Salveo HomeCare - My Care Plan

My Care Plan
Care Partner Email
example@example.com
Date of initial submission

DayMonthYear
Date of initial submission
This care plan has been developed to align with your current health, goals, preferences, and support needs. Your voice, choices, and lived experience are central to shaping how your care is delivered. This care plan outlines the services and supports in place to help you live the life you choose at home, in your community, and on your own terms.
This Care Plan was created collaboratively, in partnership with you, and reflects our commitment to CARE values.

C–COMPASSION ensuring compassion extends to both our customers and our dedicated staff.

A–ADAPTABILITY be aware of different needs and preferences of our customers and delivering services in accordance with those needs

R–RESPECTevery customer is unique, and we value their individuality, diversity and choices

E–EMPOWERING improving the quality of life of every customer and engaging them in every decision that affects their care
This Care Plan Is For:
Full Name*

First NameLast Name
Preferred Name*
Date of Care Plan*

DayMonthYear
Date
Purpose of this Care Plan*
Version
e.g. second care plan = version 2.
My Aged Care Reference ID*
Date of Birth*

DayMonthYear
Date
Phone Number*
Email*
input email of the person signing the care plan - e.g. MPOA, NOK
Address*

Street Address

Street Address Line 2

SuburbState

Post Code
Gender Identity*
Place of Birth*
NoYes, AboriginalYes, Torres Strait IslanderYes, both
Cultural Background*
Preferred Language/s*
Yes → Face to faceYes → By PhoneYes → for written documentsYes → National Relay Service (NRS)No
Does not need help communicatingSometimes needs help to communicateDoes need help communicating
SMSEmailPhone CallNo preferencesPostOther
SMSEmailPhone CallNo preferencesPostOther
Things To Consider About My Cultural, Diversity, Values and Belief*
FemaleNo preferenceMale
My care worker, communication and service delivery preferences*
Important things i need my care workers to know when communicating with or delivering services to me. This may include any dignity of risk.
Classification Level*
Care Management Type*
Interim funding allocated (Minimum Service Offer – MSO) 60% of participant approved Support at Home classificationParticipant receiving MSO is assigned FSO (FSO/ full funding)Not applicable – Full funding allocated from commencement
Applicable Supplements or Additional Funding*
YesNo
Details of additional supports needed
additional support
Yes - Assistive technologyYes - Home modificationsYes - BothNoApplication has been made
LowMedHigh
LowMedHigh
Assistive Technology & Home Modifications (AT-HM) the participant is receiving:
Enter in any amounts known, Cost of Equipment etc
Person Responsible for making decisions: *
People involved in developing My Care Plan:*
Specify name and relation to the Care Recipient. Separate by comma, e.g. Jane Doe - Daughter, John Doe - Son
YesNoNot applicable
Representative / Substitute Decision-Maker Details and Comments
Representative / Substitute Decision-Maker Details
YesNoNot advised
YesNoNot advised
Comments
My Support People

My Preferred Support People (e.g. preferred support worker, gardener, etc.)*

Rows	Name	Role/Relation	Contact Number
Person #1
Person #2
Person #3
Person #4

Important Things To Know About Me
Family Background and Life History
OLD - Life History
Interests
Informal Supports*
Medical Information
My Medical History
Allergies and Alerts*
Include the reaction if know. Type Significant allergies or alerts in CAPS LOCK. Separate by comma, e.g. ANAPHYLAXIS TO DAIRY, allergy to nuts, WANDERER
Medication Management
YesNo
I self-administer my medication independentlyI self-administer with supportA support worker or nurse administers my medicationShared responsibility (family and provider)
During the assessment, the participant and/or their representative advised that they wish to self-administer their medication. This preference was discussed in detail, including the participant’s understanding of their medications, dosing, timing and storage.
Prompting only (verbal reminders to take medication)Assistance with medication (e.g. opening packaging, handing medication, positioning)Supervision while taking medicationAdministration of medication by authorised workerMonitoring for side effects or adverse reactionsAssistance collecting medication from pharmacyOther (please specify)
YesNo
YesNo
YesNo
OLD - Details of medication assistance needed
If applicable
YesNo
Upload a copy of the medication management plan

Cancelof
Dignity of risk discussed and acceptedDignity of risk discussed – further review requiredNot applicable
Dignity of Risk Statement
The participant has been informed of the identified risks associated with self-administration of medication. Despite these risks, the participant has chosen to continue managing their own medications. This decision has been made with an understanding of the potential consequences and reflects the participant’s right to dignity of risk, choice, and independence
Medication list reviewed and providedWebster pack / dose administration aid recommendedReminder system discussed (alarms, phone, calendar)Family oversight agreedRegular review by providerGP / pharmacist involvement encouragedEscalation plan discussedNo mitigation strategies requiredOther

Likelihood	Descriptor
Almost Certain	The event is expected to occur in all circumstances. At least once per week.
Likely	The event will occur in most circumstances. At least once per month.
Possible	The event will probably occur at some time. At least once per year.
Unlikely	The event could occur at some time. At least once in two years.
Rare	The event may occur in exceptional circumstances, or never Less than once in 100 years

Consequence	Descriptor
Catastrophic	• Fatality/Death • Permanent injury and irreversible loss of function or capacity • Significant governance failing
Major	• Serious injury/ harm to participant requiring lengthy hospitalisation • Permanent impairment impacting independence • Major governance failing
Moderate	• Temporary injury/harm to participant requiring brief hospitalisation and/or medical treatment • Temporary reduction in function or wellbeing • Injury requiring increased care for more than four days • Some protocol breaches
Minor	• Minor harm to participant requiring medical treatment • No ongoing impact • Injury requiring increased care for 1 to 4 days • Minor protocol breaches
Insignificant	• Incident or near miss with no injury or increased level of care • Minor harm to consumer requiring first aid • No protocol breaches

Rows	Details
Goal
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Rows	Details
Goal
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Rows	Details
Goal
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Rows	Details
What do I want to achieve?
Current needs and challenges
What are you able to do?
How will we do this?
What are the considerations, and how will we support your choices?
When will it be done? (time, day, frequency)
Start Date
Review Date
Has this goal been achieved? (Yes, No, In Progress)
Comments (In relation to the goal being achieved)

Rows	Applicable?	Details
Care Management
Living Companion
Personal Care
Domestic Assistance
Nursing Care
Home and Garden Maintenance
Social Support
Transport
Allied Health Services
Continence Management
Skin integrity
Medication Management or Assistance
Meal Management or Assistance
Activities of daily living
Memory
Cognition
Falls Frequency
Communication
Personal Alarm
Financial Management
Behaviours

Record of Edits