Unit of competency Outline
Date retreived
22/07/2026 2:54 PM AWST
22/07/2026 2:54 PM AWST
Whilst all efforts are made to provide accurate and timely information from the relevant source/documentation, please be aware that the information supplied may not be the most current version. The accuracy of the detail has not been confirmed by the Department and therefore should not be relied upon without first confirming the contents.
Implement goal directed care planning
Implement goal directed care planning
Unit of competency
National Code
CHCCM702B
CHCCM702B
State Code
WC830
WC830
TGA Status
Replaced
Replaced
DTWD Status
Replaced
Replaced
State Implementation and Classification
Approved Date
21/07/2014
Field of Education
090599 - Human Welfare Studies And Services, N.e.c.
Original Release Date
21/07/2014
Nominal Hours
60
Description
DescriptorThis unit describes the knowledge and skills required to plan care for clients through provision of services and resources aimed at maximising and enhancing their independence and quality of life
Notes
Elements and Performance Criteria
1. Undertake care planning to address identified client needs and goals
- 1.1 Work with client to identify realistic and relevant goals as a basis for care planning
- 1.2 Undertake care planning to address identified goals and in line with needs assessment and document in line with organisation requirements
- 1.3 Undertake consultation with other organisation representatives to plan care in complex situations where multi-organisation involvement is required
- 1.4 Ensure care plan recognises and supports person's strengths and abilities as well as addressing their needs
- 1.5 Recognise and respect person's right to self-determination within legal parameters
- 1.6 Plan care in consultation with the person, their carer/s and family, friends or others involved in advocacy or decision-making on their behalf
- 1.7 Support person to make informed decisions about their care, reflecting understanding of their current situation, probable future situation and ensuing care needs
- 1.8 Investigate range of options available to address client-identified needs and achieve their goals
- 1.9 In conjunction with client, structure a range of services in a manner that supports informal care arrangements such as family support, and support of friends and/or neighbours
- 1.10 Devise alternative strategies to meet identified client needs when specific services are not available
- 1.11 Provide the person with cost details as required and work with them to ensure care plan is within their financial resources
- 1.12 Identify work health and safety (WHS) risks and plan for their management
- 1.13 Write care plan and clearly identify all work tasks and who is to perform them
2. Implement care plan in conjunction with relevant others
- 2.1 Seek and obtain person's consent before undertaking any referrals
- 2.2 Provide person with clear understanding of available services and choices, so they are an informed participant in all stages of care planning
- 2.3 Work in collaboration with appropriate professionals and organisations to ensure services are provided in a manner that maximises person's potential for achieving their goals and addresses identified needs
- 2.4 Ensure planning clearly articulates roles and responsibilities of each service provider, including coordination role/s
- 2.5 Maximise involvement of client and carer/s in care planning processes and decision-making
- 2.6 Ensure effective involvement of relevant health/ community services professionals in care planning where clients have chronic or complex needs
- 2.7 Establish and maintain communication strategy and processes to ensure effective implementation of care plan
- 2.8 Ensure mechanisms are in place to support sharing of information between organisations and maintenance of updated information to all involved organisations
- 2.9 Support and develop person's ability to independently access alternative resources to ensure their needs are addressed in an appropriate manner
3. Monitor implementation of client care plan
- 3.1 Regularly monitor planned services, support and resources against client-identified goals to ensure effective implementation of their care plan
- 3.2 Ensure appropriate level of rapport and communication with client is maintained as required to support disclosure of information regarding delivery of services and resources in line with care plan
- 3.3 Maintain collaborative relationships with clients, carers and other service providers to support people with complex needs
- 3.4 Promptly identify problems with implementation of care plan and make adjustment as necessary to best meet person's needs
- 3.5 Document and report any variations to care plan in line with organisation requirements and communication strategy
4. Undertake review of care plan
- 4.1 Respond appropriately to informal monitoring of health and well being of the person and/or their carer by volunteers, carers or family
- 4.2 Undertake regular and systematic reviews to ensure assessed needs of clients are being addressed effectively
- 4.3 Use regular reviews to re-prioritise client needs for service and to ensure equitable access based on ongoing appraisal of prioritised needs
- 4.4 Contribute to adjustments in care plan in response to changes in client or carer health; review of risk management/WHS needs; or as specified in person's care plan or as required by personal circumstances
5. Respond appropriately to diversity
- 5.1 Ensure care planning for CALD and Aboriginal and Torres Strait Islander clients is culturally sensitive
- 5.2 Ensure appropriate interpreter support is provided in line with organisation protocols
- 5.3 Where appropriate, work in conjunction with ethno-specific and multicultural organisations and with Aboriginal and Torres Strait Islander communities and organisations
- 5.4 Recognise and support the role of these organisations in linking their communities into the service system
- 5.5 Where appropriate involve Aboriginal and Torres Strait Islander community and/or organisation representatives in the care planning process
6. Respond appropriately to people with different levels of need including those with complex needs
- 6.1 Facilitate access to assessment for people with different levels of need including those in complex circumstances and identified as having high levels of need
- 6.2 Maintain and promote inter-organisation relationships and agreements as appropriate to address client, family and carer needs
- 6.3 Ensure care planning builds on person's strengths and motivation to improve their quality of life
7. Evaluate client outcomes
- 7.1 Undertake periodic evaluation of care planning based on analysis of outcomes
- 7.2 Obtain information from clients, carers, families and other service providers to determine progress and evaluate against identified goals in care plan
- 7.3 Take into account adjustments made to services and resources to better address person's ongoing situation and changing needs
- 7.4 Ensure evaluation includes determination of client satisfaction, comparison of costs against benefits received and assessment of quality and effectiveness of service delivery and case management components
- 7.5 Work with person to evaluate ongoing support needs to meet their goals, including review of parameters for disengagement, where applicable
- 7.6 Demonstrate accountability for adjustments to the care plan and associated financial outcomes
- 7.7 Identify opportunities for person to maintain or develop independence within any aspects of their overall care
- 7.8 Document and report quantifiable impacts experienced by person as a result of implementation of care plan and indicate how client-centred outcomes have been achieved
RANGE STATEMENT
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.
Care planningmay include, for example:
Identifying range and type of specific services to be provided
Planning details of each specific service to be provided, such as
domestic assistance
respite
nursing care
Consideration of WHS and risk management issues and strategies to address these
Referral strategies as required to address breadth of client needs
Information about services, resources or activities the client may follow up independently, such as:
Health promotion
Local social or active living opportunities
Self management strategies and activities
Self-referral to other services
Complex needs may refer to:
Client needs requiring multiple service types with heightened needs for collaboration between service providers
Clients with a range of needs that may not be met by available services and resources
Clients who have family and carer needs that require additional service inputs
People who have broad range of care needs related to chronic and/or multiple health issues and who require assistance to access the service system as well as a high level of ongoing advocacy
People in complex circumstances and identified as having high levels of need may refer, for example, to:
Families with children with disabilities where a number of different organisations are providing support
People with disabilities with a diverse range of needs arising from physical and behavioural causes
People with disabilities requiring the development of appropriate responses for personal and/or respite care
People with complex medical issues which may pose critical issues for assessment and care planning
Older people with chronic illness and unstable health conditions requiring coordinated management across acute, sub acute and community health sectors
Older people with dementia and/or other cognitive impairment
Older people who are extremely socially isolated and withdrawn
Circumstances involving difficult WHS issues for community sector workers
People with mental health issues, whose functional limitations may fluctuate substantially over time
People with psychiatric disabilities where inter-organisation agreements may be required to access specialist assessment expertise
People with family and carer needs that require additional service inputs
Inter-organisation relationships and agreementsmay relate to:
Access to specialist expertise for secondary consultations , advice or assessment
Extent and type of information provided on referral
Joint assessment
Case conferencing
Care planning and ongoing support
Use of specialist assessment tools
Involvement in assessment of family members and other organisations providing services
Receiving relevant information from health practitioners and/or support workers
The Range Statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Add any essential operating conditions that may be present with training and assessment depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts.
Care planningmay include, for example:
Identifying range and type of specific services to be provided
Planning details of each specific service to be provided, such as
domestic assistance
respite
nursing care
Consideration of WHS and risk management issues and strategies to address these
Referral strategies as required to address breadth of client needs
Information about services, resources or activities the client may follow up independently, such as:
Health promotion
Local social or active living opportunities
Self management strategies and activities
Self-referral to other services
Complex needs may refer to:
Client needs requiring multiple service types with heightened needs for collaboration between service providers
Clients with a range of needs that may not be met by available services and resources
Clients who have family and carer needs that require additional service inputs
People who have broad range of care needs related to chronic and/or multiple health issues and who require assistance to access the service system as well as a high level of ongoing advocacy
People in complex circumstances and identified as having high levels of need may refer, for example, to:
Families with children with disabilities where a number of different organisations are providing support
People with disabilities with a diverse range of needs arising from physical and behavioural causes
People with disabilities requiring the development of appropriate responses for personal and/or respite care
People with complex medical issues which may pose critical issues for assessment and care planning
Older people with chronic illness and unstable health conditions requiring coordinated management across acute, sub acute and community health sectors
Older people with dementia and/or other cognitive impairment
Older people who are extremely socially isolated and withdrawn
Circumstances involving difficult WHS issues for community sector workers
People with mental health issues, whose functional limitations may fluctuate substantially over time
People with psychiatric disabilities where inter-organisation agreements may be required to access specialist assessment expertise
People with family and carer needs that require additional service inputs
Inter-organisation relationships and agreementsmay relate to:
Access to specialist expertise for secondary consultations , advice or assessment
Extent and type of information provided on referral
Joint assessment
Case conferencing
Care planning and ongoing support
Use of specialist assessment tools
Involvement in assessment of family members and other organisations providing services
Receiving relevant information from health practitioners and/or support workers
EVIDENCE GUIDE
The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.
Critical aspects for assessment and evidence required to demonstrate this unit of competency:
The individual being assessed must provide evidence of specified essential knowledge as well as skills
This unit of competence will be most appropriately assessed in the workplace or in a simulated workplace and under the normal range of workplace conditions e.g. writing care plans based on case studies, writing case notes based on case studies
Assessment may be conducted over one or more occasions and should include both the development and promotion of best practice
Access and equity considerations:
All workers in community services should be aware of access, equity and human rights issues in relation to their own area of work
All workers should develop their ability to work in a culturally diverse environment
In recognition of particular issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on Aboriginal and/or Torres Strait Islander clients and communities
Context of and specific resources for assessment:
This unit can be assessed independently, however holistic assessment practice with other community services units of competency is encouraged
Resources required for assessment include access to:
an appropriate workplace where assessment can take place
simulation of realistic workplace setting
Method of assessment:
Assessment may include observation, questioning and evidence gathered from the workplace setting
Examination of written examples of care plans and written examples of case notes
The evidence guide provides advice on assessment and must be read in conjunction with the Performance Criteria, Required Skills and Knowledge, the Range Statement and the Assessment Guidelines for this Training Package.
Critical aspects for assessment and evidence required to demonstrate this unit of competency:
The individual being assessed must provide evidence of specified essential knowledge as well as skills
This unit of competence will be most appropriately assessed in the workplace or in a simulated workplace and under the normal range of workplace conditions e.g. writing care plans based on case studies, writing case notes based on case studies
Assessment may be conducted over one or more occasions and should include both the development and promotion of best practice
Access and equity considerations:
All workers in community services should be aware of access, equity and human rights issues in relation to their own area of work
All workers should develop their ability to work in a culturally diverse environment
In recognition of particular issues facing Aboriginal and Torres Strait Islander communities, workers should be aware of cultural, historical and current issues impacting on Aboriginal and Torres Strait Islander people
Assessors and trainers must take into account relevant access and equity issues, in particular relating to factors impacting on Aboriginal and/or Torres Strait Islander clients and communities
Context of and specific resources for assessment:
This unit can be assessed independently, however holistic assessment practice with other community services units of competency is encouraged
Resources required for assessment include access to:
an appropriate workplace where assessment can take place
simulation of realistic workplace setting
Method of assessment:
Assessment may include observation, questioning and evidence gathered from the workplace setting
Examination of written examples of care plans and written examples of case notes
Replaces
| State Code | National Code | Title | Type |
|---|---|---|---|
| D2302 | CHCCM702A | Implement goal directed care planning | Unit of competency |
Replaced By
| State Code | National Code | Title | Type |
|---|---|---|---|
| AVC27 | CHCCSM001 | Facilitate goal directed planning | Unit of competency |
| State Code | National Code | Title | Type |
|---|---|---|---|
| D331 | CHC70208 | Graduate Certificate In Community Services Practice (Client assessment and case management) | Qualification |