Care Plans in Aged Care: Examples and Templates for Individualised Plans

As an aged care provider or support worker, your goal is to provide individualised, effective care that supports the needs and goals of your clients. That’s where an aged care plan comes in.

This guide provides an overview of aged care plans and how to create an aged care plan, along with an example and a template for you to use.

What are aged care plans?

A care plan is a comprehensive document that details your client’s individual needs and health goals, along with the services they’ll need to meet their goals. Ultimately, a care plan is in place to help support their quality of life.

Regardless of whether your client lives in residential care or at home, they should have an aged care plan that details all the information you need to provide the best level of care. Not to mention, they’re also a government requirement under Australia’s Aged Care Quality Standards.

Why are care plans important?

Aged care plans are tailored to each individual’s unique preferences, medical needs and goals. They account for a range of factors, including medical conditions, mobility challenges, dietary requirements and emotional wellbeing. This high level of personalisation ensures that care is respectful and meaningful, improving the resident’s quality of life.

Detailed care plans allow caregivers and support workers to proactively identify and manage health conditions. By setting clear goals, strategies and interventions, care plans promote effective treatment and monitoring, reducing the risk of complications. For example, regular physiotherapy for a client with mobility issues can help to prevent falls and enhance their independence.

Care plans are also a central reference point for all caregivers and healthcare providers. They ensure continuity of care, even when staff changes occur or multiple professionals are involved. This reduces the likelihood of errors, such as missed medications or conflicting therapies.

Finally, aged care plans encourage family involvement and open communication between the client’s family and their care team. This helps to foster trust and boost confidence in the care system. Regular updates to the care plan ensure that families are always informed about their loved one’s progress.

Key components of an aged care plan

An aged care plan should include the following essential details:

• Personal details
• Comprehensive health assessment
• Health and wellness goals
• Interventions and strategies
• Nutritional and dietary requirements
• Social and recreational activities
• Risk management
• Evaluation and updates.

Care plans should be comprehensive and tailored to each individual, so some of the components will likely differ depending on their circumstances.

How to create an aged care plan

While it’s usually up to the care provider to create an aged care plan, it should be a collaborative effort between the provider, the client and possibly even their family.

Step 1: Complete a comprehensive assessment

Care plans should start with a comprehensive assessment of the client’s physical, mental, emotional and social wellbeing to understand their current condition and potential risk factors. This also includes understanding their social and lifestyle preferences.

For example, a client’s assessment could include the following:

• Medical History:
  
  • Arthritis affecting mobility in knees and hands.
  • Type 2 diabetes, managed with oral medication and diet.
  • Mild hearing loss in the left ear, using a hearing aid.

• Mental Health: Occasionally feels isolated but no history of depression or anxiety.

• Mobility: Requires a walker for longer distances. Uses grab rails in the bathroom and bedroom.

‍

Step 2: Set clear goals and objectives

Once you’ve completed your initial assessment, you can work with your client and their family to develop a set of clear short- and long-term goals and objectives. Short-term goals should address immediate needs, such as stabilising a medical condition or improving mobility. Alternatively, long-term goals focus on sustaining quality of life, managing chronic conditions or enhancing independence.

Ultimately, all goals and objectives should follow the SMART approach, meaning they’re specific, measurable, achievable, relevant and time-bound.

For example, a client’s health and wellness goals could include:

‍

1. Short-Term Goals:
   
   • Improve mobility through physiotherapy exercises.
   • Maintain stable blood sugar levels through diet and regular monitoring.
   • Ensure a safe home environment to prevent falls.
2. Long-Term Goals:
   
   • Maintain independence in daily activities.
   • Reduce arthritis pain and maintain joint function.
   • Stay socially connected to combat feelings of isolation.

Step 3: Select services and strategies

A care plan should provide details of the services and strategies in place to meet the client’s needs and help them achieve their goals. This can include:

• Daily care tasks: Plan routines for hygiene, meals and activities.

• Medical care: Document treatments, therapies and medication schedules.

• Emotional support: Incorporate activities that promote mental wellbeing, such as counselling or group interactions.

• Preventive measures: Address safety concerns like fall prevention, infection control or dietary adjustments.

As part of this stage, it’s essential to also determine who will be responsible for providing specific services and supports. From key professionals, like nurses and carers, to family members and the clients themselves, it’s important that everyone’s roles and responsibilities are clearly detailed in the care plan.

Example intervention and care strategies could include:

• Daily Living Assistance:
  
  • Home care support worker visits twice a week on Monday and Thursday for cleaning, laundry and meal preparation.
  • Personal care assistant visits every morning at 7am for two hours to help with showering and dressing.

• Health Management:
  
  • Weekly physiotherapy sessions every Friday at 2pm at a local clinic to strengthen joints and improve mobility.
  • Blood sugar levels monitored daily at 9am using a glucometer; reports reviewed during fortnightly GP appointments.

• Social and Recreational Activities:
  
  • Participation in an online book club every Wednesday at 10am.
  • Weekly gardening sessions with a local community group on Saturdays at 8am.
  • Monthly family visits coordinated by her son, Michael.

• Home Modifications and Equipment:
  
  • Grab rails installed in the bathroom and along stairs.
  • A walker and ergonomic kitchen tools provided to support mobility and arthritis management.
  • Lifeline alarm system installed for emergency support.

Step 4: Monitor progress and evaluate effectiveness

A care plan isn’t a set-and-forget type of document. Instead, it should be used regularly to evaluate the effectiveness of the services, supports and strategies against the client’s needs and goals. From here, you can adjust the plan to ensure the client receives the best possible care.

Step 5: Regularly review and update care plan

While monitoring the effectiveness of the care plan regularly is important, it’s essential to complete a more thorough review of the care plan on an annual or as-needed basis. This ensures that your clients receive the best quality of care as their circumstances change.

At Caremaster, our aged care software is designed to help you provide the best possible care to your clients. Create and store aged care plans for each of your clients that can be easily accessed and shared with the rest of their care team. Use our care plan template to create your own care plans for your aged care clients.

Download Template: Click Here

Book a free demo to learn more about how we can simplify your care plan management.

‍