Scenario 2: Assessments, reviews and care planning for Clint
As dementia touches on all aspects of life, it can be very difficult to know where to start, what to ask in an assessment or review to identify needs or risks, what to do next in the care plan to develop mitigation strategies, or what you may have missed.
The Topics (middle column) and Sections (rightmost column) act as checklists to anticipate their journey and needs, and you can use this to plan and support them throughout the journey. Topics are loosely ordered from early to later stages of dementia, and it’s very likely that families will need to cover almost all Topics at some point on their journey.
You can track this progress through the “View as Drew and Clint” feature, which shows the number of Sections shared against the total. This can work side-by-side with your assessment, review and care planning templates.
If a new client comes to you in later stages of dementia, be sure to go back and check if the carer has implemented some of the earlier Topics as this helps to build a strong foundation to manage more complex challenges later on.
You can watch the video below to learn more (video coming soon).
Tasks to complete
Think of a client for whom you are assessing, developing or reviewing a care plan.
Look down the list of Topics. What have you already covered with them and what do you think they may need next? E.g. financial planning, respite care, incontinence, simple techniques to manage at home, etc.
Review the respective resource(s), insert the relevant ones into your care plan for the future. In the PRO, you can save the Topic or Section under “View as client & carer” to mark it as a follow-up item.
When appropriate, implement the care plan by taking your clients through a subject (Topic or Section) and sharing the resources with them afterward.
In this scenario, you need to conduct an onboarding or initial assessment and create a care plan for a new client (Clint) and his carer (Drew).
Where do you start? How do you know what needs to be covered off?
Note, this is also a requirement of the Aged Care Quality Standards and also one of the most common non-compliant findings in audits.
Checking for needs, risks and potential deterioration
During the care review or assessment (or in your prep work), you can select “View as Clint and Drew” within the PRO and it brings up Clint’s dementia journey. Working alongside your assessment or review templates (see pic below), you can then work your way down the checklist to guide your review or assessment, to identify needs, risks or potential deterioration.
As dementia touches on all aspects of life, almost all clients and families will go through the majority of the Topics and Sections in their journey.
Note: currently, there is no assessment or care planning template that guides you through it.
Putting this into a care plan
When you create the care plan, you can have your care plan template open side-by-side with the PRO (see pic above). Referring to the risks, needs or potential deterioration identified, you can go down the list of Topics and Sections to cross-check potential gaps and find actionable solutions for each gap. For example, you discovered that:
they don’t know much about legal or financial planning, or at least didn’t realise it is something they had to think about
Clint is still trying to drive and won’t give it up
Drew is becoming exhausted.
Using the PRO, you can incorporate the following Topics as part of the care plan to help support them to live well with dementia:
Use the Section list in "Future planning: legal matters” and “Future planning: financial matters” to guide you on what they have and do not have in place, e.g. advance care planning, enduring power of attorney, administration, etc.
Cover off Topics on “Driving and transport with dementia”, document the relevant Sections to be actioned, such as planning for driving, having a conversation about driving, legal requirements and not accepting license suspension. You can also reassess if they have their transport-related subsidies documented, e.g. disability parking, taxi voucher scheme, etc.
Refer Drew to relevant services and helpline, such as carers counseling, teach her about respite services, carer subsidies and entitlements, etc.
The most important thing here is that when the relevant support is identified, you can simply share this information within a few clicks. Learn how to share here.
Note: practicing person centred care, you don't need to share all of the above information in one go which may overwhelm them. Please prioritise and walk them through relevant Sections over time as needed.
Tracking their progress and journey
As the PRO helps to map out one’s journey, you can also:
Save the Topic under “View as Clint and Drew” to mark this as a work-in-progress
Use the “Shared” symbol and a tally (counter) of Sections shared to track their progress through the journey.
This will help you track your actions as part of the care plan and by the time Clint and Drew finish their journey with you, you would ideally see that all Sections and Topics have been shared.
As dementia is progressive in nature, almost all clients and families will go through the majority of Topics and Sections in their journey.
The PRO can offer you peace of mind that key items are not missed and the confidence to deliver best practice care
New clients starting at a later stage of the dementia journey
You may have new clients starting with you in moderate or later stages of dementia. This means you can start using the list of Topics from a little further down.
However, it is important to note that everyone could benefit greatly if you go back up the list and check if they have been managed or covered off by the client and carer. This is important because:
we still see too many families who are many years into their dementia journey and don’t understand some of the most basic subsidies that they are eligible for, are unaware of the many simple dementia care strategies they can use to manage behaviours and daily challenges, and many other techniques or approaches they can use to live well with dementia
earlier Topics help the family to build a strong foundation and resilience to manage more complex challenges later on. It can also help with preventing challenges from worsening.
The scenarios do not cover all of the content in My Dementia Companion, nor all the ways it could be used. Please keep exploring!
All the information is curated from reputable sources that are designed for people like Jane and Bill. So, assess and if relevant, share with confidence!
Contact us if you have any questions via the “Questions?” button or the chat icon within the tool, email us or sms/call us 0406 257 729 during business hours.