National Screening and Assessment Form:
scroll down for Questions Asked
will be used by My Aged Care contact centre staff, the My Aged Care Regional Assessment Service (RAS), and Aged Care Assessment Teams (ACAT’s) when screening and assessing the aged care needs of clients.
The National Screening and Assessment Form Fact Sheet: https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/06_2018/national_screening_and_assessment_form_fact_sheet_-_june_2018.pdf
27 June 2018
https://agedcare.health.gov.au/programs-services/my-aged-care/national-screening-and-assessment-form-user-guide
The national screening and assessment process, facilitated through using the NSAF, has three components:
Screening conducted over-the-phone by My Aged Care contact centre staff
Home Support Assessment conducted face-to-face by the Regional Assessment Service (RAS)
Comprehensive Assessment conducted face-to-face by ACATs.
Your Home Aged Care and Residential Care providers will receive electronic referrals from My Aged Care and they will contact you. In the meantime, you can have a look for yourself...
Information for Assessors about My Aged Care and the assessor portal.
https://agedcare.health.gov.au/programs-services/my-aged-care/information-for-assessors
27 June 2018
National Screening Assessment Form User Guide:
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/06_2018/national_screening_and_assessment_form_user_guide_-_may_2018.pdf
A guide to the information required to be considered and recorded during the My Aged Care assessment process Home Support Assessors and Comprehensive Assessors May 2018.
How do I find a home care service provider?
The Aged Care Assessment Team (ACAT) team can refer you to home care service providers in your local area. They might also give you a list of all the home care service providers in the area. If you want you can do your own research at www.myagedcare.gov.au or you can phone 1800 200 422.
https://www.youtube.com/watch?v=fvwg8lb4-Io
My Aged Care – Home Care Package Service Finder
Published on Feb 28, 2017
This video provides an overview of how to use the Home Care Package service finder to find a provider that best meets your needs. The video guides you through:
• how to do a basic search based on your location, or the provider’s name (if known);
• how to do an advanced search to narrow your results to providers who offer specialised services, or cater to specific cultural, religious and language specialisations;
• how to interpret the information from your search result; and
• how to create a short-list of your preferred providers.
· Home support assessment conducted face-to-face by the RAS.
Home Support Assessment conducted face-to-face by the RAS.
o This holistic assessment will determine eligibility for CHSP services and will result in the development of a goal-oriented Support Plan. This will include the consideration of both formal and informal services that are most appropriate to provide the client with support.
Holistic assessment of client need
The screening and assessment process provides the opportunity for contact centre staff and assessors to understand a client’s needs holistically. The NSAF facilitates the collection of information on:
the client’s current level of support (formal and informal) and engagement
carer availability and sustainability
health concerns and priorities
functional status
psychosocial and psychological concerns
home and personal safety considerations
decision making capabilities.
It also identifies any complexities a client may have that indicate a level of vulnerability.
· Comprehensive assessment conducted face-to-face by ACATs. 16 March 2017.
o This holistic assessment will include the development of a goal-oriented Support Plan and will assist to determine a client’s eligibility for services under the Act, subject to delegate approval. This will include the consideration of both formal and informal services that are most appropriate to provide the client with support.
. Assessors will need to assess and approve eligible home care clients at a specific package level (i.e. home care level 1, 2, 3 or 4). Clients will be able to access a home care package at a lower level than their approval as an interim arrangement and will be able to indicate a minimum level that they would accept.
. Assessors will use the assessor portal to manage referrals, conduct assessments (which can be done offline as well as online), refer clients to services, and review and update your client record with support plan and assessment outcomes.
Information about the changes that were made to My Aged Care on 12 September 2016.
NOTE: If YOU want to stay with a preferred Provider, Do Tell the assessment team, as the service referrals will either be sent to services in your order of preference, broadcast to all suitable and available services if not, or given to you via a referral code. These Providers will be notified by an email, minus your identifying information when they have been sent a Referral.
Be aware also that your assessors will not directly refer clients to non-government funded services through the My Aged Care. If you want a particular Service Provider, you have to tell your assessor during your assessment time. Note too that for the first time, aged care service providers will have to give a reason for rejecting a service referral, which will help reduce any possible 'cherry picking' of clients.
How it Works:
The My Aged Care contact centre staff will screen clients by asking a series of questions over the phone. This occurs after you have phoned 1800 200 422 and registered with My Aged Care, and you have a client record created.
Client Record – Client Details Overview
. The collection of accurate client details is extremely important for My Aged Care and the client. It will allow for the establishment of a client record and the identification and verification of clients as they progress through My Aged Care. The collection of client details might occur over several screening and assessment events, and may also need to be updated as the client’s circumstances change.
page 16 onwards...
The National Screening and Assessment Form Fact Sheet: https://agedcare.health.gov.au/programs-services/my-aged-care/national-screening-and-assessment-form
28 February 2018
For a more in-depth look at the questions that can be asked:
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/02_2017/user_guide_for_the_guidance_framework.pdf
In-depth details from page 7 onwards - Februry 2017.
and
Information for Assessors
https://agedcare.health.gov.au/programs-services/my-aged-care/information-for-assessors
Page last updated: 27 February 2017
Home Care Package Delegate Decisions from 27 February 2017
The Australian Government is improving the way home care is delivered to older Australians.
Since 27 February 2017 home care packages have changed in three main areas:
Review of the Client's Support Plan:
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/06_2016/35._fact_sheet_-_review_support_plan.pdf
This functionality provides assessors with the ability to conduct review(s) of a client’s Support Plan from within the Assessor Portal. This change will allow assessors to review and, where appropriate, to amend a client’s Support Plan. If necessary, assessors will also be able to initiate a new assessment for a client following the review. This enables assessors to ensure that a client’s needs continue to be met through the services and strategies identified in the Support Plan.
The screening addresses a client’s needs, circumstances and functional ability. The contact staff will develop an action plan with the client to identify the pathway You, the client will take – to home support assessment, comprehensive assessment and/or direct to Commonwealth Home Support Programme services.
Don’t worry, the centre staff will also provide relevant information to you, including where no further assessment or service provision is required.
Overview of questions:
Screening Details Reason for contact; particular service request
Current Support Services and support currently being received
Function Transport; shopping; meal preparation; housework; medicine management; money management; walking;
showering; dressing; eating; transfers; toilet use - assistance received, assistance required
Health and Home Health concerns impacting on independence; recent falls; pain; weight loss or nutritional concerns;
feeling lonely, down or socially isolated; memory loss or confusion; risks, hazards or safety concerns in the home, including environmental concerns; special needs
===============================================================================================================================
Home Support Assessment
Home Support Assessments which are undertaken by the RAS, will build on the information collected at screening (if applicable), and are undertaken face-to-face generally in the client's usual accommodation setting to determine a client's eligibility to receive Commonwealth Home Support Programme services.
During the assessment, the assessor will explore your
They will then work with you to establish a support plan that reflects your strengths and abilities, areas of difficulty, and the support that will best meet your needs and goals. This will include the consideration of formal and informal services as well as reablement and/or restorative pathways.
The following areas may be addressed as part of a home support assessment.
Profile Overview of questions
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Reason for Contact Reason for contact; particular service request
Key circumstances triggering contact
Current Support Services and support currently being received
Carer Overview Support currently being received
Type of care provided/being provided, difficulties or concerns with the caring relationship, sustainability of the caring relationship; sustainability of the caring relationship; client as a carer
Family, Community Personal and family support networks, involvement in activities and client interests, engagement with
Engagement and Support family and social/community groups, recent changes to family/cultural/social situation
Health Health conditions noted; weight loss or nutritional concerns; recent falls; pain
General observations, health and wellbeing challenges, allergies/sensitivities, recent hospital discharge; oral health discharge; oral health concerns; appetite concerns; fluid intake; skin conditions; continence issues; health literacy; vision/hearing/speech; sleep difficulties; alcohol and tobacco consumption; physical activity
Function Transport; shopping; meal preparation; housework; medicine management; money management; walking; showering; dressing; eating; transfers; toilet use - assistance received; assistance required
Cognitive Memory problems or confusion
Changes in memory and thinking; changes in personality; behavioural problems; psychological symptoms associated with memory loss; decision making
Psychosocial Feeling lonely, down or socially isolated
Feeling nervous, depressed or lonely; stressful events; changes in mental state; social isolation
Home and Personal Safety Risks, hazards or safety concerns in the home; including environmental concerns
Self-neglecting of care; equipment/modification required to maintain independence; personal and smoke alarms; personal emergency plan; driving ability; concerns with living arrangements; concerns with financial situation; safety concerns; legal issues
Complexity indicators Special needs
Complexity indicators; risk of vulnerability; impact on ability to live independently.
Support Plan Client strengths and abilities; areas of difficulty; satisfaction with level of independence; hopes for change; areas of concern; goals, motivation, agreed action to be taken
Questions in black text are questions that may be asked as part of the Screening process and are to be verified or completed as part of the Home Support Assessment process.
Questions in green text are additional questions to be asked as part of a Home Support Assessment.
====================================================================================================================================
Comprehensive Assessment (undertaken by ACAT's)
Comprehensive assessment, undertaken by ACATs, builds on the information collected at Screening and Home Support Assessment (if applicable), and is undertaken face-to-face (generally in the client's usual accommodation setting) to determine a client's eligibility for care types under the Aged Care Act 1997 (the Act).
Where a care type under the Act is identified as the most appropriate type of support to meet the client's needs, and the client meets eligibility criteria, the assessor will make a recommendation for approval by a Delegate of the Secretary (ie ACAT Delegate). A client may be approved for a Home Care Package, Residential Care, Residential Respite Care or Flexible Care (Transition Care or Short Term Restorative Care). Clients may also be referred to Commonwealth Home Support Programme services where appropriate.
The following areas may be addressed as part of Comprehensive Assessment:
Domain Profile Overview of questions
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Social Domain Reason for Contact Reason for contact; particular service request
Key circumstances triggering contact
Current Support Services currently being received
Current formal/informal support
Carer Overview Support currently being received
Type of care provided/being provided; difficulties or concerns with the caring relationship; sustainability of the caring relationship; client as a carer
Family, Community Personal and family support networks; involvement in activities and client interests; engagement with family Engagement and and social/community groups; recent changes to family/cultural/social situation
Support
Medical Domain Health Health conditions; weight loss or nutritional concerns; recent falls; pain
General observations; health and wellbeing challenges; clinical services; medical history; allergies/sensitivities; recent hospital discharge; oral health concerns; appetite concerns; fluid intake; skin conditions; continence issues; health literacy; mobility difficulties; vision/hearing/speech; sleep difficulties; alcohol and tobacco consumption; physical activity
Physical Domain Function Transport; shopping; meal preparation; housework; medicine management; money management; walking; showering; dressing; eating; transfers; toilet use - assistance received; assistance required
Psychological Cognitive Memory loss or confusion
Domain Changes in memory and thinking; changes in personality; behavioural problems; psychological symptoms associated with memory loss; decision making
Psychosocial Feeling lonely, down or socially isolated
Feeling nervous, depressed or lonely; stressful events; changes in mental state; social isolation
Psychological Memory problems; behavioural problems; mental health problems; disorientation
Home and Risks, hazards or safety concerns in the home, including environmental concerns Personal Safety Self-neglecting of care; equipment/modification required to maintain independence; personal and smoke alarms; personal emergency plan; driving ability; concerns with living arrangements; concerns with financial situation; safety concerns; legal issues
Complexity Indicators Special needs
Complexity indicators; risk of vulnerability; impact on ability to live independently
Support Plan Client strengths and abilities; areas of difficulty; satisfaction with level of independence; hopes for change; areas of concern; goals, motivation, agreed action to be taken; referral information
Key:
Supplementary Assessment Tools
These are included as part of the NSAF and may be used by an assessor to inform a holistic assessment of a client's needs. The use of these clinically-validated assessment tools is not mandatory, but should be used if a need is identified that required a greater level of assessment. An assessor may also choose to use other clinically-validated tools at their discretion, but should record within the NSAF the name of the assessment tool used, the result of the assessment and also attach a copy of the assessment to the client's record.
The following Supplementary Assessment Tools are available:
Assessment type Supplementary Assessment Tools
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Home Support Assessment - Caregiver Strain Index
- Mini Nutritional Assessment
- Older Americans Resources and Services Activities of Daily Living (OARS-ADL)
- Barthel Index of Activities of Daily Living
- Kimberley Indigenous Cognitive Assessment - Activities of Daily Living (KICA-ADL)
- Kessler - 10
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Comprehensive Assessment - Caregiver Strain Index
- Kessler - 10
- Brief Pain Inventory (Short Form)
- Residents Verbal Brief Pain Inventory
- Abbey Pain Scale
- Alcohol Use Disorders Identification Test (AUDIT)
- South Australian Oral Health Referral Pad
- Oral Health Assessment Tool (OHAT) for Non-Dental Professionals
- Revised Urinary Incontinence Scale
- Revised Faecal Incontinence Scale
- Mini Nutritional Assessment
- Older Americans Resources and Services Activities of Daily Living (OARS ADL)
- Barthel Index of Activities of Daily Living
- Kimberley Indigenous Cognitive Assessment - Activities of Daiy Living (KICA-ADL)
- Standardised Mini-Mental State Examination (SMMSE)
- Rowland Universal Dementia Assessment Scale (RUDAS)
- The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
- Kimberley Indigenous Cognitive Assessment (KICA-COG)
- Geriatric Depression Scale
================================================================================================================================
Decision support within the National Screening and Assessment Form
The NSAF includes a set of decision support rules that assists the screening and assessment workforce to make recommendations for the type of support a client requires. There are five types of decision support rules:
National Screening and Assessment Form Fact Sheet – February 2017
Page last updated: 28 February 2017
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/02_2017/national_screening_and_assessment_form_fact_sheet_-_february_2017.pdf
This fact sheet provides information about the National Screening and Assessment Form (NSAF) that will be used by My Aged Care contact centre staff, the My Aged Care Regional Assessment Service (RAS) and Aged Care Assessment Teams (ACATs) when screening and assessing the aged care needs of clients.
Aged Care Assessment Program
Page last updated: 10 August 2016
https://agedcare.health.gov.au/programs/aged-care-assessment-program
Aged Care Assessment Program National Training Strategy
Page last updated: 29 November 2016
The Aged Care Assessment Program (ACAP) National Training Strategy provides an overarching training strategy to promote best practice and national consistency for all ACAT members.
Application for Home Carer Services
Page last updated: 20 March 2017
https://agedcare.health.gov.au/ageing-and-aged-care-programs-services-aged-care-assessment-program-forms-for-aged-care-assessors/aged-care-client-record-application-form
The Aged Care Client Record (ACCR) Application Form can be used by clients wishing to apply for Australian Government-subsidised aged care and by aged care service providers seeking approval for providing care in an emergency case. Service providers should note that the emergency approval application must be received by the Aged Care Assessment Team within five business days of the commencement of care.
===============================================================================================================================
Online and Offline capability
Assessors will have several options for recording assessment information, including:
Information for Assessors
https://agedcare.health.gov.au/programs-services/my-aged-care/information-for-assessors
29 June 2020
Information about the changes to My Aged Care
Information about the changes that were made to My Aged Care on 12 September 2016 is available.
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/02_2018/summary_of_my_aged_care_system_changes_-_26_february_2018_0.pdf
25 November 2020
scroll down for Questions Asked
will be used by My Aged Care contact centre staff, the My Aged Care Regional Assessment Service (RAS), and Aged Care Assessment Teams (ACAT’s) when screening and assessing the aged care needs of clients.
The National Screening and Assessment Form Fact Sheet: https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/06_2018/national_screening_and_assessment_form_fact_sheet_-_june_2018.pdf
27 June 2018
https://agedcare.health.gov.au/programs-services/my-aged-care/national-screening-and-assessment-form-user-guide
The national screening and assessment process, facilitated through using the NSAF, has three components:
Screening conducted over-the-phone by My Aged Care contact centre staff
Home Support Assessment conducted face-to-face by the Regional Assessment Service (RAS)
Comprehensive Assessment conducted face-to-face by ACATs.
Your Home Aged Care and Residential Care providers will receive electronic referrals from My Aged Care and they will contact you. In the meantime, you can have a look for yourself...
Information for Assessors about My Aged Care and the assessor portal.
https://agedcare.health.gov.au/programs-services/my-aged-care/information-for-assessors
27 June 2018
National Screening Assessment Form User Guide:
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/06_2018/national_screening_and_assessment_form_user_guide_-_may_2018.pdf
A guide to the information required to be considered and recorded during the My Aged Care assessment process Home Support Assessors and Comprehensive Assessors May 2018.
How do I find a home care service provider?
The Aged Care Assessment Team (ACAT) team can refer you to home care service providers in your local area. They might also give you a list of all the home care service providers in the area. If you want you can do your own research at www.myagedcare.gov.au or you can phone 1800 200 422.
https://www.youtube.com/watch?v=fvwg8lb4-Io
My Aged Care – Home Care Package Service Finder
Published on Feb 28, 2017
This video provides an overview of how to use the Home Care Package service finder to find a provider that best meets your needs. The video guides you through:
• how to do a basic search based on your location, or the provider’s name (if known);
• how to do an advanced search to narrow your results to providers who offer specialised services, or cater to specific cultural, religious and language specialisations;
• how to interpret the information from your search result; and
• how to create a short-list of your preferred providers.
· Home support assessment conducted face-to-face by the RAS.
Home Support Assessment conducted face-to-face by the RAS.
o This holistic assessment will determine eligibility for CHSP services and will result in the development of a goal-oriented Support Plan. This will include the consideration of both formal and informal services that are most appropriate to provide the client with support.
Holistic assessment of client need
The screening and assessment process provides the opportunity for contact centre staff and assessors to understand a client’s needs holistically. The NSAF facilitates the collection of information on:
the client’s current level of support (formal and informal) and engagement
carer availability and sustainability
health concerns and priorities
functional status
psychosocial and psychological concerns
home and personal safety considerations
decision making capabilities.
It also identifies any complexities a client may have that indicate a level of vulnerability.
· Comprehensive assessment conducted face-to-face by ACATs. 16 March 2017.
o This holistic assessment will include the development of a goal-oriented Support Plan and will assist to determine a client’s eligibility for services under the Act, subject to delegate approval. This will include the consideration of both formal and informal services that are most appropriate to provide the client with support.
. Assessors will need to assess and approve eligible home care clients at a specific package level (i.e. home care level 1, 2, 3 or 4). Clients will be able to access a home care package at a lower level than their approval as an interim arrangement and will be able to indicate a minimum level that they would accept.
. Assessors will use the assessor portal to manage referrals, conduct assessments (which can be done offline as well as online), refer clients to services, and review and update your client record with support plan and assessment outcomes.
Information about the changes that were made to My Aged Care on 12 September 2016.
NOTE: If YOU want to stay with a preferred Provider, Do Tell the assessment team, as the service referrals will either be sent to services in your order of preference, broadcast to all suitable and available services if not, or given to you via a referral code. These Providers will be notified by an email, minus your identifying information when they have been sent a Referral.
Be aware also that your assessors will not directly refer clients to non-government funded services through the My Aged Care. If you want a particular Service Provider, you have to tell your assessor during your assessment time. Note too that for the first time, aged care service providers will have to give a reason for rejecting a service referral, which will help reduce any possible 'cherry picking' of clients.
How it Works:
The My Aged Care contact centre staff will screen clients by asking a series of questions over the phone. This occurs after you have phoned 1800 200 422 and registered with My Aged Care, and you have a client record created.
Client Record – Client Details Overview
. The collection of accurate client details is extremely important for My Aged Care and the client. It will allow for the establishment of a client record and the identification and verification of clients as they progress through My Aged Care. The collection of client details might occur over several screening and assessment events, and may also need to be updated as the client’s circumstances change.
page 16 onwards...
The National Screening and Assessment Form Fact Sheet: https://agedcare.health.gov.au/programs-services/my-aged-care/national-screening-and-assessment-form
28 February 2018
For a more in-depth look at the questions that can be asked:
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/02_2017/user_guide_for_the_guidance_framework.pdf
In-depth details from page 7 onwards - Februry 2017.
and
Information for Assessors
https://agedcare.health.gov.au/programs-services/my-aged-care/information-for-assessors
Page last updated: 27 February 2017
Home Care Package Delegate Decisions from 27 February 2017
The Australian Government is improving the way home care is delivered to older Australians.
Since 27 February 2017 home care packages have changed in three main areas:
- allowing funding to follow the consumer;
- establishing a new national process for prioritising access to home care;
- and reducing red tape to become an Approved Provider of aged care.
- Consumer eligibility will continue to be determined by an Aged Care Assessment Team (ACAT) through a comprehensive assessment using the unchanged National Screening and Assessment Form (NSAF).
- From 27 February 2017 assessors will need to recommend a client’s priority for home care services to the delegate for approval. A client’s priority for home care services indicates a client’s risk in the absence of timely services based on the comprehensive assessment and the assessor’s clinical judgment.
Review of the Client's Support Plan:
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/06_2016/35._fact_sheet_-_review_support_plan.pdf
This functionality provides assessors with the ability to conduct review(s) of a client’s Support Plan from within the Assessor Portal. This change will allow assessors to review and, where appropriate, to amend a client’s Support Plan. If necessary, assessors will also be able to initiate a new assessment for a client following the review. This enables assessors to ensure that a client’s needs continue to be met through the services and strategies identified in the Support Plan.
The screening addresses a client’s needs, circumstances and functional ability. The contact staff will develop an action plan with the client to identify the pathway You, the client will take – to home support assessment, comprehensive assessment and/or direct to Commonwealth Home Support Programme services.
Don’t worry, the centre staff will also provide relevant information to you, including where no further assessment or service provision is required.
Overview of questions:
Screening Details Reason for contact; particular service request
Current Support Services and support currently being received
Function Transport; shopping; meal preparation; housework; medicine management; money management; walking;
showering; dressing; eating; transfers; toilet use - assistance received, assistance required
Health and Home Health concerns impacting on independence; recent falls; pain; weight loss or nutritional concerns;
feeling lonely, down or socially isolated; memory loss or confusion; risks, hazards or safety concerns in the home, including environmental concerns; special needs
===============================================================================================================================
Home Support Assessment
Home Support Assessments which are undertaken by the RAS, will build on the information collected at screening (if applicable), and are undertaken face-to-face generally in the client's usual accommodation setting to determine a client's eligibility to receive Commonwealth Home Support Programme services.
During the assessment, the assessor will explore your
- current level of support (including formal and informal forms of support),
- family and community engagement,
- health and lifestyle considerations,
- functional ability,
- cognitive or psychosocial considerations, and
- any issues relating to home and personal safety.
They will then work with you to establish a support plan that reflects your strengths and abilities, areas of difficulty, and the support that will best meet your needs and goals. This will include the consideration of formal and informal services as well as reablement and/or restorative pathways.
The following areas may be addressed as part of a home support assessment.
Profile Overview of questions
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Reason for Contact Reason for contact; particular service request
Key circumstances triggering contact
Current Support Services and support currently being received
Carer Overview Support currently being received
Type of care provided/being provided, difficulties or concerns with the caring relationship, sustainability of the caring relationship; sustainability of the caring relationship; client as a carer
Family, Community Personal and family support networks, involvement in activities and client interests, engagement with
Engagement and Support family and social/community groups, recent changes to family/cultural/social situation
Health Health conditions noted; weight loss or nutritional concerns; recent falls; pain
General observations, health and wellbeing challenges, allergies/sensitivities, recent hospital discharge; oral health discharge; oral health concerns; appetite concerns; fluid intake; skin conditions; continence issues; health literacy; vision/hearing/speech; sleep difficulties; alcohol and tobacco consumption; physical activity
Function Transport; shopping; meal preparation; housework; medicine management; money management; walking; showering; dressing; eating; transfers; toilet use - assistance received; assistance required
Cognitive Memory problems or confusion
Changes in memory and thinking; changes in personality; behavioural problems; psychological symptoms associated with memory loss; decision making
Psychosocial Feeling lonely, down or socially isolated
Feeling nervous, depressed or lonely; stressful events; changes in mental state; social isolation
Home and Personal Safety Risks, hazards or safety concerns in the home; including environmental concerns
Self-neglecting of care; equipment/modification required to maintain independence; personal and smoke alarms; personal emergency plan; driving ability; concerns with living arrangements; concerns with financial situation; safety concerns; legal issues
Complexity indicators Special needs
Complexity indicators; risk of vulnerability; impact on ability to live independently.
Support Plan Client strengths and abilities; areas of difficulty; satisfaction with level of independence; hopes for change; areas of concern; goals, motivation, agreed action to be taken
Questions in black text are questions that may be asked as part of the Screening process and are to be verified or completed as part of the Home Support Assessment process.
Questions in green text are additional questions to be asked as part of a Home Support Assessment.
====================================================================================================================================
Comprehensive Assessment (undertaken by ACAT's)
Comprehensive assessment, undertaken by ACATs, builds on the information collected at Screening and Home Support Assessment (if applicable), and is undertaken face-to-face (generally in the client's usual accommodation setting) to determine a client's eligibility for care types under the Aged Care Act 1997 (the Act).
- During the assessment, the assessor will assess
- the client's physical, medical, psychological, social and restorative needs.
- The assessor and the client will work together to establish a support plan that reflects the client's strengths and abilities, areas of difficulty, and the support that will best meet their needs and goals. This will include the consideration of formal and informal services as well as reablement and/or restorative pathways.
Where a care type under the Act is identified as the most appropriate type of support to meet the client's needs, and the client meets eligibility criteria, the assessor will make a recommendation for approval by a Delegate of the Secretary (ie ACAT Delegate). A client may be approved for a Home Care Package, Residential Care, Residential Respite Care or Flexible Care (Transition Care or Short Term Restorative Care). Clients may also be referred to Commonwealth Home Support Programme services where appropriate.
The following areas may be addressed as part of Comprehensive Assessment:
Domain Profile Overview of questions
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Social Domain Reason for Contact Reason for contact; particular service request
Key circumstances triggering contact
Current Support Services currently being received
Current formal/informal support
Carer Overview Support currently being received
Type of care provided/being provided; difficulties or concerns with the caring relationship; sustainability of the caring relationship; client as a carer
Family, Community Personal and family support networks; involvement in activities and client interests; engagement with family Engagement and and social/community groups; recent changes to family/cultural/social situation
Support
Medical Domain Health Health conditions; weight loss or nutritional concerns; recent falls; pain
General observations; health and wellbeing challenges; clinical services; medical history; allergies/sensitivities; recent hospital discharge; oral health concerns; appetite concerns; fluid intake; skin conditions; continence issues; health literacy; mobility difficulties; vision/hearing/speech; sleep difficulties; alcohol and tobacco consumption; physical activity
Physical Domain Function Transport; shopping; meal preparation; housework; medicine management; money management; walking; showering; dressing; eating; transfers; toilet use - assistance received; assistance required
Psychological Cognitive Memory loss or confusion
Domain Changes in memory and thinking; changes in personality; behavioural problems; psychological symptoms associated with memory loss; decision making
Psychosocial Feeling lonely, down or socially isolated
Feeling nervous, depressed or lonely; stressful events; changes in mental state; social isolation
Psychological Memory problems; behavioural problems; mental health problems; disorientation
Home and Risks, hazards or safety concerns in the home, including environmental concerns Personal Safety Self-neglecting of care; equipment/modification required to maintain independence; personal and smoke alarms; personal emergency plan; driving ability; concerns with living arrangements; concerns with financial situation; safety concerns; legal issues
Complexity Indicators Special needs
Complexity indicators; risk of vulnerability; impact on ability to live independently
Support Plan Client strengths and abilities; areas of difficulty; satisfaction with level of independence; hopes for change; areas of concern; goals, motivation, agreed action to be taken; referral information
Key:
- Questions in black text are questions that may be asked as part of the Screening process and are to be verified or completed as part of the Comprehensive Assessment process.
- Questions in orange text are additional questions to be asked as part of a Comprehensive Assessment.
Supplementary Assessment Tools
These are included as part of the NSAF and may be used by an assessor to inform a holistic assessment of a client's needs. The use of these clinically-validated assessment tools is not mandatory, but should be used if a need is identified that required a greater level of assessment. An assessor may also choose to use other clinically-validated tools at their discretion, but should record within the NSAF the name of the assessment tool used, the result of the assessment and also attach a copy of the assessment to the client's record.
The following Supplementary Assessment Tools are available:
Assessment type Supplementary Assessment Tools
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Home Support Assessment - Caregiver Strain Index
- Mini Nutritional Assessment
- Older Americans Resources and Services Activities of Daily Living (OARS-ADL)
- Barthel Index of Activities of Daily Living
- Kimberley Indigenous Cognitive Assessment - Activities of Daily Living (KICA-ADL)
- Kessler - 10
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Comprehensive Assessment - Caregiver Strain Index
- Kessler - 10
- Brief Pain Inventory (Short Form)
- Residents Verbal Brief Pain Inventory
- Abbey Pain Scale
- Alcohol Use Disorders Identification Test (AUDIT)
- South Australian Oral Health Referral Pad
- Oral Health Assessment Tool (OHAT) for Non-Dental Professionals
- Revised Urinary Incontinence Scale
- Revised Faecal Incontinence Scale
- Mini Nutritional Assessment
- Older Americans Resources and Services Activities of Daily Living (OARS ADL)
- Barthel Index of Activities of Daily Living
- Kimberley Indigenous Cognitive Assessment - Activities of Daiy Living (KICA-ADL)
- Standardised Mini-Mental State Examination (SMMSE)
- Rowland Universal Dementia Assessment Scale (RUDAS)
- The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
- Kimberley Indigenous Cognitive Assessment (KICA-COG)
- Geriatric Depression Scale
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Decision support within the National Screening and Assessment Form
The NSAF includes a set of decision support rules that assists the screening and assessment workforce to make recommendations for the type of support a client requires. There are five types of decision support rules:
- Pathway and eligibility (eg this client should be referred for comprehensive assessment)
- Priority (eg access to assessment or service is a high priority)
- Recommended actions (eg the client should visit a GP)
- Complexity indicators (eg the client is living in inadequate housing or with insecure housing or is already homeless)
- Needs identification (eg behavioural concerns)
National Screening and Assessment Form Fact Sheet – February 2017
Page last updated: 28 February 2017
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/02_2017/national_screening_and_assessment_form_fact_sheet_-_february_2017.pdf
This fact sheet provides information about the National Screening and Assessment Form (NSAF) that will be used by My Aged Care contact centre staff, the My Aged Care Regional Assessment Service (RAS) and Aged Care Assessment Teams (ACATs) when screening and assessing the aged care needs of clients.
Aged Care Assessment Program
Page last updated: 10 August 2016
https://agedcare.health.gov.au/programs/aged-care-assessment-program
Aged Care Assessment Program National Training Strategy
Page last updated: 29 November 2016
The Aged Care Assessment Program (ACAP) National Training Strategy provides an overarching training strategy to promote best practice and national consistency for all ACAT members.
Application for Home Carer Services
Page last updated: 20 March 2017
https://agedcare.health.gov.au/ageing-and-aged-care-programs-services-aged-care-assessment-program-forms-for-aged-care-assessors/aged-care-client-record-application-form
The Aged Care Client Record (ACCR) Application Form can be used by clients wishing to apply for Australian Government-subsidised aged care and by aged care service providers seeking approval for providing care in an emergency case. Service providers should note that the emergency approval application must be received by the Aged Care Assessment Team within five business days of the commencement of care.
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Online and Offline capability
Assessors will have several options for recording assessment information, including:
- Online/real time - information is recorded during the assessment process via a mobile device (such as a laptop or table) connected to the internet
- Offline - information is recorded on a mobile device that is not connected to the internet. Data is transferred when the device is connected to the internet at a later time
- Manual - information is written on a paper form during the assessment and subsequently, when online, can be keyed into the NSAF via the Assessor Portal at the first available opportunity for the assessor.
Information for Assessors
https://agedcare.health.gov.au/programs-services/my-aged-care/information-for-assessors
29 June 2020
- The My Aged Care assessor portal
- Support material for using the My Aged Care assessor portal
- ICT support
- Further information
Information about the changes to My Aged Care
Information about the changes that were made to My Aged Care on 12 September 2016 is available.
https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/02_2018/summary_of_my_aged_care_system_changes_-_26_february_2018_0.pdf
25 November 2020