Implement complex health care plans
This unit describes the performance outcomes, skills and knowledge required to review health assessments and contribute to the development of complex health care plans as part of a multidisciplinary health care team.
It covers skills to implement, monitor and review plans for the care of clients with complex health conditions, including chronic disease, that require systematic long term management. Plans might include a focus on modification of lifestyle risk factors. Implementation involves making referrals, administering clinical treatments and coordinating ongoing care.
This unit is specific to Aboriginal and/or Torres Strait Islander people working as health practitioners. They work as part of a multidisciplinary primary health care team to provide primary health care services to Aboriginal and/or Torres Strait Islander clients.
No regulatory requirement for certification, occupational or business licensing is linked to this unit at the time of publication. For information about practitioner registration and accredited courses of study, contact the Aboriginal and Torres Strait Islander Health Practice Board of Australia (ATSIHPBA).
Health Care and Support
Aboriginal and/or Torres Strait Islander Health
Elements describe the essential outcomes
Performance criteria describe the performance needed to demonstrate achievement of the element.
- Contribute to the planning of treatment and care for clients with long-term or complex conditions.
- Review client history and health assessments to ascertain specific requirements of health care plan.
- Evaluate current status of client’s condition and impact of previous treatment strategies.
- Identify proposed treatments using organisational standard treatment protocols and within scope of own practice.
- Discuss with multidisciplinary team members treatment proposals and options that respond to the complexity of client needs.
- Develop proposed care plan in collaboration with multidisciplinary primary health care team.
- Establish clear responsibilities for implementing care plan.
- Communicate proposed health care plan to client.
- Use culturally appropriate and safe communication to discuss proposed care plan with client and explain how it relates to health assessment results.
- Provide client with information about each aspect of proposed care plan and reasons for inclusion.
- Encourage client questions about proposed care plan to support understanding, cooperation, and agreement.
- Assist client to express their needs, preferences and goals, and encourage their choices about own health care.
- Encourage active involvement of client and/or significant others in health management to ensure optimum plan outcomes.
- Explain to client importance of regular check-ups, tests and reassessments in the ongoing management of their health.
- Consult with primary health care team about client-suggested plan changes and adjust as appropriate.
- Update client records to include the finalised plan, according to organisational policies and procedures.
- Implement referrals and clinical treatments.
- Select and use medical equipment suited to purpose of treatment and according to manufacturer’s specifications.
- Implement required infection control precautions according to treatment requirements.
- Administer clinical treatments according to scope of practice and standard treatment protocols used by the organisation.
- Demonstrate and explain, to client, correct techniques for self-care treatments.
- Discuss required lifestyle modifications and offer brief interventions for smoking cessation and reduction or cessation of alcohol consumption, as relevant.
- Facilitate referrals to health professionals and support services according to client needs and preferences.
- Update client records to include details of referrals, treatments and self-care information provided.
- Monitor client’s health and review effectiveness of health care.
- Organise follow-up care for client and use active recall strategies for overdue care.
- Monitor client’s health through ongoing scheduled assessments incorporated in care plan.
- Gain feedback from client and/or significant others about their level of comfort and adherence to care plan.
- Evaluate improvement of client’s health, compare with care plan expectations and consult with primary health care team to determine impact of health care.
- Provide clear information to client and/or significant others about health outcomes and relationship to care plan and adherence.
- Coordinate review of care plan to suit client’s current health status and for ongoing health management.
Foundation skills essential to performance in this unit, but not explicit in the performance criteria are listed here, along with a brief context statement.
Reading skills to:
- interpret complex and sometimes unfamiliar health assessments involving health terminology and abbreviations
- interpret sometimes complex and unfamiliar standard treatment protocols involving medical terminology and abbreviations.
Writing skills to:
- use fundamental sentence structure, health terminology and abbreviations to complete forms and reports that require factual information.
Oral communication skills to:
- provide unambiguous information to clients using plain language and terms easily understood
- incorporate motivational interviewing techniques into client interactions and brief interventions
- ask open and closed probe questions and actively listen to elicit information from clients and to determine client understanding of information provided.
Numeracy skills to:
- interpret sometimes complex medical numerical data and abbreviations in standard treatment protocols and client records
- complete a range of calculations for treatments and plan evaluations involving volume, percentages and ratios.
UNIT MAPPING INFORMATION
No equivalent unit.
For details, refer to the full mapping table in the Draft 2 Validation Guide.
Companion Volume Implementation Guide