
Incidental and leisure activity
Incidental activities are those where physical activity is undertaken as part of routine activities, for
example, walking to the dining room, transferring or dressing. Many other leisure activities also have a
physical activity component, for example, lawn or carpet bowls and dancing. Many of these activities can
5 http://www.adhc.nsw.gov.au/individuals/support/directing_my_own_life

be modified for participation by frailer or chair bound residents.
A six-week activity program conducted by an occupational therapist three times weekly in a hostel setting
(average age 82 years) resulted in significant improvement in time spent standing and walking, compared
to a control group. The activity program incorporated recreational, functional and physical activity in a
hostel setting, with each session lasting two hours. Types of activities included walking, gardening,
cooking and indoor bowls.
Many other forms of activity have the potential to achieve positive health outcomes. Programs need not
be confined or limited to those where there is current evidence of health benefits, but should use this
evidence as a basis for facilitating a broad involvement by residents in a wide range of activities.
Helping residents benefit from physical activity:

• Take the time and provide the opportunity for those residents who can, to walk to the dining
room/bathroom/toilet instead of using a wheelchair
• Encourage residents to shower and dress themselves
• Encourage residents to participate in a variety of leisure activities they find interesting, for example
gardening, lawn bowls, tai-chi, dancing
• Ensure that facilities for physical activity accommodate and encourage residents to participate.
• Planoutdooractivitiesthatincludeopportunitiesforresidentstobephysically active
• Encourage residents to try different types of dancing, such as ballroom, folk, Irish, line, tap and belly
• Health care providers can routinely talk to residents about incorporating physical activity into their
lives
Support the older person to access community support agencies to facilitate the achievement of established
goals
There are many external or community support agencies that clients can access to assist them to reach
their desired goals. Below we will talk about just a few.
Leisure Activities
Addressing support in leisure programs and daily recreational activities is essential to maintaining the
quality of life of your care recipients. Appropriate activities program will help to bring joyful pleasure into
the lives of your care recipients from culturally and linguistically diverse backgrounds, as well as foster
self-esteem and a sense of purpose and belonging.
Key considerations:
• Foster links with local community organisations that share the culture, language and religion of care
recipients
• Facilitate community and family involvement in activities
• Support care recipients to remain engaged with existing community networks
• Integrate activities with local community events
• Plan regular outings to places of significance to your care recipients
• Ask care recipients and/or their families which festivals and special days they would like to celebrate,
and how they would like to observe these occasions

• Explore the availability of community volunteers to provide social visits in the preferred language of
care recipients
• Support care recipients' access to media (including the internet, radio, TV and newspapers) as
desired
• Ensure that staff responsible for developing and implementing activities programs have been trained
in activity and leisure access processes
Additional resources and links:

• Australian Government Department of Social Services
• The Community Visitors' Scheme is a national program that provides companionship to socially
isolated people living in Australian Government-funded aged care facilities
• Seniors Card - The Seniors Card is a Government initiative in partnership with the private sector to
encourage people who have retired or who are working part time to continue to engage with the
community. Cardholders are able to obtain a wide range of discounted goods and services from
participating businesses including travel, accommodation, hospitality, entertainment and leisure
• The Companion Card - The Companion Card allows people with a profound disability, and who
require on-going attendant care, to participate in community activities and events without
discrimination. Companion Cards can be presented at participating organisations where cardholders
will not be required to pay an admission fee for their companion who is providing attendant care.6
Aged Care Service List
There is available for public download information on aged care services subsidised by the Australian
Government under the Aged Care Act 1997, including:
• Residential aged care services (aged care homes)
• Services that provide Home Care Packages
• Transition Care
• Innovative Pool
• Multi-Purpose Services providing aged care
• Services funded under the National Aboriginal and Torres Strait Islander Aged Care Flexible Aged
Care Program
The files are current as at 30 June 2014 and are updated annually.
Service Lists - Each downloadable file contains:

• The name and physical address of each service
• The aged care planning region of each service
• The types of care provided
• Residential aged care
6
http://www.culturaldiversity.com.au/resources/practice-guides/leisure-activities

• Home care packages

• Transition care
• Innovative pool
• Multi-purpose services
• Aboriginal and Torres strait islander flexible aged care
• The number of operational places for each type of care
• The name of the approved provider of the service
• The organisation type, (i.e.: not for profit, for profit, local government, state government)
• The remoteness classification of each service according to the Australian statistical geography
standard (ASGS), Australian bureau of statistics, 2011.
Note that some Home Care services deliver care in a different region or state from that in which the
Home Care service are based and that some Multi-Purpose Services serve more than one location.
These spreadsheets generally list places according to the location in which the service is based, rather
than the region in which the care is delivered. Consequently, regional totals derived from these
spreadsheets may differ from data published elsewhere in which places operated by cross-regional
services have been divided between the regions in which the services are delivered. This resource can be
found at:
My Aged Care https://www.dss.gov.au/our-responsibilities/ageing-and-aged-care/tools-and-

resources/aged-care-service-list
Recognise when a service and/or support worker is no longer able to provide the
level of service required and take action to minimise disruption to service delivery
There will be times when your service cannot assist a client and you may need to get advice from others.
There are many people that you could seek advice from when you are not sure what to do for example:
• Nurse practitioner
• GP
• Self-help groups
• Physiotherapist
• Occupational therapist
• Dept. of human services
• Police
• Ambulance
• Pain management clinic
• Psychologists
• Counsellors
Of course there are thousands more we could name but these few give you the idea.
Your organisation will have a list of people that they use regularly to consult on patient care. You should
familiarise yourself with this list and ensure you have current and up-to-date contact details on hand.

Determining options for referrals to other service providers
If a client requires support that does not fall within the scope of your agency, you may need to
investigate other options and refer them to another service provider. There are a number of important
issues to consider when you choose to refer a client to another agency, or to another member of your
team, be it an emergency referral or part of treatment planning. The most important consideration
should be:
• Is this the best possible service provider to refer this client to?
• Will they be able to adequately meet the needs of this client?
• Are there specific protocols (cultural and/or otherwise) that must be followed to ensure effective
referral processes?
To do this, you need a good understanding of the services and requirements of the agency that you are
providing referrals to, and of the skills and expertise of other members of your own team.
Service providers
Service providers are workers in agencies who can offer your clients a service, resource or program to
meet their needs. They could be government, private or community-based agencies. They could
specialise in meeting particular needs, such as drug and alcohol support services, or they could offer
general support to your client, such as counsellors or foster and respite care.
When you think about identifying other service providers for your client, consider:
• Existing service providers. Do your clients already have workers and agencies involved in their life?
• New service providers. What services/assistance do your clients agree they need and who can
provide it?
Make sure you are fully aware of the service options available to your client. You may need to locate a
resource file that lists service provider details, such as telephone numbers. You need to understand the
referral protocols for various services/agencies in your area.
If you decide that your agency cannot help the client, consult them about other options they would be
willing to investigate or give them a choice about alternative services.
You may need to negotiate with another service directly or on behalf of a client to make sure that the
referral is agreed upon and the roles and expectations of the service provider and client are clear.
A word of caution: Service providers only need to know as much personal information about your client
as will directly help them deliver their particular service. It would not be necessary, for instance, to reveal
personal details about your client’s family history to the worker helping them with job training skills.
* Remember to obtain your client’s consent to discuss their needs with service providers and assure
them that some information remains confidential. Most agencies have a form outlining ‘Consent to
Release of Information’ which clients sign; this identifies the type of information they consent to being
shared and the names of agencies with whom this information can be shared.
Finally, it is important that you are familiar with any policies or procedures that exist in your agency for
exploring other options and referring to other services. If you do not know, ask your supervisor for
assistance.

Make sure you are clear about your agency’s guidelines for the release of information.7
Protocols, policies and procedures for client referrals
The urgency of referral will be determined by several factors:

• Level of risk involved
• Wishes of the client
• Immediate nature of the demands for service (that is, response to crisis v. Response to long-standing
needs)
• Ability of yourself and/or your agency or service to meet all or some of the client's needs
• Wishes of other relevant stakeholders, e.g. Family, friends and other members of the treating team
After the initial assessment, you should have a reasonably good understanding of the above factors and
you will need to make a decision relating to the need for referral. There may be no need for referral at all.
This would occur, for example, when your service is able to meet all of the client’s immediate needs.
If your service is unable to meet the immediate needs of the client and, in particular, if there is a high
level of risk involved (for either self-harm or harm to others), the urgency of referral will be high.
You will need to make a quick decision about what to do and where to refer the client. In order to do this
effectively, you will need to have a good knowledge of what emergency procedures may be required and
what other services or agencies are available within the community. It is useful to keep a list of most
frequently used services handy so that you can recommend the best possible care for the client.
Support worker inabilities
There is extensive literature about the prevalence of stress in the healthcare workforce. A number of
significant risk factors have been identified:
• Conflict and interpersonal issues in the workplace
• Workload and/or lack of control over the work environment, lack of balance between home and
work life
• Unresolved losses, unrecognised mental health issues
• Personality and coping style
• Mismatch between motivations and expectations, and the actual reality of day-to-day work, and
• Problems with identifying boundaries and setting limits on expectations – either those of patients or
colleagues, or the clinician’s own expectations of him or herself.
Occupational fatigue / burnout
Burnout is a syndrome of emotional exhaustion, depersonalisation and reduced accomplishment that

occurs in health workers and others who work in human services. Burnout occurs when the stressors
exceed the person’s ability to cope. It is frequently assessed using the Maslach Burnout Inventory, which
has been well validated and is widely used in research.
Some markers of burnout are:
7 http://legacy.communitydoor.org.au/resources/etraining/units/chccs402a/section2/section2topic09.html

• Negative or cynical attitudes about patients and their needs

• Negative attitudes to work, the workplace, and/or colleagues
• Pervasive feelings of dissatisfaction and unhappiness related to work, and
• Physical and emotional symptoms (fatigue, boredom, irritability, headaches, weight loss, etc.) which
can be associated with absenteeism.
The impact of burnout on the healthcare worker, on the quality of the care they can provide, on their
workplace and colleagues, and on their family and friends, are potentially highly significant. Burnout is a
significant cause of psychiatric morbidity and of loss of staff.
Compassion Fatigue
What also needs to be considered is compassion fatigue, which results from the relationships between
clinicians and patients and their families. This ongoing issue for those who work with the dying, with the
constant need to form new relationships and then subsequent losses, can contribute to stress and to
burnout.
Resilience is the capacity to adapt under stress, and the ability to thrive and find satisfaction from
producing good outcomes in difficult situations. The resilient palliative care provider is able to monitor
their own levels of distress and identify and deal with potential problems in their practice. There is an
evolving literature on resilience and how to promote the qualities that also support professional survival
and growth.8
Service changes
During your care role with a client you may notice physical or mental changes that mean the service is no
longer appropriate for the client. For example: an elderly lady who has in the past lived at home and you
have assisted her with house work and personal care has become very unwell and is no longer able to
safely in her own home. She has deteriorated so much that she can no longer get around her own home
and is not eating at all.
You should report this to your supervisor and arrangements should be made for her that will suit her
changing needs. This may include:
• Arranging for nursing home care
• Admission to hospital
• Arranging an aged care assessment
• Respite until she becomes well again
Your supervisor will advise you on the action to take but if your role changes to the point where you have
to perform tasks outside your level of responsibility or outside those identified in the individualised plan
then they MUST be reported.
8 http://www.caresearch.com.au/caresearch/tabid/2179/Default.aspx

TOPIC 3 – SUPPORT FAMILY AND CARERS

Recognise the impact of support issues on the carer/s and families and refer
appropriately and Provide support and respite for carer/s
Responding to the needs of carers is the most vital part of the relationship, you not only need to identify
issues they may have but you need to act in accordance with that need.
People who care for a family member or friend can experience many rewards:
• The opportunity for personal growth and the development of new skills
• Proving that they can meet new challenges
• The satisfaction of knowing they have helped someone who needs them and done the best they
could to improve their quality of life
• Strengthening the relationship with the person they care for and knowing how much they
appreciate the help
• Receiving the acknowledgement of family and friends
On the other hand they also can experience some quite difficult challenges:
• Financial hardship
- 50% of primary carers are on a low income and many find it hard to cover living expenses, save
money or build up superannuation
- The extra costs of caring can be enormous. Caring families often have to find money for extra
expenses like heating and laundry, medicines, disability aids, health care and transport
• Health and wellbeing
- Caring can be emotionally taxing and physically draining. Carers have the lowest wellbeing of
any large group measured by the Australian Unity Wellbeing index
- Carers often ignore their own health and are 40% more likely to suffer from a chronic health
condition. Some health problems, like back problems, anxiety and depression, can be directly
linked to caring
- Many carers are chronically tired and desperately need to refresh with just one night of
unbroken sleep, a day off or an extended period with no caring responsibilities
• Social isolation and relationships
- Many carers feel isolated, missing the social opportunities associated with work, recreation and
leisure activities
- The demands of caring can leave little time for other family members or friends
- Carers often have to deal with strong emotions, like anger, guilt, grief and distress, that can spill
into other relationships and cause conflict and frustration
• Disadvantage
- Many carers miss out on important life opportunities, particularly for paid work, a career and

education
- Caring can take the freedom and spontaneity out of life
If you identify any of these problems then you will need to respond by providing assistance or referring
the carer to the appropriate service.
Caring for an elderly person can be a drain on any person. The main thing is that they are encouraged to
use the supports that are available to them. Supports may include:
• Respite - Respite care can give the carer a well-earned break and the person they care for variety
and extra social opportunities
• Counselling - counselling can provide all parties with a means to talk openly about their feelings and
can give everyone the release they need to just feel free to talk without offending or burdening
others
• Home care - can offer services to assist with cleaning, cooking and shopping
• Meals on wheels - provides daily meals for people in need when they are unable to cook them for
themselves
• Home nursing - can provide assistance with medications, wound management, showing, personal
care
Each of these services provide a different support and can be utilised in order to give the client, the
families and friends a break from the day-to-day care of the person.
Many carers see themselves as a family member who looks after a person they love, not as a carer. This
means that they may not think to look for, or ask for help. There are a wide range of services available to
help them in their caring role. Whatever the service, whether it’s short-term respite or counselling, it is
designed to lend them the support and assistance they may need. It’s things like having some extra help
and support that may mean they can stay in their caring role for longer.
If you are unsure about who to send them to or how to assist them please ensure you ask your supervisor
or manager. It is not enough just to acknowledge there is a problem, you will need to ensure you provide
these support they need in their time of need. Never let it wait until later. Act immediately!

TOPIC 4 – COORDINATE FEEDBACK

Explain to all service providers the mechanism/s for providing feedback on the
effectiveness of the individualised plan and Obtain feedback from service providers
on the effectiveness of the individualised plan and report to supervising health
professional
If you are the coordinator of service provision there are some things that need to do in order to support
your client’s and your staff members.
There are different mechanisms for the provision of feedback on individualised plans that may include:
• Communicating daily with client or significant others about meeting of needs: It is important to
ensure that effective two-way communication is undertaken on a daily basis with the client and
other personnel, carers or people involved in delivering the support services that make up part of
the case management plan. Communication may occur using a variety of different methods
depending on who is involved in the communication. Face to face conversations, and direct
questioning may be appropriate when communicating with the client and their carer while reports
and emails may be more appropriate and informative from personnel involved in the delivery of
other support services. It is important that the client feels comfortable talking with the case
manager and that they can communicate in an honest and productive manner, it is the responsibility
of the case manager to foster this type of relationship with the client to ensure that effective and
informative feedback may be able to be collected. Notes should be kept regarding how the client is
feeling and what their successes and concerns are throughout the case management
implementation process
• Participating in a case conference: Case conferences are collaborations and meetings between a
series of professionals that are involved with the these consist of planned meetings between
professionals where the case management implementation and procedures for a particular case are
discussed and the community services professionals attempt to provide feedback and insight into
the practices that they believe would have the most benefit to the client
• Recording observations about progress on activities: There are a series of tools and activities that can
be used in order to collect feedback on the success or impact of the case management
implementation. Activities may include games, role plays, specially designed tasks and procedures. A
series of observation points will need to be recorded on specially designed observation recording
tools that a case worker can use to record any progress or regression that a client is making, This
type of feedback can be used in determining the success and impact of the case management
procedures that are being used in a particular clients’ case
This feedback may be used to better improve the program and to better tailor the individualised plan and
services involved in the clients’ care. Some services may be more or less beneficial for different clients
and it is important to ensure that the services selected and the techniques used in order to support a
client to their goals are suitable for that particular client.

Feedback is an essential part of the review process and can be used to determine:
• That the services provided are actually being implanted as planned
• If needs of the client have changes
• Any potential barriers to the case management implementation
• Whether a change in the implementation process is required
• Whether the case management plan needs to be altered
• Engagement with the client continues
• That benefits of the case management plan continue
• That the plan is assisting the client in reaching their goals
Feedback is an essential part of the case management implementation review, it will be necessary to
constantly review the plan throughout implementation to ensure that the processes and services that are
being offered to and provided to the client are suitable to meet a particular clients,’ constantly evolving
and changing needs.
You will need to ensure you provide service providers with the information including any organisational
templates and instructions on the procedures for providing feedback.
Once you have received any feedback from service providers you will need to report it to their
supervising health professional.
Types of feedback that you may receive or have to provide may be in relation to:
• Health and physical changes
• Response to plan
• Changes in the plan
• Changes in capabilities
• Changes to abilities and skills
Your reporting mechanisms may be written or verbal and may include case plan meetings or templated
reports.
Seek feedback from the older person and/or their advocate and report to
supervising health professional
How can service delivery be modified in response to feedback?
The most critical aspect of reviewing client services is to act on the feedback gathered. If people do not
see some changes as a result of feedback they have provided, they will be unlikely to provide feedback
next time. Giving feedback requires a considerable investment of time and effort by the client; this
should be acknowledged in a formal way. Acting on the feedback is vital to continuous improvement for
your organisation.
Depending on the type of feedback provided you may have options on the responsibilities for example: If
the feedback relates to the service generally, e.g. office hours, referral procedure, and range of services
offered, it will probably be dealt with by the management committee or the manager and the board. If
the feedback relates to specific staff or support, it is probably going to be addressed by the relevant staff
member and their immediate supervisor.

For some service provider’s effectiveness is about whether the outcome is achieved, e.g. achieving
targets for people placed in jobs or integrated into the community. For most service providers, however,
effectiveness is about the client’s satisfaction levels with the support they are being provided with to
achieve their goals, and that they are being treated with dignity and respect and any information they
provide you is handled confidentially and with care.
Irrespective of the level or type of review of service quality, client feedback is essential. A service or an
individual may have quality systems and good intentions, but unless the individual or client is happy,
there is no quality service.9
Support the older person to seek advice and assistance from relevant health
professionals when their goals are not being reached
You will need to ensure you assist the older person to seek advice and assistance from relevant health
professionals if and when their goals are not being reached.
Advice may be sought from their:

• G.P.
• Physiotherapist and Occupational Therapists
• Social workers
• Psychologists
• Pastoral Care Workers
• Pharmacists
• Other health professionals
G.P
A G.P. or general practitioner can assist with medications, diagnosis of illness, both physical and mental
and can also assist the older person to manage deterioration and ailments that affect their daily living.
Many older people have had the same Doctor for many years and trust them implicitly so ensuring they
attend their Doctor on a regular basis can help to sustain and encourage them to do what is best for
them. Many older people will listen to their Doctor and perhaps not listen to you or a family member.
Physiotherapists and Occupational therapists
Physiotherapists help people to keep moving and to function as well as they can. Occupational therapists
look for any changes that may be needed in the home. This may include hand rails in the toilet or shower.
It could be a temporary ramp for a wheelchair. These aids can all help with your client’s daily life. These
changes can help them to stay at home safely. It will also help to support the family in providing care.
Physiotherapists and occupational therapists will often work together to help support people at home.
9 http://legacy.communitydoor.org.au/resources/etraining/units/chccs402a/section5/section5topic03.html

Social workers
A social worker can help client’s understand what is happening in the system. They can help them
understand any issues that will have to be tackled. This could be emotional, social or practical. Their role
is to help client’s adjust to changes they experience. They can also support family members and others
close to the client as they adjust to their illness.
Psychologists
Psychological care can be given in hospitals and palliative care units. It can also be given in private
practices with a referral from a GP. Psychologists look at behaviour, emotions and social factors related
to the management of palliative and ongoing care. This can include non-drug approaches to managing
pain. They can help the client and their carer as well as health professionals.
Pastoral Care Workers
Pastoral care workers and chaplains provide pastoral and spiritual care for everyone. It doesn’t matter
what religion, or none, that they have. Pastoral care workers see clients, their families and health
professionals. All will have different spiritual and emotional concerns.
A Chaplain is usually formally qualified. A pastoral care worker in health care will usually have some
training. Chaplains and pastoral care workers have often also been trained or had experience in another
field (e.g., nursing, teaching, social work) before they work in pastoral care.
Pharmacists
Pharmacists may be a member of the care team. They may also work in chemists or in hospitals. They
often provide helpful information on the effects of the drugs that clients are taking. They may go to their
home to review the client’s medicines and make sure that they know what they are on. They may talk to
the client’s health professionals or to their carer about medications.
Other health professionals
Dietitians, speech therapists, and complementary therapists can all help to improve a client’s quality of
life.10
Case management
Case managers are sometimes assigned to help coordinate care.
The role of the caseworker is to ascertain what the specific needs of a client are and then provide for
these needs by contributing to the organisation, planning and implementation of a case/care plan. The
purpose of a care plan is to ensure the client receives a range of services that meet their individual needs.
The plan will need to be created in accordance with the client and a range of specialised service
providers.
10
http://www.caresearch.com.au/caresearch/ForPatientsandFamilies/AboutPalliativeCare/WhoProvidesPalliativeCare/TheRoleofH
ealthProfessionals/tabid/954/Default.aspx

Needs are identified within requirements established by:

• International, commonwealth and state legislation
• Organisation policy and procedures
• Relevant program standards
Needs are identified for the purpose of:

• Reporting
• Planning for the full range of support e.g. day to day care, mid-term care, and family support
• Planning activities and/or program
The case plan will support and assist the client to meet their needs in order to reach a set of desired
outcomes.
When contributing to the creation of a case plan for an individual client a caseworker will need to take a
number of steps including:
• Support the client in determining their own needs
• Support the client in determining their own goals
• Organise a range of services and support to assist the client in meeting these goals
• Support the client throughout the entire process
• Monitor the plan to ensure it is effectively meeting the clients’ needs
The contexts for monitoring activities within case plan include:

• Placement setting; e.g. home, alternative care placement, and detention facility
• Client/s involvement
The main elements of casework are:

• Assessment of client needs and eligibility
• Determining client objectives
• Case planning to meet objectives
• Implementation of the case management plan
• Service referral and coordination
• Monitoring of the implementation and progress of the case management plan
• Reviewing of the case management plan and practices
• Transitioning the case to another manager if required
• Closing the case if no longer required
It is the role and responsibility of the caseworker to ensure that effective relationships are built between
themselves and the client or other carers and involved personnel to ensure that the client will feel
supported and that they can trust and rely on the case worker at all times. The caseworker will need to
assist the client in developing relationships with other service providers as well to ensure that the
implementation and carrying out of the case management plan will be beneficial and productive for the
client in question.

TOPIC 5 - FURTHER KNOWLEDGE

The social model of disability
What is the social model of disability?
The social model of disability says that disability is caused by the way society is organised, rather
than by a person’s impairment or difference. It looks at ways of removing barriers that restrict life
choices for disabled people. When barriers are removed, disabled people can be independent and
equal in society, with choice and control over their own lives.
Disabled people developed the social model of disability because the traditional medical model did
not explain their personal experience of disability or help to develop more inclusive ways of living.
An impairment is defined as long-term limitation of a person’s physical, mental or sensory function.
Medical model of disability
The social model of disability says that disability is caused by the way society is organised. The
medical model of disability says people are disabled by their impairments or differences.
Under the medical model, these impairments or differences should be 'fixed' or changed by medical
and other treatments, even when the impairment or difference does not cause pain or illness.
The medical model looks at what is 'wrong' with the person, not what the person needs. It creates
low expectations and leads to people losing independence, choice and control in their own lives.
Social model of disability: some examples
A wheelchair user wants to get into a building with a step at the entrance. Under a social model
solution, a ramp would be added to the entrance so that the wheelchair user is free to go into the
building immediately. Using the medical model, there are very few solutions to help wheelchair
users to climb stairs, which excludes them from many essential and leisure activities.
A teenager with a learning disability wants to live independently in their own home but is unsure
how to pay the rent. Under the social model, the person would be supported so that they can pay
rent and live in their own home. Under a medical model, the young person might be expected to
live in a communal home.
A child with a visual impairment wants to read the latest best-selling book, so that they can chat
about it with their sighted friends. Under the medical model, there are very few solutions. A social
model solution makes full-text audio recordings available when the book is first published. This
means children with visual impairments can join in cultural activities with everyone else.11
11 http://www.scope.org.uk/about-us/our-brand/social-model-of-disability

Manifestations and presentation of common health problems associated with

ageing, appropriate actions in response to these problems and when to refer
Age-related changes
When working in the community and dealing with older people it is very important that you take into
account the physical changes that are associated with ageing.
Some age-related changes, such as wrinkles and grey hair, are inevitable. It was once thought that
changes to muscles, bones and joints were unavoidable too. However, researchers now suggest that
many factors associated with ageing are due to inactivity and that performing physical activity can help to
reduce or reverse the risk of disability and chronic disease
Muscle and bone conditions in older age
Nearly half of all Australians over the age of 75 years have some kind of disability. Common conditions
affecting muscles and the skeleton, or the musculoskeletal system, in older people include:
• Osteoarthritis – the cartilage within the joint breaks down, causing pain and stiffness
• Osteomalacia – the bones become soft, due to problems with the metabolism of vitamin d
• Osteoporosis – the bones lose mass and become brittle. Fractures are more likely
• Rheumatoid arthritis – inflammation of the joints
• Muscle weakness and pain – any of the above conditions can affect the proper functioning of the
associated muscles.
Age-related changes in muscle
Muscle loss size and strength as we get older, which can contribute to fatigue, weakness and reduced
tolerance to exercise. This is caused by a number of factors working in combination, including:
• Muscle fibres reduce in number and shrink in size
• Muscle tissue is replaced more slowly and lost muscle tissue is replaced with a tough, fibrous tissue
• Changes in the nervous system cause muscles to have reduced tone and ability to contract
Age-related changes in bone
Bone is living tissue. As we age, the structure of bone changes and this results in loss of bone tissue. Low
bone mass means bones are weaker and places people at risk of breaks from a sudden bump or fall.
Bones become less dense as we age for a number of reasons, including:

• An inactive lifestyle causes bone wastage
• Hormonal changes – in women, menopause triggers the loss of minerals in bone tissue. In men, the
gradual decline in sex hormones leads to the later development of osteoporosis
• Bones lose calcium and other minerals

Age-related changes in joints
In a joint, bones do not directly contact each other. They are cushioned by cartilage that lines your joints
(articular cartilage), synovial membranes around the joint and a lubricating fluid inside your joints
(synovial fluid). As you age, joint movement becomes stiffer and less flexible because the amount of
lubricating fluid inside your joints decreases, and the cartilage becomes thinner. Ligaments also tend to
shorten and lose some flexibility, making joints feel stiff.
Many of these age-related changes to joints are caused by lack of exercise. Movement of the joint, and
the associated ‘stress’ of movement helps keep the fluid moving. Being inactive causes the cartilage to
shrink and stiffen, reducing joint mobility.
Physical activity can help
Exercise can prevent many age-related changes to muscles, bones and joints – and reverse these changes
as well. It’s never too late to start living an active lifestyle and enjoying the benefits.
Research shows that:

• Exercise can make bones stronger and help slow the rate of bone loss
• Older people can increase muscle mass and strength, through muscle-strengthening activities
• Balance and coordination exercises, such as Tai chi, can help reduce the risk of falls
• Physical activity in later life may delay the progression of osteoporosis as it slows down the rate at
which bone mineral density is reduced
• Weight-bearing exercise, such as walking or weight training, is the best type of exercise for
maintenance of bone mass. There is a suggestion that twisting or rotational movements, where the
muscle attachments pull on the bone, are also beneficial
• Older people who exercise in water (which is not weight bearing) may still experience increases in
bone and muscle mass compared to sedentary older people
• Stretching is another excellent way to help maintain joint flexibility
See your doctor before you start any new physical activity program. If you haven’t exercised for a long
time, are elderly or have chronic diseases (such as arthritis), your doctor, physiotherapist or exercise
physiologist can help tailor an appropriate and safe exercise program for you. If you suffer from
osteoporosis, you may also be advised to take more calcium. Sometimes, medications are needed to
treat osteoporosis.12
Typical Physical Changes
Some of the typical physical changes that can occur as a person ages are:
• Wrinkles
• Graying or loss of hair
• Thickening of the body
• Decline in senses
• Decline in reaction time
12 http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Ageing_muscles_bones_and_joints

• Arthritis (pain, limited movement)

• Decline in the elasticity of the muscles and skin (body)
Also, there are changes to the body systems themselves. For example:
Integumentary system;
As the skin ages, it flattens due to the loss of sub-cutaneous fat, skin cells, sebaceous (oil) glands,
sweat glands, melanocytes (pigment cells), and hair follicles. Lentigo (senile freckles) occurs, blood
flow to the skin is decreased, and nerve endings are lost or become less sensitive.
As a result, the skin loses some of its effectiveness: as a protector against bacteria, as an insulator,
as a thermal regulator, and as a sensory receptor. Since these losses cause wrinkling, loss of
elasticity, freedom of movement and expression are inhibited. The slowing of circulation results in
slower healing. The loss of color is also seen, as the hair becomes gray.
The skin generally functions well throughout life, though, and most changes in the skin due to aging
are not life-threatening. Most of the deleterious changes in the skin are cosmetic, as the drying and
thinning result in sagging and wrinkling, the hair becomes sparser and gray or white, and the
fingernails become rigid, tend to yellow, and are prone to splitting.
Skin disorders more common in the aging skin are senile pruritis (itching), keratoses (thickening in
patches), skin cancer, and decubitus ulcers (pressure sores), and herpes zoster (shingles).
The Skeletal System:
The primary factor in the aging of the skeletal system is the loss of bone matter. This loss is called
osteoporosis and refers to bone loss. The basic cause of bone loss is the fact that the relative rates
of production of osteoblasts (bone forming cells) and osteoclasts (bone dissolving cells) changes so
that more bone matter is dissolved than is laid down. This loss is much greater in women than in
men.
Other factors in the aging skeletal system are loosened cartilage around the joints, depleted
lubricating fluid in the joints, and hardened and contracted ligaments. These factors occur more in
men than in women.
The effects of these changes on our health status are significant. Bones become brittle and less
supportive of our activities, resulting in less activity, which in turn results in poorer health. The
excess bone taken up tends to reside in the arteries and local blood vessels, causing decreased
circulation. As broken bones occur, less mobilization results in other health hazards.
The social implications of these effects are widespread, especially in advanced conditions. One
becomes more dependent upon others, who might begin to avoid. One is less able to visit and to
participate in social events.
The alternatives to immobilization are difficult. Family, friends, and the community must be open to
assisting these individuals, and must be alert to avoid ascribing more limitations than are actual.
Other alternatives are preventive techniques.
The following diseases tend to increase the incidence of osteoporosis, and so should be treated
diligently: chronic alcoholism, diabetes, hyperthyroidism, uraemia, and collagen disease

(rheumatoid arthritis).
The Muscular System:
Since muscle cells are post-mitotic cells (unable to replace themselves once they are formed), all
muscle cell loss is permanent. Even though muscular response gradually slows with age even under
the best conditions, the loss of muscular capabilities is by far mostly the result of cell loss due to
inactivity. As muscle cells are lost, weakness and slowness increase.
The effects of these changes on our health status are not, in themselves, greatly deleterious. The
muscles, however, are the main tools for effecting strong circulation throughout the body.
The social implications of these changes are related both to appearance and to movement.
As the muscles become smaller, including the muscles in the face, and as adipose (fat) tissue
accumulates, including in the face, the entire appearance changes to that of an older person, with
all the ramifications described above in the description of skin changes. In addition, as muscle fibres
decrease, weaken, and slow, it becomes increasingly difficult to keep up with younger people, who
may make allowances, but who may also become avoidant.13
For further information on the bodies response to aging please go to:
http://www.longestlife.com/ebook/change.html
Other areas that may be affected by ageing are the senses, these include:
• Touch
• Smell
• Taste
• Sight
• Hearing
13 http://www.longestlife.com/ebook/change.html

SUMMARY
Now that you have completed this unit, you should have the skills and knowledge to provide services to
an older person. It involves following and contributing to an established individual plan.
If you have any questions about this resource, please ask your trainer. They will be only too happy to
assist you when required.

REFERENCES
http://www.haccohs.adhc.nsw.gov.au/service_planning_and_delivery/care_and_service_planning
http://www.advocare.org.au/help-with-aged-care-complaints/signs-and-symptoms-of-eld/
http://www.adhc.nsw.gov.au/individuals/support/directing_my_own_life
http://www.adhc.nsw.gov.au/individuals/support/directing_my_own_life
http://www.culturaldiversity.com.au/resources/practice-guides/leisure-activities
http://legacy.communitydoor.org.au/resources/etraining/units/chccs402a/section5/section5topic03.htm
l
http://legacy.communitydoor.org.au/resources/etraining/units/chccs402a/section2/section2topic09.htm
l
http://www.caresearch.com.au/caresearch/tabid/2179/Default.aspx
http://www.caresearch.com.au/caresearch/ForPatientsandFamilies/AboutPalliativeCare/WhoProvidesPal
liativeCare/TheRoleofHealthProfessionals/tabid/954/Default.aspx
http://www.scope.org.uk/about-us/our-brand/social-model-of-disability
http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Ageing_muscles_bones_and_joints
http://www.longestlife.com/ebook/change.html
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Version control & document history

Learner Guide| Version 2.0 October 2016 2 of 39

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TOPIC 1 – COORDINATE THE DELIVERY OF THE INDIVIDUALISED PLAN

When gathering information from clients, it is useful to:

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When working with a client, you must ensure you:

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Home assistance and support programs

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The aims of physiotherapy are to:

Occupational therapists can make assessments relating to:

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Community care nursing

In this dynamic context it is essential that public sector services continue

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Preparing a care plan including WHS considerations

Ensure you inform clients of your organisation’s policies regarding:

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Equipment may be required for:

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Common examples of home modifications to improve safety include:

Assignment of the support worker to the client

Consider client factors such as:

Consider support worker factors such as:

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That may include observations of:

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• Prompting the client where necessary

Recognise signs consistent with financial, physical or emotional abuse or neglect of

Read the complete article here: http://www.abc.net.au/4corners/stories/2014/11/24/4132812.htm

Learner Guide| Version 2.0 October 2016 13 of 39

Forms of elder abuse

Signs and symptoms of elder abuse and neglect in care

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Family violence is recognised in Tasmania as a range of behaviours perpetrated against a spouse or

Family violence occurs across all cultural and socioeconomic groups.

Identify the instance of abuse

When abuse is suspected:

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TOPIC 2 – LIAISE AND NEGOTIATE WITH APPROPRIATE PERSONNEL AND

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Higher care needs

Incidental and leisure activity

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be modified for participation by frailer or chair bound residents.

Helping residents benefit from physical activity:

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Additional resources and links:

Aged Care Service List

Service Lists - Each downloadable file contains:

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• Home care packages

My Aged Care https://www.dss.gov.au/our-responsibilities/ageing-and-aged-care/tools-and-

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Determining options for referrals to other service providers

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