Goal Directed Care Planning Resources

KPA has developed a range of resources to support agencies understand and embed GDCP.

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Goal Directed Care Planning Toolkit

This Goal Directed Care Planning Toolkit was developed as part of the Eastern Metropolitan Region (EMR) Home and Community Care (HACC) Goal Directed Care Planning project.

The GDCP Toolkit includes a range of practical tools to support agencies understand:

  • the rationale for GDCP and the relevant practice requirements
  • how to engage clients in the process and document meaningful GDCP
  • the organisational systems, policies and procedures that enable staff to embed effective GDCP
  • strategies to evaluate GDCP tools, practices and systems

Download (pdf – 7.5Mb)
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Service specific assessment and care planning resources

We have developed this suite of resources to support services providers reflect on their assessment and planning processes and consider ways to reduce duplication and deliver a more streamlined and person centred approach.

They include practical information about the expectations around service specific assessment and planning and how to embed those practices in your work.  They are designed to be easy to use and read, with lots of ideas and strategies you can build into your everyday work.

  • Embedding a strengths based approach in client conversations*  (download PDF)
  • Reducing duplication in Service Specific Assessments*  (download PDF)
  • Service specific goal setting and care planning***  (download PDF)
  • Monitoring, Feedback and Review of service specific care plans***  (download PDF)

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These resources were developed with the Victorian CHSP sector development teams, including the Wellness and Reablement Consultants in the Eastern*,  Northern and Western*** Metropolitan Melbourne regions.   While they have been developed within the context of the Commonwealth Home Support Programme (CHSP), the key principles, practices and strategies described in these resources support good practice across a range of service types and client groups.

Where to find information on the NSAF

NSAF Information Collected
This resource maps the information that is commonly collected during an assessment to the domains of the National Screening and Assessment Form (NSAF).
The NSAF is the assessment tool that is used to collect information for the screening and assessment processes conducted by the My Aged Care team and assessment staff (RAS & ACAT).
This simple tool is designed to help service providers locate relevant information to inform your service specific assessments (i.e. which domains to look at within the NSAF).
Download (pdf – 60 kb)

What is a Care Plan?

Staff use many different terms to describe care plans. This often creates confusion and can make communication and information sharing difficult.
This resource describes different types of care plans and provides examples about how they are used in practice.

Download (pdf – 1Mb)

Top tips for documenting GDCP

We know that staff are committed to working in person centred ways and constantly tailor their approach to match each client’s priorities, strengths and abilities. Often though, staff report that translating this approach into writing and documenting meaningful GDCPs is challenging. This resource provides tips about how to document a GDCP that can become a valuable tool for you and your clients.

Download (pdf – 154 kb)

Top tips for Aged Care assessors.

Documenting assessment summaries and support plans:

GDCP Frequently Asked Questions

This FAQ sheet provides answers to some of the most common questions we are asked about GDCP.

Download (pdf – 91 kb)

GDCP Templates

We have developed a range of template examples, that demonstrate how the key elements can be integrated into a simple and easy to use template:


GDCP Audit Tools

We have developed a range of tools that assist agencies evaluate and monitor their GDCP approach. While these tools were developed for the HACC sector, we have mapped the GDCP requirements across a range of quality standards and practice guidelines including:

  • National Health Standards
  • Victorian Service Coordination Practice Manual and Continuous Improvement Framework
  • Community Care Common Standards (CCCS)
  • The VHA Clinical Indicators
  • Victorian DHS Standards and Client File Audit Tool 2014
  • QIC Health and Community Services Standards (6th Edition)
  • ACHS Evaluation and Quality Improvement Program (ACHS EQuIP5)

We are therefore confident that the audit tools are relevant to, and consistent with the care planning guidelines across a number of sectors.

Template Audit Tool

Organisations need to ensure that their care planning template is simple, easy to use and provides prompts to document the information required to meet the relevant quality standards.

The Audit tool for Care Planning Templates (PDF) provides a quick and easy way to review your existing templates and identify areas for improvement.

Audit Criteria for Completed Care Plans

GDCP Audit criteria
The Audit Criteria for Completed Care Plans describe the key information that should be documented during the development and review of care plans. This enables staff to objectively assess and measure the quality of documentation.

Assessing care plans against the criteria can be valuable to build the knowledge and awareness of staff and to support ongoing quality improvement.

The Audit tool for Completed Care Plans has been setup so that staff can easily audit a number of client files on one page.

Checklist of Organisational Systems to support GDCP

The Checklist of Organisational Systems to support GDCP (PDF and word) has been developed to support agencies review their progress in relation to developing organisational systems that support effective GDCP.

GDCP Conversation Tools

Effective GDCP is reliant on staff’s skill and confidence in having a conversation with the client (and their carer/s), understanding their needs, priorities and identifying how best to support them to achieve their goals. This requires us to move away from a ‘tick the box’ style assessment and adopt a more conversational, in depth approach.

The Learning Community for Person Centred Practices and Helen Sanderson Associates have developed a range of tools and approaches that provide staff with practical, easy to understand strategies to support GDCP.

Basic Microsoft Word templates, for a number of these tools, are provided with permission from The Learning Community for Person Centred Practices and Helen Sanderson Associates.

For more information about these tools, please refer to: