The multidisciplinary team (MDT) collaborates to create a personalised plan that addresses the individual's needs, considers the preferences of their family/whānau, and aligns with the team's objectives to achieve specific goals. This comprehensive plan aims to support the person's needs holistically. As part of your role, you may be involved in contributing to the development of certain aspects of the person's plan. To actively participate in the development of the personal plan, you must fully comprehend your role as a support worker responsible for its implementation. This means having a clear understanding of how you contribute to putting the person's personal plan into action once it has been devised. Familiarise yourself with the policies and procedures specific to your workplace, as they outline the necessary steps and expectations. By understanding your role, and adhering to workplace policies you can play a crucial role in ensuring the successful implementation of the individual's personalised plan.
Personalised care planning is an ongoing process that leads to the development of a comprehensive care plan, which is regularly reviewed. It takes a holistic and systematic approach, focusing on the individual's strengths, values, and aspirations, with their goals, choices, and lifestyle preferences placed at the centre of the process.
It's a dynamic process involving discussions, negotiations, decision-making, and reviews between the individual and the care professionals, fostering an equal partnership. This approach is planned, proactive, and anticipatory, including regular follow-ups and crisis episode planning.
Individuals are encouraged to actively participate in their care, provided with information, and guided to make informed decisions while considering managed risks. Assessment and care planning consider the individual as a whole and take a person-centred approach.
Ultimately, this process results in a single, overarching care plan owned by the individual but accessible to those directly involved in their care.
To create a personal plan, the initial step involves assessing an individual's specific requirements. This assessment process involves gathering relevant information about the person's health status, which aids in identifying the appropriate support they need. Based on this assessment, a detailed plan is formulated to outline how these support needs will be addressed.
Accurate assessment of a person's condition, situation, and needs is of utmost importance to provide them with optimal support that enhances their functional abilities. When conducting an assessment in your workplace, the primary goal is to gain a comprehensive understanding of the person's:
- General health status
- Mental health status
- Daily life assistance requirements
- Level of support received from whānau and/or friends
- Future outlook
- Family/whānau concerns.
A Care Plan should include information relating to:
- Any challenges or problems the resident is currently facing
- Goals of the resident and their family
- Medications and other medical management solutions
- Dietary requirements
- An action plan for the future
- A crisis plan, including actions to be taken in an emergency
- Instances when family must be contacted
- Information about who is responsible for what
- An outline of when the plan should be reviewed.
Case Study: Mr. James Anderson
Mr. James Anderson is an 80-year-old widower living alone in his suburban home. He has a history of hypertension, type 2 diabetes, and mild cognitive impairment. He enjoys gardening, painting, and spending time with his grandchildren. Recently, his family has noticed some difficulties in his ability to manage his medications, maintain his home, and engage in social activities. Assessment: Upon a comprehensive assessment conducted by a geriatric nurse and a social worker, the following observations and needs were identified:
- Medical Conditions: Hypertension and type 2 diabetes requiring medication management
- Cognitive Function: Mild cognitive impairment affecting memory and decision-making
- Activities of Daily Living (ADLs): Mr. Anderson requires assistance with meal preparation, medication administration, and grooming
- Social Isolation: Limited social interactions and engagement with hobbies due to transportation challenges
- Safety Concerns: Risk of falls due to mobility issues and clutter within the home.
Comprehensive Care Plan:
| 1. Medical management |
|
| 2. Cognitive stimulation |
|
| 3. Nutrition and meals |
|
| 4. Social interaction |
|
| 5. Home environment |
|
| 6. Regular evaluation and updates |
|
| 7. Emergency plan |
|
Outcome: Mr. James Anderson's comprehensive care plan focuses on enhancing his quality of life, promoting independence, and addressing his medical and social needs. The coordinated efforts of healthcare professionals, family members, and support services ensure that Mr Anderson receives holistic and personalised care, allowing him to continue enjoying his hobbies and maintaining a meaningful and fulfilling lifestyle while staying safe and well-cared-for in his own home.
A comprehensive care assessment in aged care is a thorough and detailed evaluation of an elderly individual's physical, emotional, mental, and social well-being. This assessment is typically conducted by healthcare professionals, such as nurses, doctors, or geriatric specialists, to gather comprehensive information about the older person's health status, needs, preferences, and circumstances. The primary goal of a comprehensive care assessment is to create a holistic care plan that addresses all aspects of the individual's life and provides the necessary support to enhance their quality of life and overall well-being.
Reflection
What assessment tools might you be required to use in your role? Do some research and identify an assessment tool that you are familiar with or have used in your organisation. The tool used is:
Use your organisation's policies and procedures to answer the questions.
- What is the purpose of the assessment?
- What is the process used for the assessment?
- How does the assessment relate to the personal plan?
- What are the legislative requirements (if any)?
- What changes in a person’s condition/circumstances may require reassessment?
- What are the recording and reporting requirements?
- What are your roles and responsibilities in the assessment process?
Reading
The New Zealand Guidelines Group has developed a best practice, evidence-based guideline providing recommendations for appropriate and effective processes for assessment of personal, social, functional and clinical needs in older people.
Read this article for a general summary and overview of the recommendations.
Effective collaboration is a cornerstone of providing high-quality care for older adults, especially those with complex needs. As workers in the field of aged care support, understanding the significance of collaboration is essential for delivering comprehensive and person-centred care. This involves working closely with healthcare professionals, individuals in your care, and their family/whānau to create a holistic and responsive care plan.
The principles of effective collaboration for healthcare professionals working with people with complex needs and their family/whānau to plan and deliver comprehensive care and support include:
Activity - Scenario and Quiz
John is a support worker in a residential aged care facility in Hamilton. One evening, while assisting Mr. Te Hira with his evening meal, John observes that he appears restless and experiences some difficulty swallowing. Recognising the importance of attentive listening, John engages Mr. Te Hira in a conversation, inquiring about his discomfort and any specific challenges he's facing. John also involves Mrs. Te Hira in the conversation when she visits, knowing that her insights are invaluable in understanding her husband's well-being. She shares her observations and expresses her concerns about his recent fatigue and appetite changes.
John takes Mr. Te Hira's concerns seriously and promptly shares his observations with the nursing staff and speech therapist during the shift handover meeting.
Following the shift handover meeting, John updates Mr. Te Hira's care plan to include his observations of the evening. The team carefully documents Mr. Te Hira's restlessness and swallowing difficulties, as well as the team's discussion about involving the speech therapist for a specialised assessment.
Throughout Mr. Te Hira's care journey, John maintains a keen awareness of his own professional limitations and recognises the strengths of his colleagues within the healthcare team. When discussing Mr. Te Hira's swallowing difficulties during the team meeting, John actively cooperates with the speech therapist, seeking guidance on how to better assist Mr. Te Hira during meals.
Answer the following questions based on the scenario above.
We have looked at how working collaboratively leads to enhanced client care, however, this approach can also pose challenges.
| Benefits | Challenges |
|---|---|
| Improved Health: Studies indicate that seniors with strong social connections, including family, tend to have better physical and mental health. This can lead to lower rates of depression, anxiety, and cognitive decline, as well as a reduced risk of chronic diseases or functional impairments. | Distance and Availability: Depending on their location and personal commitments, family members may not always be physically present to offer support or assistance. This can pose challenges, especially for families living far from the senior or those with demanding schedules. |
| Enhanced Quality of Life: Family involvement can help seniors maintain independence, dignity, and purpose, positively impacting their overall quality of life. It also fosters a sense of connection to loved ones and the community, which is especially valuable as they age. | Differing Care Perspectives: Family members may hold varying opinions on the best approach to care for the senior, potentially leading to conflicts and misunderstandings. Establishing open lines of communication and finding ways to compromise and reach a consensus on care decisions can be beneficial. |
| Peace of Mind for Families: Involving family members in senior care allows them to actively participate, providing a sense of control and peace of mind. It ensures that they stay informed and can contribute to decision-making, increasing confidence in their loved one's care. | Communication Hurdles: Communication barriers may exist based on the senior's cognitive abilities and language skills. This can make effective communication between family members, the senior, and support workers challenging. Support workers may need to consider solutions like interpreters or alternative communication methods such as written notes or visual aids. |
| Improved Communication and Coordination: Family involvement encourages open and frequent communication between support workers and family members, leading to better coordination and consistency in senior care. It helps prevent misunderstandings and ensures the senior's needs and preferences are met. | Emotional Challenges: Involving family members in senior care can be emotionally demanding, particularly when the senior has significant complex needs. Support workers can encourage family members to prioritise their emotional and physical well-being and seek support from friends, professionals, or support groups when required. |
| Enhanced Cultural Competence and Sensitivity: Collaborative efforts with clients and their families provide opportunities to learn about and respect cultural values, traditions, and preferences, leading to culturally competent care. | Legal and Financial Considerations: Legal and financial matters, such as power of attorney, financial decision-making, and funding for care, may arise when family members are involved in senior care. |
| Holistic Approach: Working collaboratively allows for a holistic approach to care, addressing not only physical health but also emotional, social, and psychological well-being, resulting in comprehensive support. | Privacy Concerns: Balancing the need for open communication with respecting client and family privacy can be challenging. Support workers must maintain confidentiality while sharing essential information. |
Reflection
Think about your workplace in aged care: Can you recall a challenge you've faced when working together with healthcare professionals, clients, and their families/whānau while caring for elderly clients with complex needs? How did it affect the care?
Addressing the challenges
- Promote Open Communication: Encourage clients and their families/whānau to openly share their concerns, preferences, and ideas. Create accessible communication channels for them to express their needs and stay informed about the client's care
- Define Roles and Responsibilities: Collaborate with clients and their families/whānau to identify their strengths and interests. Find meaningful ways for them to contribute to the client's care, such as participating in care planning, assisting with daily activities, or offering emotional support
- Respect Client Autonomy: Acknowledge that the client has the primary role in decision-making regarding their care. Involve them in decisions to the extent they are capable, respecting their autonomy and preserving their dignity
- Cultivate a Positive Environment: Encourage clients and their families/whānau to maintain a respectful and supportive attitude toward support workers. Foster a welcoming atmosphere that promotes trust and strengthens relationships among all parties involved
- Seek Assistance When Needed: When conflicts or challenges arise, support workers should not hesitate to seek guidance or support from supervisors, healthcare professionals, or relevant resources. Additionally, clients and their families/whānau may benefit from accessing support groups.
Activity - Is it a benefit or a challenge?
Scenario
Read the following scenario and reflect on how you would address the challenges of working collaboratively with the client and their family.
You are a dedicated support worker in an aged care residential facility, responsible for providing comprehensive care and support to Meena, a 78-year-old Hindi-speaking woman who has been a resident for the past year. Meena has complex care needs, including diabetes and dementia, which require specialised attention. Her close-knit family, including her three children, visit her regularly, expressing their strong desire to see Meena improve and return to her previous state of health.
Meena's primary language is Hindi, and her proficiency in English is limited. This language barrier complicates communication, making it challenging to understand her needs, preferences, and emotions accurately. You need to find creative ways to overcome this language barrier to ensure effective caregiving and facilitate meaningful interactions.
Meena's family, especially her children, are deeply invested in her care and well-being. They have high expectations and a strong desire to see her health improve. However, managing these expectations can be challenging, as Meena's complex health conditions, including diabetes and dementia, may limit the extent of improvement that can be achieved. Ensuring that the family understands the realistic goals of care while maintaining their trust and support is a delicate balancing act.
Meena's cultural background, influenced by her Hindi heritage, shapes her values, beliefs, and expectations regarding care. Understanding and respecting her cultural sensitivities and ensuring that her care aligns with her cultural preferences can be a nuanced challenge. It necessitates cultural competence and the ability to provide culturally sensitive care that respects her identity and values.
Watch
Watch this video and listen to how the staff at the aged care facility work collaboratively with their client’s family/whānau.
Our Story - Aged care providers NZ - Radius Care
Reflection
Reflect on any improvements you could make in your workplace to work more collaboratively with clients and their family/whānau.
As we have learned in previous modules, in New Zealand's aged care sector, cultural competence and sensitivity are integral to providing quality care. New Zealand's unique cultural heritage, values, and legislation play a crucial role in shaping the cultural competence and sensitivity required in the creation and execution of care plans within the country's healthcare system.
Firstly, a reminder, that fundamental to all health approaches in New Zealand is the firm commitment to the cultural considerations of our heritage and to honouring Te Tiriti o Waitangi. The concept and practice of care planning, in its purpose and intent of empowering an individual and their family/whānau to participate in their own health care, are closely aligned with Te Whare Tapa Whā and the Whānau Ora strategy to promote a model of care that builds upon Māori values, aspirations and intent. Additionally, the concepts of care planning align with the Pacific health model of care Fonofale.
Cultural considerations when working collaboratively in the development and implementation of care plans include:
- MDTs supporting assessors of older Māori, Pacific people or clients from other cultural backgrounds should include a Māori, Pacific, or culturally appropriate healthcare professional. All members of the team should have competency (where appropriate) or experience in working with older people.
- Clients and their health care professionals should identify the family/whānau and significant others whom the person wishes to be involved in care planning discussions.
- All decisions are made within the cultural context of the individual and therefore the extent to which decision-making is shared will vary. For example Asian patients may prefer family-based decision making processes and refuse to make individual decisions in regard to their care planning.
Activity - Scenario & Quiz
Meet Mrs. Chen, a 78-year-old Chinese woman living in a residential aged care facility in New Zealand. Mrs. Chen has complex health needs, including heart disease and diabetes. She primarily speaks Mandarin and relies on her son, Wei, for support. Mrs. Chen's healthcare team consists of her primary care nurse, support worker, a cardiologist, a diabetes specialist, and a cultural liaison officer.
The Multidisciplinary Team (MDT) gathers for the initial care planning meeting to discuss Mrs. Chen's unique healthcare needs. The team recognises the importance of cultural sensitivity in the planning process in the following ways:
- The cultural liaison officer, Mei, ensures that cultural norms and preferences are respected throughout the process.
- The team acknowledges that certain Asian cultures, including Mrs. Chen's, prefer to communicate information about serious illness and death subtly, using facial expressions, voice tone, and nonverbal cues.
- The team discusses Mrs. Chen's medical history, her views on disclosure, and her preferences for advance care planning, always respecting the subtlety preferred in her culture.
Tailoring the Care Plan - Cultural Sensitivity Considerations:
- Mei ensures that Mrs. Chen's favourite Chinese dishes are included in her meal plan
- The team schedules regular Tai Chi sessions, which Mrs. Chen enjoys and considers a vital part of her daily routine
- During discussions with Mrs. Chen, healthcare providers pay attention to her nonverbal cues and tone to gauge her comfort level with specific topics
- The diabetes specialist, Dr. Wong, suggests modifying Mrs. Chen's diabetes management plan to align with traditional Chinese dietary practices
- Mei coordinates the celebration of Chinese festivals within the facility to maintain cultural connections for Mrs. Chen
- Wei actively participates in discussions, using subtle cues to express his mother's wishes and concerns.
What you can do?
As a support worker, it is important to try to understand and ‘connect with’ things from another person’s point of view or to put yourself in that person’s position. Ways you can contribute to culturally sensitive care planning include being:
- empathetic
- respectful
- caring
- valuing
- supportive.
It is useful to ask yourself:
- How would I feel in this situation?
- How would I like to be supported?
- What is important in my culture?
Overall, it is important for support workers to be aware of their own cultural identity and how it may influence their practice. Acknowledging this can help you to be more sensitive to the needs of clients from diverse cultural backgrounds and provide culturally appropriate support.
Reflection
Consider how your own cultural identity may influence your practice as a support worker. For example, a support worker from a collectivist culture may prioritise the needs of the group over the individual, while a support worker from an individualistic culture may prioritise the needs of the individual. This difference in cultural values can impact how support worker approaches their work, including how they communicate with clients, how they understand the client’s needs, and how they develop support plans.
