PAG. pathways. a guide to implementing an active service approach to planned activity groups

Transcription

1 PAG pathways a guide to implementing an active service approach to planned activity groups

2 This project has been a joint initiative between: Yarra Ranges Council Caladenia Dementia Care EACH Social and Community Health Golden Wattle Department of Health Home and Community Care The HACC program is supported by funding from the Commonwealth and Victorian Governments 2 PAG pathways > planned activity groups

3 PAG pathways a guide to implementing an active service approach to planned activity groups Contents 4 Acknowledgements 5 Purpose of this Guide 7 Planned Activity Groups 7 Aim of our PAGs 9 What makes a PAG special 9 PAG target groups 10 Activity Planning 12 Well For Life 13 What is the Active Service Model? 17 Why has the ASM been introduced 19 Person Centred Planning 20 Five dimensions of inclusion 21 What is Active Ageing 23 Active Service 23 A changing way to support people attending PAGs 25 ASM language 27 Four key ASM PAG Procedures (Including flow charts) 27 Intake / Assessment (Flowchart) 29 Social Profile / Care Plans (Flowchart) 32 Example of a completed social profile 36 Enactment of personal emergency plan 39 Service Delivery (Flowchart) 39 Planning your program 42 Training for staff and volunteers 44 Benefits of being in a positive and active PAG 45 Tips and comments 45 How will you know if you have been successful in implementing active service? 47 Discharge 47 Person initiated (Flowchart) 49 Service initiated (Flowchart) 51 Where to find information and local services 56 Useful Resources 57 Forms 59 Commonly used Acronyms

4 Acknowledgements The reference group generously shared their skills, experience, passion and time and without their assistance, this project would not have been possible. Project Worker Christene Wilson-Altamura Yarra Ranges Council Aged and Disability Services Toni Clancy Thank you to all the staff, volunteers and people attending the PAG programs for their contribution and commitment. Without their participation and assistance, this project and guide would not have been possible. Thank you also to Shannon Reddaway for taking the photos used in this manual. Caladenia Dementia Care Sarah Yeates EACH Social and Community Health Community Inclusion and Support Services Golden Wattle Luisa Williams Department of Health Home and Community Care EMR ASM Alliance 4 PAG pathways > planned activity groups

5 Welcome The purpose of this guide is to assist you with the Active Service Model (ASM) principles, to build on your confidence with ASM and to assist you to look at the different ways of supporting people attending your Planned Activity Group (PAG). Many staff and volunteers are already practising various principles of the ASM. This guide is designed to be a companion and reference for all staff and volunteers supporting people (and if applicable their carers) who attend a PAG. You are encouraged to read this resource and use relevant parts in your team meetings, volunteer meetings, and we suggest making ASM a regular item on your team meeting agenda. Please share this resource guide with others who may find it useful. If you have any questions, please do not hesitate to discuss your question with your Supervisor.

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7 Aim of our Planned Activity Groups Planned Activity Groups (PAGs) are supported social groups offering the opportunity for frail and older isolated people, people with disabilities, people with dementia and their carers to continue to be active and connected within the community. This is done by providing meaningful social and recreational activities in a supported and nonthreatening group environment. The individual programs address the physical, social, cultural, emotional and recreational needs of the people who attend, and provide opportunities for social interaction and support. The programs are designed around choice and ability of the people attending, and emphasis is on enjoyment and fun, improving self-esteem through independence, both socially and maintaining or improving physical or cognitive capacity. The groups provide a planned and reliable service for people attending, focussing on maintaining peoples ability to live at home and being involved in the community. Careful program planning and implementation ensure that individual needs are catered for, within the wider group programming and the activities focus on enhancing and/or maintaining the skills people require for daily living. There is a focus on being aware of the abilities and strengths of the members and what they have to offer, rather than what they are unable to do. The PAG staff welcome input and provide regular opportunities through surveys and forums etc. for suggestions from people attending the groups (and carers) for activities and outings for the Group. Activities are held both in-house at the PAG venue and within the community. For example, shopping outings, 10 Pin Bowling, concerts, movies, day trips and holidays. PAGs also provide support and respite for the carers of people attending the groups.

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9 What makes a PAG special? Provides an opportunity for social connections for people who are often isolated Encouragement and support for people to actively participate as much as possible Friendship A place of belonging Respect and dignity to all Non threatening and safe Meaningful activities and enjoyable outings Can improve quality of life People are seen as individuals and the program is person centred No sense of hierarchy everyone in the PAG is important Having a voice / opportunity for feedback and suggestions that will be heard Activities and outings that are designed or modified to suit the needs, abilities and desires of group members A link into your local community and possibly an opportunity to link into other services whilst attending the PAG (particularly if geographically isolated) Maintaining or improving skills and abilities of people attending Opportunities to learn from guest speakers for example: Occupational therapists regarding suggestions on making a home safer (ramps, internal and external grab rails & handles, personal alarms etc) services available from local council and service providers to assist a person to stay in their own home for as long as possible and practical local Police or Neighbourhood Watch regarding home safety health promotion (Men s health, quit smoking, stroke awareness, weight management etc..) Quality respite for carers Support for carers individually and in groups Enjoyable and fun The HACC program is designed to support people whose capacity for independent living is at risk, or who are at risk of premature or inappropriate admission to long-term residential care. Eligibility does not depend on age or income. HACC providers use priority of access guidelines to manage demand for services. PAG Target Groups Primarily People who are eligible to receive Home and Community Care (HACC) services are: People living independently at home, even with the support of carers but still living at home (not living in residential settings - hostels, nursing homes, facility based accommodation etc.) frail, older people people with a physical, functional, sensory, intellectual or psychiatric disability people with dementia people with an acquired brain injury, and carers and their families to assist them in their role by providing respite, information and support. Within the HACC target group, special needs groups have priority of access to HACC services according to their assessed individual needs: people from culturally and linguistically diverse backgrounds; indigenous people; people with dementia or other related disorders; people who are financially disadvantaged; people who are frail aged and other people with disabilities living in remote or isolated areas; and people with multiple disabilities and complex support needs. And people whose level of need is consistent with the service we are able to offer, people who will benefit from participating in the centre-based group activities, and/or whose carer will benefit from the respite.

10 Extract from Victorian HACC Program Manual Feb 2003: Page Activity Planning: The activity plan should be sufficiently structured in content and process to ensure that there is adequate opportunity for consumers to meet and relate to each other in a personal and friendly atmosphere. Planned activity programs should be regularly assessed and reviewed in relation to their suitability, effectiveness and outcomes, including cultural and age appropriateness and relevance to consumer s assessments and care plans. When planning activities the preferences of consumers should be sought. Consumers should have an opportunity, at least once per month, to discuss future activities, including group and individual preferences and cultural and age appropriateness of activities. When planning activities it is useful to consider the following questions: Does the plan take notice of feedback from staff, volunteers, consumers and carers about past activities and preferences expressed for new activities? Is the plan responding to information about individual consumer needs gathered during the assessment? Does it create opportunities for companionship and friendship? Are activities designed to enhance daily living skills? Are the activities appropriate for the age of the consumers? For example with older people use past life experiences in an oral history project Does it include and encourage appropriate levels of physical exercise and activities? Is there a balance between social, intellectual and physical stimulation and between large group, smaller group and individual activities? Have some different ideas for activities been sought from relevant publications and from other PAG providers? Does it provide opportunities for celebration of culturally relevant festive days, holidays or other celebrations such as birthdays and anniversaries? Can the group participate in local community activities, such as street festivals, art exhibitions, library activities, concerts etc? Are people having fun and at the same time, participating in activities that will maintain skills, such as hand / eye coordination? 10 PAG pathways > planned activity groups

11 to meet and relate to each other in a personal and friendly atmosphere

12 Well for Life Well for Life is primarily understanding and promoting the inter-relationship and benefits of good nutrition, physical activity, social participation and emotional wellbeing which supports and promotes independence and healthy aging. Well for Life principles work very effectively and complement the ASM principles. Well for Life focuses on and supports older people who participate in Home and Community Care (HACC) services, live in public sector residential aged care services (PSRACS) and live in public housing. Well for Life is part of the Department of Health s priority of promoting physical and mental health, and wellbeing among older people. Well for Life has been operating in Victoria since By developing and encouraging Well for Life principles and initiatives within your PAG, this may promote older people s health and wellbeing, physical activity and emotional wellbeing. For example, combining fun and gentle exercise as a group activity in your program. At the Yarra Ranges Council, the Yarra Junction PAG have regular exercise sessions and this is made available to anyone in the group who wishes to participate. Other examples include: Falls prevention programs Walk and Talk Strength training through gentle exercise There is much laughter as the group exercises and it is obvious that everyone is enjoying the activity, plus they are gaining benefit from it. People are seated in two rows the two rows facing each other. Staff improvise and give each person a swimming noodle, there is a person seated at one end who throws a balloon into the middle and then it is game on! Each team tries to get the balloon to the other end using their noodle. There is a small prize and much glory for the winning team. While superficially, the activity appears to be a great game it also incorporates and develops many other proficiencies such as mobility, coordination, communication and prolonged concentration. 12 PAG pathways > planned activity groups

13 What is the Active Service Model? The ASM approach is supported by five key principles: 1. People wish to remain autonomous 2. People have the potential to improve their capacity 3. People s needs should be viewed in an holistic way 4. HACC services should be organised around the person and his or her carer 5. A person s needs are best met where there are strong partnerships and collaborative relationships between the person; their carers and family; support workers and service providers What this really means: Working with the person to stay as active, connected and independent as possible 1. People want to remain autonomous This means respecting a person s self determination, choices and decision making, that people want to maintain (or regain) their independence, to be informed and make decisions and choices on things that effect their life. The ASM aims to assist a person to feel supported in making their own choices and that they have control and a say in what happens in their life. As staff or volunteers working in a PAG, this model of service means being aware of providing support and encouragement for people to do things for themselves, and even to encourage people to assist each other if they are able. This is reinforcing the shift from doing for people, which can create and encourage dependency to doing with which encourages activity and being more involved. People attending the program may notice a change and comment (in jest of course) that you re not doing your job you can introduce the changes slowly and it may take a little while for some to get used to doing more for themselves but you ARE doing your job and in time they will probably accept the changes as a normal part of the program. Other examples include: managing as many of their own day to day activities as possible choice and supports to live independently for as long as possible being involved and in control of decisions which effect their life health issues, financial, holidays, housing etc.. Contributing to the desired outcomes of their social profile / goal plan etc.. 2. People have potential to improve capacity This means approaching all HACC service users as having capacity to improve their function and wellbeing, if only in small ways. An example of this is when a person wants to walk their dog daily, independently. In this instance, the worker could suggest working with an Occupational Therapist to put together a care plan outlining the steps required to meet this goal this could include participation in a falls prevention group, strength building exercises, rails on the external stairs etc.. By finding a way to continue walking the dog, the additional benefits for the person could include feeling better for being outdoors, vitamin D intake, exercising, meeting people on the walk, improved self esteem and confidence etc.. For many PAG workers this is another way of supporting people as workers we all want to help but often doing with and not doing for can be far more empowering for the person. People attending the group can be encouraged and supported to do things for themselves e.g. getting their own drinks, meals, making suggestions for activities and outings that the group could do, (if appropriate) transferring in and out of the car / bus, assisting others where able and needed, sharing the roles in the activity group and even encouragement to talk to another person attending the group. By encouraging people to talk, there is the possibility of a friendship being formed. Even if people are not big talkers they may not be confident due to a stroke, may be naturally quieter, English may be their second language, the value of sitting and listening, and being a friend and companion cannot be underestimated.

14 For the person, there is a greater sense of contributing and being valued, which can result in increased self esteem and confidence when doing more for themselves, both in the group and at home. For example (if appropriate) staff could encourage people to come and get their own lunch or drinks from the servery, or to help set up the activities, packing up, assisting others where able, any contribution is welcome and valuable. It may be necessary for PAG staff and volunteers to explore alternative ways of doing the task with the person so they are able to do the activity / task they wish. This will all help to gain/maintain confidence, self esteem and promote independence for the person. Some staff members may be concerned that allowing people to do more for themselves is dangerous people may be at risk of falling, dropping things or injuring themselves. It is important for staff members to assess each person individually and allow them as much independence and choice as possible whilst still taking into account our duty of care to the person and those around them. 3. People s needs should be viewed in an holistic way As we know, independence is broader than physical functioning. This is about working with people in a way that sees them as a whole person with a history, a life and many years of experiences and then focussing on what is meaningful and important to them. It s a person-centred approach, which promotes wellness and active participation and encourages the person to be involved in decisions that affect their life. It is accepting that individuals will have different motivations and goals and understanding these to best support the person. There is a need to look beyond the suite of services that HACC or particular agency provides and try and find the best solutions for the person. Looking at the whole person, not just seeing what they can t do but what they can do. Ask, Listen and Observe. Instead of treating an illness or responding to a physical restriction, holistic care looks at an individual s over-all physical, mental, spiritual, and emotional wellbeing. What are (and were) their interests, provide an opportunity for the person to tell their story and for it to be heard. What is their country of birth, did they immigrate, cultural background and interests, their career, travel, family/children etc.. Be aware of their personal situation what is important to them, what is their story? For example: Do they care for someone else: partner, dependent adult child, neighbour, family member, the level of care required, how are they coping, are there other services that could assist them etc Do they live alone: do they have someone (family / friend) to assist them if required, do they have the companionship of a pet, are they able to get to the shops for food, medical appointments etc., what does living independently mean to them / why is it important to them, are there other services that could assist the person etc.. Do they have a carer: What things do they like to do at home for themselves, what would they like to do more of etc.. what is important to them, what is their story? 14 PAG pathways > planned activity groups

15 4. Services organised around the person Traditionally an agency has provided a range of services and then fitted the person into the service. With this approach, it is thinking about the person first and agencies putting the person first. For example, when a new person is commencing the PAG, in full consultation, finding the day, activity level and dynamics that best meets the needs and interests of the person, and not just offering the person the group that is most convenient for the staff and program. A shift from when the PAG offered a program and people had to fit in and accept what was on offer. Many PAG s are now actively asking for suggestions for the program and this is done through conducting regular surveys and community forums which are open to the PAG attendees, carers and volunteers. This gives people the opportunity to express ideas and thoughts and if possible, these suggestions will be explored and incorporated into the monthly plan (as a one off or a regular activity). Suggestions are also gained through informal general discussion during the group, meals etc. and staff will ensure they record the idea s for future planning days. For example, can activities, an outing or a guest speaker etc be arranged that would support or be relevant to people s interests. E.g. through discussion (and from the Social Profile / Care Plan as demonstrated in chapter 4) a person attending the group shared with the group that he was a decorated RAAF pilot in the Second World War, he then went on to be a career pilot with Ansett before retiring. Perhaps suggest to the group that a visit to the RAAF Museum would be of interest, and our Pilot could be the guide for the day. 5. Collaborative working relationships A person s needs are best supported and met when there are strong partnerships and collaborative working relationships between the person, their carers and family, support workers and between service providers. The information shared is treated with respect and dignity, working towards the best outcome for the person. By forming collaborative partnerships, the person is able to receive the most appropriate level of support and should avoid under or over servicing. They should receive better care, integrated care, have more people to call on and have the right range of services. Partnerships also build trust and improve awareness of each other s work. For example, during a general discussion at the PAG, a gentleman who lives alone reveals this is one of the few outings he has in the week, the volunteer driver comes to the front door, collects him and assists into the bus. He is not able to easily and safely leave his home due to rotting, slippery external steps and railings. When asked, he admits he s had two (2) recent falls. During further discussion, the PAG worker asks him about rails around the house, including the shower etc and how he s managing his meals, grocery shopping etc and if he s losing confidence in leaving the house. He says he doesn t have any railings in the shower or on internal/ external stairs. He also said he waits for a neighbour to take him shopping but it s an informal arrangement and sometimes there s not much fresh food left in the house. The PAG Lead program worker has a chat with him and with his consent, completes a referral to: Local Community Health Centre Allied Health Team for MEPAC alarm OT assessment for stairs / showers / railings / bathroom design etc Register with Eastern Volunteers for transportation to medical appointments as required Council for review of assessment with view of: assistance with property maintenance assistance with shopping once a fortnight (as he likes to cook his own meals and consistent with the ASM, the Council will support him to continue to shop and cook for himself and not transition to Meals on Wheels as yet) There is a focus on wellness or active ageing within an ASM approach: promoting a wellness or active ageing (refer to information in chapter 2) approach that emphasises optimal physical and mental health of older people and acknowledges the importance of social connections holistic and family-centred approach to care actively involving people receiving services in setting their goals and making decisions about their care providing timely and flexible services that support people to reach their goals 1 This will assist in maximising independence and it believed that people are best supported when services are tailored and are delivered to suit the person s needs. 1.

16 What the Active Service Model is Not The active Service Model is NOT about taking services away from people who need them. Active Service Model Service Guide 2 Provision of more timely, flexible and responsive services that are capable of maximising independence and supporting people to reach their goals. Timely and Flexible Services Doing with not doing for Approach Social Connectedness Capacity building or restorative care to maintain or promote a person s capacity to live as independently as possible. The doing with not for philosophy and may involve short term services; The overall aim is to improve functional independence, quality of life and social participation. Working with people to explore what their goals are and how HACC services will assist them to achieve those goals, rather than expecting the person to fit into current services. Setting their own Goals and making decisions about their care Holistic and Person Centred Approach A holistic personcentred approach to care, that promotes wellness and active participation in the decisions about care. 16 PAG pathways > planned activity groups

17 Active Service Models guiding principles People want to remain autonomous Respecting a person s self determination, choices and decision making. People have potential to improve their capacity The belief that HACC service users have the capacity to improve their function and wellbeing, if only in small ways. People s needs should be viewed in an holistic way Working with people in a way that sees them as a whole person with a history and focussing on what is meaningful and important to them. HACC services should be organised around the person and carer Placing the focus on the person/carer and their own goals, not expecting people to fit in with the HACC services. Collaborative working relationships A person s needs are best met where there are strong partnerships and collaborative working relationships between the person, their carers and family, support workers and between service providers. 2. Produced by Toni Clancy Yarra Ranges Council Why has the ASM been introduced? This initiative has been introduced by the Department of Health HACC in Victoria, it is also a quality improvement that is being implemented into health and community settings across Australia and also internationally. Due to an ageing population, HACC expects an increase in demand for the services they provide and know there will be a need to manage this effectively, fairly and place the services where they are needed. With the improvement in medical science and services, there is an increase in number and proportion of older people (over 85 yrs) living in our community. Although people still have, or are incurring a disability during their life, people are living longer and therefore they need assistance for longer, placing more demand on services and providers. It is also imperative to provide services in a timely and targeted way. Assessment and care planning has often focused on a person s weaknesses and what they are unable to do, rather than focusing on strengths, capacity building and restorative care. In the past, when HACC provided supports to keep a person independent and at home, they may have inadvertently created dependence on support services. Traditionally, HACC services have been delivered in a task oriented way that comes from a do for approach rather than a support to do or do with approach. It is hoped that by supporting the person to achieve their goals, there will be a different outcome. Active service focuses and builds on the persons (and carers if applicable) strengths and abilities, and has an emphasis on improving their quality of life, social participation and connections. We know that by being active (mentally and physically), eating well and staying connected with family, friends and the community, people do not feel so isolated and alone. The incidences of mental health conditions such as depression are reduced, people are happier, have a sense of belonging and purpose, feel valued, build meaningful friendships and ideally have more fun and enjoyment in their lives. The Active Service Model is based on the belief that people receiving a service have the potential to improve their capacity and wellbeing and that HACC services can assist to improve their ability to make an improvement in their lives. HACC understands that most people want to remain in their own homes for as long as possible and avoid early admission to supported accommodation. The ASM was designed to assist people to live in the community as independently and autonomously as possible. When talking about Active Service, independence refers to the capacity of people to manage the day to day activities of their daily life and autonomy refers to making decisions about their life. 1 Not all HACC service recipients will be able to live in the community without some form of assistance, but the goal of this initiative is to ensure that people are able to gain the greatest level of independence they can, and equally, they can be as actively involved in making decisions about their life as they can be such as the type of services they receive and the goals they wish to achieve

18 What is an Active Service Model Approach? The Active Service Model approach can be defined as: Assuming that change is possible and meaningful Goals that are specific to the person, are achievable and are reviewed regularly Empowering individuals Open to challenge if the system is rigid Restorative Building strong collaborative partnerships that will benefit the person Open communication People having a voice and being heard Doing with not doing for Choices Encouraging independence and building confidence Seeing the whole person ASM is people-centred, not agency centred. ASM is a new way of thinking, not just a new way of doing. 2 If ageing is to be a positive experience, longer life must be accompanied by continuing opportunities for health, participation and security. Active ageing makes the most of these opportunities in order to enhance quality of life Page PAG pathways > planned activity groups

19 Person Centred Planning is: Person Centred not Staff Centred Planning with not Planning for Talking with the person not Talking about the person Starting with what is important to the person not Starting with what s wrong Health and safety addressed not Health and safety dictate Where the person wants to live not Where you live with no inference of choice Power is shared not Staff are in charge Living Plans change with the person not Dead Plans updated annually if at all How we see people: Capacities not Deficits Gifts and interests not Inabilities Members / participants / person attending not Clients All of us not Not us Proud not Shameful Need for assistance/support not Private troubles

20 Five dimensions of inclusion 1 Written by John O Brien Ask any group of people what makes life worth living and what makes for a good life and they tend to say the same things. John O Brien outlined the five service accomplishments or the five dimensions of inclusion. These attempt to capture what makes a good life under five headings: 5 Dimensions of inclusion: Choice and control Belonging Contributing Sharing Ordinary Places Being Somebody What makes life worth living Family love choices friends something to look forward to having people respect me money doing something worth doing making a difference excitement interests my work being free being an individual hobbies holidays having people notice im there Contributing We all have gifts and capacities. But as John McKnight says gifts aren t gifts until they are given. Giving our gifts, and using our capacities, are important parts of living a full life. Being someone We all want to be noticed, to be valued by others. We want people to notice if we re missing, to want to know our opinions, to see us as equals. We want people to care what we think of them. Belonging We all want to belong. To have friends, to be loved, to have people want to have us around. Belonging is about who we want to be around, and who wants us around. It isn t what happens when we learn to cope with having been put with others (because they are seen to be like us). And belonging is about personal, not professional relationships. Sharing ordinary places None of us like to be put away, kept apart from the real world. It is in ordinary places that belonging and contributing matter to us. We want to be free, not locked away, or put aside. Choice and control We all want to be allowed to strive for our own unique identity and future. We want to have as much power over our destiny as other people, not to have others taking decisions for us and when we need help we want to be in control of what happens not to be carried along in the current. Our individuality, our personhood, is not made up of just big things but also of our many tiny and seemingly insignificant decisions and preferences. 1. Robert Weetman, Based on the work of John O Brien, We want to be free, not locked away, or put aside. 20 PAG pathways > planned activity groups

21 There is a world wide movement towards the principles of active ageing. What is active ageing? Active ageing is the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age. It applies to both individuals and population groups. Active ageing allows people to realize their potential for physical, social, and mental well-being throughout the life course and to participate in society, while providing them with adequate protection, security and care when they need. The word active refers to continuing participation in social, economic, cultural, spiritual and civic affairs, not just the ability to be physically active or to participate in the labour force. Older people who retire from work, ill or live with disabilities can remain active contributors to their families, peers, communities and nations. Active ageing aims to extend healthy life expectancy and quality of life for all people as they age. Health refers to physical, mental and social well being as expressed in the World Health Organisation definition of health. Maintaining autonomy and independence for the older people is a key goal in the policy framework for active ageing. Ageing takes place within the context of friends, work associates, neighbours and family members. This is why interdependence as well as intergenerational solidarity are important tenets of active ageing

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23 Active Service: A changing way for staff and volunteers to support people attending our PAG s Traditionally PAG staff and volunteers have stepped in where they saw a need or an opportunity to assist someone and did it for the person. This was well meaning, the intention was to support and nurture, and frankly sometimes it can be quicker to do it yourself. People attending the group will have differing abilities, and this is where your skill and experience is valued and needed to discern when to encourage, motivate and support, and when to assist. It is encouraging to see what people are capable of, or what they can learn when they are given the opportunity, the time, the skills and the support they require. PAG staff and volunteers have commented that it will be challenging to step back, to observe first, to give people time to do things themselves they are concerned it may appear they are not doing their job. Encouraging and supporting people to be independent, and doing things which will increase their independence and capacity means you ARE performing your job. People attending the program may notice a change and comment on being encouraged to do more themselves but you can introduce the changes slowly. It may take a little while for some to get used to doing more for themselves but you ARE doing your job, and in time they probably won t notice. It will be much easier for new members as they join the group. Most of the principles come naturally to people who work or volunteer in PAG s and when done effectively, the people attending our PAGs will benefit in many ways. With the ASM, there is a shift: From: Doing FOR the person To: Doing WITH the person. There is a risk that a person may not do something for themselves if someone else is going to willingly do it for them. For example this means the person may remain seated for most of the PAG which could result in: not socialising and engaging as much with others always sitting next to the same people not moving and exercising their bodies people not feeling encouraged or motivated to make suggestions and contribute not getting involved and just sitting back and allowing things to happen around them not learning / relearning skills that can assist people to remain independent it doesn t encourage people to make their own choices and decisions With the introduction and implementation of ASM, examples of an alternative approach would be : Taking a step back to encourage people to do things for themselves (and others if they wish eg passing glasses of water to others on the table, coming up to the servery and assisting to serve plated meals, clearing dishes etc. ) Asking first if the person needs assistance not assuming they do Offer choices so the people attending the PAG can decide for example: what activities they would like to do what outings they would like to participate in planning menu choices Supporting people to order and pay for their own meals when out etc.. Obviously some people attending the PAGs will have more capacity to contribute to the group and do things for themselves but with time, encouragement and support, everyone will be able to gain something from an ASM way of life.

24 Some comments received from PAG staff and volunteers after recent ASM PAG training included: Question: Now you have done the training what will you do differently at work? Stop and think before acting Be more observant Be much more aware of standing back and allowing people to do more for themselves not being too quick to step in and offer assistance Assess a persons ability before doing for them Not to feel the need to do for people as much Allow time for people to do it themselves Encourage more active participation Let people help where possible Have a generally more aware attitude and openness in looking for opportunities to encourage autonomy Don t take independence away from people Enjoy and smile 24 PAG pathways > planned activity groups

25 ASM Language Something else to be aware of is a shift in the language we use in PAG s. There is a shift away from the term client and most PAG s are already doing this. Client is most commonly used in a medical sense and can be perceived as condescending or the person using it having a sense of empowerment. Common alternatives include: Person (attending the service) Member Participant Conversations might look more like: Less: More : What can you do? What s stopping you? How can we support you to do... What can t you do? Looking at what the person can do, how their situation can be improved? Acknowledging a persons skills, talents and abilities I hear you want to join a social group and arrange some home-help and so I d like to send someone out to assess you I can t do this because of Health and Safety reasons Assuming we know what is best for the person Instead of starting with: What s wrong? Automatically doing things for the person Seeing the person in an holistic way looking at the whole person not just the presenting issue. I hear you would like to talk about how we can support you to join a social group and stay living at home longer We can address the Health and Safety issues to seek an alternate solution Asking questions for example: What does independence mean to you? Start with asking what is important to the person Taking a moment to assess if the person needs assistance, Then asking the person Then doing things with the person if they need assistance

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27 The Four Key Steps Within the framework of the ASM, when supporting a person in your program, there are four key steps. Even when the person is established in the group, there will be ongoing review and assessment. The four key steps are: 1. Initial contact and assessment 2. Care planning (ongoing reviews) 3. Delivery of services and how they are delivered 4. Review and reassessment (can include Discharge from the PAG) Initial contact and assessment Assessment (which includes the intake and initial needs identification process) is critical to identifying opportunities to improve individual capacity, to deliver health promotion information, to advise on local support or service options, and to hear the person s story. Assessment is not a one off event. It is an ongoing process of building a relationship with the individual (and carer) that begins at the first point of contact and continues through to service delivery, review and reassessment. There are two layers of assessment offered in HACC that can occur simultaneously or independently: service specific or Living at Home assessment. Service specific assessment occurs when the person has fairly straight forward needs such requesting to join a PAG or short term meals on wheels. The purpose of a service specific assessment is to identify specific requirements and develop a service specific care plan to meet the person s goals. Service specific assessment may also be required when a person comes to the service following a fairly comprehensive assessment from another part of the sector such as ACAS or hospital. Living at Home assessments (LAHA) are really designed for people who are new to HACC or present with a range of needs that have not been recently assessed. The purpose of a LAHA is to gain a broad understanding of the type and range of opportunities to maximise their ability to remain living in the community. A LAHA involves assessment broader that the service types being sought by the person and broader than the service types being offered by the assessing agency. Changes in existing HACC clients circumstances may also mean that they might benefit from a LAHA. For example, an existing PAG participant may benefit from a LAHA if their usual carer is no longer able to continue their current role. Excepts from presentation: Catherine Stoove, ASM Industry Consultant, Eastern Metropolitan Region Being aware of the ASM principles, when meeting, assessing and reviewing people wishing to attend your PAG, please keep in mind: what strengths and abilities the person has, not just what their needs are are there any supports the person needs to actively participate does the person have any needs, particular likes or dislikes to be aware of what goals would the person like to achieve at the group why is coming to the group important to the person it could be a combination of social, emotional and function needs (eg: to make or be with friends, to learn a new skill, to link into the community etc) discuss other opportunities for social participation are any supports or services needed for the person to achieve their goal whose cooperation is needed to make this happen may need to be done in conjunction with carers/ support person and the PAG staff. is the person supported by a carer and can the PAG assist the Carer through social and support groups. using approved processes / forms to capture all relevant information and an opportunity to embed principles of ASM dignity for the person around having some sense of control in their life being aware and maintaining their privacy

28 General PAG Referral and Assessment Flow Chart (For non HACC Assessment Services) PAG referrals received(by Intake and / or PAG Coordinator) Contact is made with the person (or carer) to discuss the program and determine if the person is eligible for the program and meets HACC requirements No Yes Refer to, or provide information on other suitable services / agencies Intake or PAG Coordinator complete the applicable forms with the initial information PAG Coordinator / Area Coordinator / Manager checks availability of the programs and arranges a home /social visit Attend social / home visit and get to know the person (and carer if applic),. What are the persons interests, any concerns, likes, dislikes, strengths and abilities, any support needs they may have, what they hope to gain from the group, which days best suit, is PAG transport required and if applicable, any carer needs /respite that can be supported by the PAG. Discuss PAG and persons/ carer responsibilities. Person welcome to come for an initial social visit Eligible No Yes Provide person / carer with info. on other services / agencies Remaining HACC / PAG and consent forms completed & signed. Mutually decide program/ day that best suits the person / carer. If applic., invite carer to attend initially to support the person. Care /Goal Plan commenced Arrange transport if required Advise staff and volunteers of the new person commencing, and advise of any requirements / considerations or supports required New person commences the Group Complete Care Plan with full consultation Ongoing regular review with the person and modify Care / Goal Plan as required. Eventually 6 12 month reviews This is a guide only so please refer to the assessment procedures within your own organisation. 28 PAG pathways > planned activity groups

29 Social Profile / Care Plans People use different terms for this document. For the purposes of this manual, we will be using the following social profile to capture all the information. For example, not all people attending feel they need to set goals for themselves. This is just a guide and although it is a comprehensive document, it is only necessary to complete the sections that apply to the person and your program. It is just a suggestion and you can amend it to suit your needs. Not every section needs to be completed for every person just use the relevant ones. The care plan is designed to also incorporate the ASM principles. There is an example of a Social Profile / Care Plan in this chapter. This example was designed to: Gain an holistic knowledge of the person, not just the required information of name, address, contact information, medical information etc. but including the person s likes, dislikes, interests, what works for them, option to describe how to best support the person (mobility, speech, capacity building etc) and goals etc. Opportunity to jointly set goals with the person (and carer if applicable) that are meaningful Identify services received and options for other referrals and connections Documenting the steps towards reaching a persons goals, which are specific, measurable, achievable, realistic and have a timeframe (SMART) and outcomes that enable people to measure progress. And a review which is designed to: monitor how the person is progressing towards their goals opportunity to reassess the person if their needs and abilities are changing. After the initial contact and assessment with a person, the second stage is creating a Social Profile / Care Plan. This may include the involvement and contribution of several people for example: The person attending the PAG, if applicable their carer or a support person, the PAG Program Leader / PAG program workers and any other relevant person providing a service or support including if volunteers wish to have input. The benefit of people being involved and setting their own goals within their care plan is they feel a sense of control, that it s not all happening around them and they have a say in decisions. The person feels their needs, concerns, goals and opinions are valued and they are able to express what is important to them. There is often more commitment to working towards the goals if the person has direct input into the plan and they feel the goals are relevant and important to them. The revised care plan assists to not only capture the traditional core information but also the essence and holistic picture of the person, and how the PAG can provide the best experience for them, and if applicable, their carer. Following, there is an example of a care plan. Although it is a comprehensive document, it is only necessary to complete the applicable sections and you can amend it to suit the needs of the person and your program. The care plan is designed to incorporate the ASM principles and there are examples. An electronic copy can be obtained from Sarah Yeates at Caladenia Dementia Care and click on resources. Although there are five principles of the ASM (listed previously in chapter 2) often there is no definite principle the information can be categorised into as it will often overlap, this is not a problem at all. In time, the ASM will become second nature as people become very familiar with the principles. There is a matrix following on the next page that has examples of the five (5) ASM principles and where you would find questions / prompts within the care plan. As an example, by working through the actual care plan document, you will be prompted for information about the person that helps form a detailed picture of the person and how the PAG can best support them (and the carer if applicable).: You will notice that the care plan covers not only their emergency contacts, alerts, medical and support needs but also seeks to gather a holistic picture of the person. It covers what is important to the person, what their goals are, who will assist the person to achieve them, what the timeframes are, review dates etc. Also, capturing information relating to other services that are supporting the person to remain at home so a collaborative approach is provided.