Welcome! This guide is the first in a two-part series designed to support your journey in wellness and reablement care planning. Whether you’re new to this process or looking to boost your skills, we’ll walk you through every step of the way.

Our guidance aligns with requirements from the Department of Health and Aged Care (DoHAC) and the Aged Care Quality and Safety Commission (ACQSC).

This means you can confidently use our resources to meet Commonwealth Home Support Programme (CHSP) obligations, the Strengthened Aged Care Quality Standards. and requirements of the new Aged Care Act (2025).

Before you start: Having a good understanding of wellness and reablement will help you get the most from this guide. If you’re not familiar with these concepts, head to our ‘What is wellness and reablement?‘ page first.

Disclaimer: This guide focuses specifically on wellness and reablement aspects of care planning, not the entire care planning process including financial or administrative requirements.

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Where does care planning occur in the client journey?

Care planning begins after your organisation accepts a client referral. But it’s helpful to understand the steps leading up to this point:

• Referral to My Aged Care: The person is referred to My Aged Care. They can refer themselves or be referred by a family member, their doctor, or another health professional.
• Eligibility assessment: An Aged Care Needs Assessor (hereby referred to as the assessor) meets the person to evaluate their support needs. The assessors uses the Integrated Assessment Tool to determine what support the person needs.
• Support plan developed: The assessor creates a support plan showing what the person can do well and where they might need support. The support plan also includes some suggestions for reablement.
• Eligibility decision: A delegate from My Aged Care reviews the assessment and determines what services the person is eligible for. They then send a Notice of Decision to the person outlining their approved services.
• Provider selection: After receiving the Notice of Decision, the person chooses a provider. That organisation will receive a referral through the My Aged Care Portal. Once the referral is accepted, the care planning process can begin. The person’s assessment and support plan can be viewed via the portal and offers a starting point for understanding the person’s needs.
• Initial assessment: You’ll meet with the person to learn more about their needs, goals, preferences, and existing supports. This conversation forms the basis of a personalised care plan, which we’ll discuss later.

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Support plans and care plans: What’s the difference?

Support plans and care plans might sound similar, but they serve different purposes in the aged care system.

The support plan comes first. It’s created by an Aged Care Needs Assessor with an older person and outlines their support needs and goals. You’ll receive a copy when the person chooses your organisation as their provider.

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What does good care planning look like?

Good care planning is much more than just paperwork: it’s a process. The Support at Home manual outlines components of good care planning. A good care plan:

• Builds on information from the client’s Notice of Decision and support plan
• Applies the principles of wellness and reablement, prioritising the client’s choices, rights, and dignity
• Ultimately provides the roadmap for supporting the client’s independence and quality of life

To create this roadmap, you’ll work closely with your client to capture key elements such as:

• Their strengths and current abilities
• Areas where support is required
• Clear goals broken down into achievable steps
• Specific actions to help reach these goals
• Who will provide support and when
• How family and friends might be involved
• Any cultural considerations or personal preferences that ensure respectful, safe, and supportive care

Care planning is a collaborative process. In line with the principles of wellness and reablement, the best care plans are created by ‘doing with’ your client, not ‘doing for’ them.

By recognising your client as the expert in their own life, you build trust and pave the way for a positive partnership.

Don’t forget: This guide focuses specifically on wellness and reablement aspects of care planning. For information on broader care planning requirements, including administrative and compliance elements, refer to page 67 of the Support at Home Manual.

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Why is good care planning important?

For you and your organisation:

• Staff feel more confident with clear guidelines to follow
• You uphold the Statement of Rights while meeting key obligations in Standards 1, 2, and 3 of the Strengthened Aged Care Quality Standards
• It’s easier to show the quality of your care during audits, reducing stress for the whole team
• You can easily track client progress and use this information for outcomes reporting
• Your clients have better experiences, leading to good reviews and more business

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What steps are involved in care planning?

Care planning might seem simple, but it’s a process that unfolds over time. Breaking this process into clear steps makes it easier for both you and your client to navigate the journey together.

The care planning journey has three main stages:

1. Preparation
2. Care planning meeting
3. Review

In the following sections, we’ll guide you through each stage, offering tips and resources to help you succeed.

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Step 1: Preparation

Important note: Before making first contact with the client, which usually happens by phone, check the assessment and support plan, available in My Aged Care and any notes attached to their referral. These might include important information from the assessor, such as:

• Who to contact: For example, if the client has cognitive decline, you may need to speak to a representative
• Special instructions: For example, calling the client twice if they’re hard of hearing

The Preparation Checklist will help you identify potential communication difficulties before they arise. Addressing these issues ahead of time can ensure a more effective first meeting. If you identify potential communication barriers, these resources can help:

• Translating and Interpreting Services (TIS National): Enables people who don’t speak English to communicate with agencies and businesses through a range of services, including immediate, pre-booked, and video remote interpreting.
• National Sign Language Program (NSLP): Provides free sign language interpreting and captioning services for deaf, deafblind, or hard of hearing older people seeking to access or receive government funded aged care services.
• Deafblind Information Australia: A website with information for deafblind people, their families, and service providers. It covers tips for communicating, daily living, and where to find support.
• ‘Communicating and Engaging with People Living with Dementia‘: A guide from Dementia Australia offering practical tips for effective communication with people experiencing cognitive changes.
• ‘Inclusive Engagement Toolkit‘: Fact sheets from Anglicare Southern Queensland providing guidance on communicating effectively with people from diverse populations and backgrounds.
• ‘Tips on communicating to patients with vision loss‘, Vision Australia.
• ‘Tips for talking to people with hearing loss‘, DoHAC.

To facilitate communication with Aboriginal and Torres Strait Islander clients, you can also access specialised language support through My Aged Care. When assisting the person with My Aged Care matters, you can call My Aged Care and request to use an interpreter. More information can be found on their website.

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Step 2: Care planning meeting

The care planning meeting itself consists of several key parts. Here’s what we’ll cover:

• Start with the support plan
• Get to know your client
• Set goals together
• SMARTA goals
• Create an action plan
• Respect dignity of risk
• Care plan agreement

Start with the support plan

Get to know your client

Now it’s time to explore what’s important to your client. Much of this information may be in the support plan, but it must be translated into the care plan.

You may need some extra details to enhance the person-centredness of the care plan. Take advantage of our Care Planning Template to effectively guide this conversation.

It contains friendly, open-ended prompts about your client’s life, needs, and hopes for the future, such as:

• Things that are going well for me…
• A good day for me looks like…
• Things that I want to keep doing…
• I would have more independence and a better quality of life if I could…

This approach puts your client in charge, encouraging them to focus on possibilities rather than limitations.

Your client might find these questions difficult to answer. If they completed the Self-Assessment Survey beforehand, you could use their responses to start and guide the discussion. If they didn’t complete a self-assessment, now might be an ideal time to introduce the questionnaire. It has a rating scale and so is also useful for reassessments.

The ‘More Good Days Wellness Wheel’ is another great resource for exploring purpose and goals with your client. You can find it on the DoHAC website.

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Set goals together

SMARTA goals

When setting goals with your client, use the SMARTA approach. This method ensures goals are clearly defined which helps you and your client know when they are achieved. DoHAC recommends developing SMARTA goals for care planning. This approach also supports Standard 3: The Care and Services of the Strengthened Aged Care Quality Standards.

Here’s what SMARTA stands for:

• Specific – Clearly describes what success looks like
• Measurable – Includes tangible ways to track progress
• Achievable – Realistic for your client’s abilities
• Relevant – Meaningful to your client’s life and values
• Time-limited – Includes a timeframe for completion
• Agreed – Developed in collaboration with your client and signed off by them in the care plan

You can use Part 3 of our Content Planning Template to document your client’s goals.

If you think that your organisation would benefit from a review of policies and processes related to goal-directed care planning, consider the care planning resources by Kate Pascale and Associates. These offer a deep dive into the topic and guidelines to support quality improvement.

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Create an action plan

At this point, your client should have goals that reflect their needs, values, and intentions for living independently.

Do you need examples of reablement-focused action items? Take a look at our sample care plans. They show a range of reablement strategies to help your clients become more independent:

• Reablement Care Plan Examples
• Wellness Care Plan Examples

As you’ll see, these examples focus on the use of 5 core reablement strategies:

1. Build capacity
2. Modify the task
3. Adapt the environment
4. Recommend Assistive Technology (AT)
5. Provide information

If you want to learn more about these strategies, check out our page, 5 Reablement strategies, for detailed explanations and practical tips.

Respect dignity of risk

Remember to honour your client’s right to make choices, even if they involve some personal risk. Document any identified risks in the care plan, along with mitigation strategies, your recommendations, and your client’s informed decision.

This approach respects your client’s autonomy. It also upholds the Statement of Rights and Standard 1: The Individual of the Strengthened Aged Care Quality Standards.

Care plan agreement

Once you’ve documented your client’s goals and action strategies, it’s time to get their formal agreement. This completes the ‘A’ (Agreed) component of the SMARTA approach.

Ask your client how they’d prefer to check the care plan:

• Some may want time alone to read it
• Others might prefer reading it with you or a support person
• Consider accessibility needs and provide alternative formats if required

After your client has checked and agreed to the plan, get them to sign it. This confirms that:

• The plan accurately represents their goals
• They actively contributed to its development
• They agree with the planned approach

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Step 3: Review care plan

Regular reviews ensure the care plan continues to meet your client’s needs. Here’s when to conduct reviews:

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Preparing for life after reablement

It’s important to prepare your client for the end of their reablement program. Work together to focus on how they’ll keep up their progress. Research shows that without this step, clients often slip back into dependency (Mulquiny & Oakman, 2021). Discuss strategies to maintain independence, such as:

• Continuing daily activities as independently as possible
• Staying socially connected
• Joining clubs or community groups
• Establishing regular exercise routines
• Engaging in mentally stimulating activities

You can also consider these steps:

• Connecting your client with ongoing support through My Aged Care, local councils, or LiveUp.
• Applying for an additional period of reablement if they are still making significant progress.

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