Care plan FAQS

What is in a Care Plan?

Care plan development needs to be driven by the consumer, in consultation with the home care provider. The care plan should clearly spell out the following:

  • the consumer’s goals – what it is the consumer would like to achieve through their package;
  • the care and services to be provided to support the identified goals;
  • who will provide the care and services;
  • when care and services will be provided, including the frequency of services and days/times when regular services are expected to be provided;
  • the level of involvement and control the consumer will exercise over the management of the package;
  • case management arrangements, including how ongoing monitoring and informal reviews will be managed; and
  • the frequency of formal reassessments (which must be undertaken at least every 12 months).

Who decides what services go into the Care Plan?

The Consumer does. The care plan must be supported by an individualised budget for the consumer.

The care planning process must be driven by the consumer, in partnership with the home care provider. Throughout the process, there should also be an emphasis on:

  • consumer choice and control;
  • support for consumer decision-making;
  • being responsive to the consumer’s customs, beliefs and background, including their relationship with carers and family members;
  • wellness and re-ablement; and
  • Maintenance of independence and continuation of participation in the community (if this is what the consumer wants).

Care planning discussions may also cover end of life planning such as advance care directives.

What is the role of the Case Manager?

Sacred Heart Mission’s approach to Services to all clients is relation based and thus this role is vital to our service model.  Our Case Managers are friendly, committed, respectful professionals there to assist throughout the client’s time within our service.  Our Case Managers are available to assist whenever problems and issues arise and to be responsive to changing circumstances.

In the context of the Home Care Packages, case management refers to advisory and support services associated with the following tasks:

  • the initial assessment by the home care provider;
  • identification of the consumer’s goals;
  • development of the Home Care Agreement, care plan and individualised budget;
  • ongoing monitoring and informal reviews of the consumer;
  • formal re-assessment of the consumer’s needs, and adjustment of the Home Care Agreement, care plan and individualised budget if required; and
  • referral to an ACAT (eg if a reassessment is needed to move to a higher level of package).
  • Ongoing monitoring, reviews and re-assessment must be undertaken by the home care provider, not by the consumer.

Clients are the experts of themselves. Case Managers are the experts of the system and know the “hows” and “whens “ of good support and where appropriate additional support from other specialist services  that can be introduced to best meet clients needs and wishes. 

Who else can help me with my plan?

The My Aged Care website or the National Contact centre on 1800 200 422.

Consumers and their families/carers an get advocates to help with understanding  home care agreement and care plan, negotiating fees,  and expressing any concerns and  complaints. The National Aged Care Advocacy line is 1800 700 600 (free call).

National Translating and Interpreting Service (TIS) (now available to Home care) this is a phone service. The Department of Social Services provides a National Translating and Interpreting Service (TIS) – phone 131 450.Home care providers are able to use TIS to provide interpreting services to assist. 

What is the role of support workers?

The role of ‘support workers’ is exactly that, to support you in your goals. Every client will have the opportunity to make goals or think about things they would like to have in their life a bit more (e.g. social contact, better exercise or diet etc.). 

Like our Case Managers our support workers are kind, welcoming, professional members of the team.

What is a reassessment?

There must be a formal re-assessment of the consumer by the home care provider at least every 12 months.

Reassessment is: assessing the consumer’s needs, goals and preferences in order to update their care plan and, if necessary, change services the consumer is receiving. This may also result in changes to the Home Care Agreement and the individualised budget.

What is a Home Care Agreement?

There is a legal requirement for us to provide all consumers with a Home Care Agreement.

This is an agreement between the service provider (Sacred Heart Mission) and a consumer that sets out key elements about how the package will be delivered.  The Agreement includes the Care plan, and a rights and responsibility statement of both parties.  Once this is signed the Care and services can formally commence.

Can I ask how much money is left in my account?

Yes you can. The easiest way to do this will be via your monthly statements. Every month you will get to see how you spent your money in the previous month, if you went over your budget or under it, and if you have any extra money for the following month.

Do budgets roll over if I don’t spend it all that month?

Yes they do, however the budgets are intended for the most part to be spent not saved. You can plan to save up to 10% of your budget, and any extra money that was planned to be spent but wasn’t will simply bank up for your use in the future.

What happens if I go to hospital? Can I bank up my services?

When a client goes to hospital, respite, transitional care or even a holiday they may want to ‘suspend’ (not use for a little bit) the services they are getting. This means that the money they usually would spend in their package on for example support workers, may not get spent.

Sacred Heart can build up the unspent funds for you, for when you get out of hospital/ back from holiday however the amount that will get paid into your budget during this time will vary depending on how long you ‘suspend’ your services for.

Understanding the Charter of Aged Care Rights

Consumers receiving Australian Government funded aged care services have the right to be properly looked after, treated well and given high quality care and services.

Consumer have the right to:

  • safe and high quality care and services;
  • be treated with dignity and respect;
  • have my identity, culture and diversity valued and supported;
  • live without abuse and neglect;
  • be informed about my care and services in a way I understand;
  • access all information about myself, including information about my rights, care and services;
  • have control over and make choices about my care, and personal and social life, including where the choices involve personal risk;
  • have control over, and make decisions about, the personal aspects of my daily life, financial affairs and possessions;
    my independence;
  • be listened to and understood;
  • have a person of my choice, including an aged care advocate, support me or speak on my behalf;
  • complain free from reprisal, and to have my complaints dealt with fairly and promptly;
  • personal privacy and to have my personal information protected;
  • exercise my rights without it adversely affecting the way I am treated.
0136,596Meals served through our meals program over the last year
069,269Hours contributed by our volunteers over the last year
05,740Responses at our Women’s House over the last year
Sacred Heart Mission acknowledges the traditional Aboriginal owners of country throughout Victoria and pays respects to them, their culture and their elders past, present and emerging.


Sacred Heart Mission has always aimed to be a place that embraces a sexuality and gender diverse community; everyone is welcome at our table and we believe a diverse community is good for everyone.