Scenario 3: assessment and care planning

Scenario takeaway

  • Because dementia touches on all aspects of life, it’s very difficult to know where to start, what you may have missedwhat to ask in an assessment/ review, or what to do next in developing the care plan.

  • The Topics act as a guide or checklist to anticipate their journey and needs, and then guide you to plan and support your clients through their whole journey. Topics are loosely ordered from early stage to late stage and it’s very likely that families will need to cover almost all of the Topics and Sections at some point in their journey.

  • You can track this progress through the “View as Bill & Jane” feature, which shows the number of Sections shared against the total. This can offer you a peace of mind and the confidence to deliver best practice care.

Tasks to complete

 

  1. Think of a client for whom you are developing or reviewing a care plan. 

  2. 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 etc.?

  3. Review the respective Topics and Sections, then insert them into your care plan for the future. In the PRO, you can save the Topic or Section under “View as client & carer” to mark as a follow-up item.

  4. When the time comes, implement the care plan by taking them through a subject (Topic or Section) and share the resources with them afterwards.

Notebook

Scenario notes

After supporting Jane and Bill through their driving journey, you may start to update his care plan for the future. Note, this is also a requirement of the Aged Care Quality Standards.

Understanding dementia and medications

To start this process, you can select “View as Jane & Bill” in the “All info” tab. Then you can scan down the list of Topics in the middle column as a guide to assess against their needs.

This is because dementia touches on all aspects of life, so almost all clients/ families will go through the majority of the Topics and Sections in their journey. However, without this list in the PRO, it’s impossible to remember them all to help you assess and guidance on.

Scanning down, the first Topics that come up relate to medication and understanding dementia. After checking this with them, they tell you that they have a good understanding of dementia and Bill's medication from their geriatrician and neurologist.

 

So you can move further down the list of Topics.

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Next Topics to cover are legal and financial planning

Looking down the Topic list as a guide on what to cover next, you may ask Jane and Bill if they have done their legal and financial plans. They say they have not and didn’t realise it is something they had to think about.

These two areas become part of their needs and care plan.

Note, without knowing what Bill and Jan don't know, it is impossible for you to remember everything about dementia care. This list list helps to prompt you against clients and carers’ potential needs and helps you structure your conversation with them, so you will not miss important matters.

Using the content to support your conversation

 

Similar to the driving journey, you can now begin to guide Jane and Bill through their journey with legal and financial matters.

 

Firstly, you can open the first two Sections of the “Future planning: legal matters” Topic and use them to guide your conversation with them, such as what does legal planning mean (e.g. advance care planning, enduring power of attorney, administration etc.) and why they are important etc.

Jane and Bill both think it’s very important and are happy for you to share all the relevant Sections for them to digest over time. You can:

  1. Save the Topic under “View as Bill & Jane” to mark this as work in progress

  2. Share a few relevant Sections with them

  3. Enter into their care plan to work through the legal matter with them over the coming months.

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You repeat the same process for the Topic “Future planning: financial matters”.

Following the instruction in the image above, now you can see:

  • A Shared symbol against each shared Section 

  • A tally (counter) of Sections shared out of the total shareable Sections in that Topic. 

    
This will help you
keep track of their progression in their legal and financial planning journey. And by the time Bill and Jane finish up their journey with you, you would ideally be able to see “8/8 Sections shared, 17/19 Sections shared…” across all Topics

As dementia is progressive in nature, almost all clients/ families will go through the majority of the Topics and Sections in their journey.
 

We hope by using it as a guide, the PRO can offer you a peace of mind and the confidence to deliver best practice care.

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A note about the first few Sections per Topic

The Section starting “Common questions about…” are usually the first Section for each Topic. They outline common questions that you may encounter about that subject. This can help you ease-into each Topic..

The second Section is usually the introductory Sections. They are structured similarly for each Topic, which gives you a brief introduction to what this Topic is about and what the following Sections will cover in dot points.

You can use this as a quick overview of the Topic and can be shared with Bill and Jane.

Note

  • 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!

  • Handy user tips include: why learn dementia careshortcuts/app icons, adding us to safe sender list, registration tipssharingextra tips and tricks

  • 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.​