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Nursing Support Plans.
What the care involves. Who does what.
Written down, for the person it is actually about.
A nurse-built support plan is a written document that outlines a person’s health support needs, the care and supports to be provided, who is responsible for delivering each aspect of care, and the actions to take if circumstances change. It is developed by an AHPRA-registered nurse who reviews the supports, clinical recommendations, and care arrangements already in place, and translates these into a practical, person-centred plan that can be consistently understood and implemented by the support team.
When someone has a complex health need, the people supporting them need to know exactly what to do. Not roughly. Exactly. That is the difference between a plan that sits in a folder and a plan your team can actually work from at three in the morning. Nurses do not diagnose, support plans are developed based of identified needs already in place, for example a person is discharged with a catheter and the support workers are unsure of how to care for the catheter and all that they are provided with is a discharge letter and some brief instructions. The nurse might gather documentation or engage other clinicians involved in the participants care to identify the needs first and develop the plan aligned to those supports.
Patients & Families
For referrers and Support Coordinators
how to fund Your Nursing Support Plan.
Nursing supports may be funded through an NDIS plan, depending on how that plan is set up. Plan-managed, self-managed and agency-managed participants can all access our nurses, and we handle the service agreements and the reporting.
Providers can also engage us directly. Where a plan is needed because of your obligations as a registered provider rather than because of one participant’s funded supports, that work usually sits with the organisation. We can invoice you directly for it.
Call us on 1800 678 647.
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What We Cover
01
Complex Bowel Care Planning
02
PEG and PEJ Tubes, and Enteral Nutrition
03
Continence Care
04
Urinary Catheter Support
We offer care of your catheter site, the routine around it, and what to do if something changes. The plan names the signs that need attention and who to call when they turn up.
05
Ventilatory Support
06
Other Complex Health Needs
How your comprehensive Plan Gets Written
A nurse assesses your health needs first. That usually means meeting you, and often your family or support workers as well, because the people there every day see things a single appointment does not.
From that, the nurse writes a care plan tailored to that person. Not a template with a name at the top. The plan sets out what the care involves, who does what, and what to do if something changes or goes wrong. It is written to be used by the people delivering the support, so it says what to do rather than describing the condition in clinical language.
Available in clinic, at home, or by telehealth, depending on the health need. Some needs have to be seen in person to be planned properly, and we will tell you plainly when that is the case.
A plan can also help a participant take a more active part in their own health care, because it makes the routine visible rather than something held in someone else’s head.
Why Their support Plan Matters Under the NDIS
If you are a registered provider delivering high intensity supports, the NDIS Practice Standards set out what has to be in place for each participant. The participant is involved in assessing and developing their own plan. With their consent, their health status is reviewed regularly by an appropriately qualified health practitioner. Workers supporting them have training that relates specifically to that participant’s needs.
A nursing care plan is how you evidence the first two, and it is what the training is built on for the third. It is also, more simply, how your team knows what to do when you are not there.
Optimum NDIS
Referrals.
Optimum NDIS
Referrals.
If you are a Support Coordinator, LAC officer, Plan Manager or another health care professional and you would like to submit a referral for one of your participants, please select one of the below options.
Get in Touch.
12 clinics across NSW & Tasmania
Email us
hello@opt.net.au
Speak to us
1800 678 647
Locations
Telehealth
Available everywhere for everyone.
In Your Home
Illawarra
Horsely
Dapto
Wollongong
Shellharbour
Albion Park
Kiama
SOUTH COAST
Nowra
Shoalhaven
SOUTH WEST SYDNEY
Moorebank
Liverpool
Warwick Farm
Casula
Chipping Norton
Wattle Grove
Common Questions About Chronic Disease Management
What is a nursing support plan?
Do I need a referral to get a support plan completed?
Who is present during the support plan development?
What happens after my support plan is finished?
Can my provider request this on my behalf?
Is this available by telehealth?
Renata Bell
OPTIMUM HEALTH SOLUTIONS
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