Support Planning Policy and Procedure

NDIS Policies and Procedures Manual – Core Module

Document Number: CM-POL-016

Document Control

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Legal Name:	Holistic Healthcare Management Services
ABN:	20695058096
ACN:	695058096
Primary address/head office:	15 Agasse Way, Tapping WA 6065
Document Name:	NDIS Policies and Procedures Manual – Core Module
Document Number:	CM-POL-016
Approved by:	Director
Date Approved:	February 2026
Version No:	1.0
Comments:	Initial Release of the Policies and Procedures Manual
Next Review Date:	May 2026

Introduction and Purpose

The purpose of this policy is to establish a clear framework for the development, implementation, and review of support plans for participants, ensuring these plans reflect their individual needs, preferences, strengths, and goals.

This policy aims to promote active participation by participants in the support planning process and ensure the plans are tailored, comprehensive, and adaptable to changing circumstances.

Scope

This policy applies to all Holistic Healthcare Management Services staff, participants, and relevant stakeholders involved in the support planning process.

It encompasses the creation, review, and implementation of support plans, including risk assessments, periodic evaluations, and collaboration with support networks and external providers.

Definition

Term	Description
Support Plan	A documented plan developed collaboratively with the participant, outlining their needs, preferences, strengths, goals, and required supports.
Risk Assessment	A systematic process to identify, evaluate, and address risks that could impact the participant’s safety, wellbeing, or daily living needs.
Preventative Health Measures	Proactive actions, such as vaccinations and regular health check-ups, aimed at maintaining the participant’s health and preventing illness.
Proactive Support	Arrangements within a support plan to ensure continuity and stability of care, especially during emergencies or disruptions.

Outcomes and Indicators

Term	Description
Each participant is actively involved in the development of their support plans. Support plans reflect participant needs, requirements, preferences, strengths and goals, and are regularly reviewed.	With each participant’s consent, work is undertaken with the participant and their support network to enable effective assessment and to develop a support plan. Appropriate information and access is sought from a range of resources to ensure the participant’s needs, support requirements, preferences, strengths and goals are included in the assessment and the support plan. In collaboration with each participant: risk assessments are regularly undertaken, and documented in their support plans; and appropriate strategies are planned and implemented to treat known risks to them. Risk assessments include the following: consideration of the degree to which participants rely on the provider’s services to meet their daily living needs; the extent to which the health and safety of participants would be affected if those services were disrupted. Periodic reviews of the effectiveness of risk management strategies are undertaken with each participant to ensure risks are being adequately addressed, and changes are made when required. Each support plan is reviewed annually or earlier in collaboration with each participant, according to their changing needs or circumstances. Progress in meeting desired outcomes and goals is assessed, at a frequency relevant and proportionate to risks, the participant’s functionality and the participant’s wishes. Where progress is different from expected outcomes and goals, work is done with the participant to change and update the support plan. Each participant’s support plan is provided to them in the language, mode of communication and terms they are most likely to understand; and readily accessible by them and by workers providing supports to them. Each participant’s support plan is communicated, where appropriate and with their consent, to their support network, other providers and relevant government agencies. Each participant’s support plan includes arrangements, where required, for proactive support for preventative health measures, including support to access recommended vaccinations, dental check-ups, comprehensive health assessments and allied health services. Each participant’s support plan anticipates and incorporates responses to individual, provider and community emergencies and disasters to ensure their safety, health and wellbeing; and is understood by each worker supporting them.

Term

Description

Each participant is actively involved in the development of their support plans. Support plans reflect participant needs, requirements, preferences, strengths and goals, and are regularly reviewed.

With each participant’s consent, work is undertaken with the participant and their support network to enable effective assessment and to develop a support plan. Appropriate information and access is sought from a range of resources to ensure the participant’s needs, support requirements, preferences, strengths and goals are included in the assessment and the support plan.
In collaboration with each participant: risk assessments are regularly undertaken, and documented in their support plans; and appropriate strategies are planned and implemented to treat known risks to them.
Risk assessments include the following: consideration of the degree to which participants rely on the provider’s services to meet their daily living needs; the extent to which the health and safety of participants would be affected if those services were disrupted.
Periodic reviews of the effectiveness of risk management strategies are undertaken with each participant to ensure risks are being adequately addressed, and changes are made when required.
Each support plan is reviewed annually or earlier in collaboration with each participant, according to their changing needs or circumstances. Progress in meeting desired outcomes and goals is assessed, at a frequency relevant and proportionate to risks, the participant’s functionality and the participant’s wishes.
Where progress is different from expected outcomes and goals, work is done with the participant to change and update the support plan.
Each participant’s support plan is provided to them in the language, mode of communication and terms they are most likely to understand; and readily accessible by them and by workers providing supports to them.
Each participant’s support plan is communicated, where appropriate and with their consent, to their support network, other providers and relevant government agencies.
Each participant’s support plan includes arrangements, where required, for proactive support for preventative health measures, including support to access recommended vaccinations, dental check-ups, comprehensive health assessments and allied health services.
Each participant’s support plan anticipates and incorporates responses to individual, provider and community emergencies and disasters to ensure their safety, health and wellbeing; and is understood by each worker supporting them.

Guiding Principles

Participant-Centred Approach: Each participant is actively involved in the assessment and support planning process, ensuring their voice is central to decisions about their care (Indicator 1).
Comprehensive Risk Management: Support plans include robust risk assessments and strategies to mitigate risks to participants’ safety, health, and wellbeing (Indicator 2).
Continuous Improvement: Support plans are regularly reviewed and updated to reflect changing circumstances, participant goals, and outcomes achieved (Indicators 5 and 6).
Accessible Communication: Support plans are communicated in a way that participants and their networks can easily understand and access (Indicator 7).
Collaborative Planning: With participant consent, support plans are shared with relevant stakeholders to ensure seamless and effective care coordination (Indicator 8).

Policy

Holistic Healthcare Management Services will ensure that all participants play an active role in the development, implementation, and review of their support plans. These plans are designed to be participant-centred, evidence-based, and focused on achieving outcomes that align with their goals, preferences, and individual needs. This commitment underscores the organisation’s dedication to empowering participants to have control over their supports while fostering collaboration and inclusivity.

Support planning processes will integrate evidence-informed practices and participant insights, ensuring plans are adaptable to their evolving circumstances. Regular reviews will be conducted to ensure support plans remain relevant and effective in addressing the participant’s aspirations and requirements.

Collaborative Assessments

The organisation is dedicated to conducting collaborative assessments with participants and their support networks to develop detailed support plans. These assessments will consider the participant’s strengths, preferences, goals, and any additional input from allied health professionals or external stakeholders. This ensures the plans holistically address their needs (Indicator 1).

Comprehensive Risk Assessments

Risk assessments will be a key part of every support plan. The organisation will identify potential risks to participants’ safety, daily living needs, or wellbeing and implement strategies to mitigate these risks effectively. Contingency plans will be documented, and participants will be involved in discussions about managing risks (Indicator 3).

Periodic Reviews and Updates

Support plans will be reviewed at least annually or earlier if participant circumstances change. These reviews will assess progress toward goals and make necessary updates to reflect evolving participant needs, preferences, or external factors. Continuous monitoring ensures plans are tailored and effective (Indicators 5 and 6).

Accessible Communication of Support Plans

Support plans will be provided in formats that are accessible and understandable to participants. These formats may include plain language, braille, or digital formats, depending on the participant’s preferences. Plans will also be shared, with consent, with relevant stakeholders to ensure continuity of care (Indicators 7 and 8).

Proactive Health and Emergency Arrangements

Each support plan will incorporate arrangements for preventative health measures such as vaccinations and allied health services, alongside strategies for responding to emergencies. These measures aim to safeguard participants’ health, safety, and wellbeing during disruptions (Indicators 9 and 10).

Procedure

Collaborative Assessment and Development

The support planning process is a collaborative, participant-centred approach designed to identify and implement tailored supports that promote independence, skill development, and overall well-being. This process is conducted in partnership with the participant and their support network to ensure that their unique needs, preferences, and circumstances are fully understood and integrated into their plan. Workers will:

Conduct a comprehensive assessment by gathering information about the participant’s needs, strengths, and goals. This involves structured interviews, observational data, and relevant documentation provided by the participant or their support network. The assessment will consider factors such as age, developmental stage, and cultural background to ensure that supports are appropriate and meaningful.
Encourage independence, problem-solving abilities, social skills, and self-care capacities by developing plans that actively support participants in enhancing their functional abilities. Plans will include strategies to build skills over time, tailored to individual capacity and aspirations, fostering greater autonomy.
Incorporate input from allied health professionals, external stakeholders, and community services to develop a holistic understanding of the participant’s needs. This may involve liaising with medical practitioners, social workers, and community organisations to ensure all aspects of support are appropriately addressed.
Empower participants to make informed decisions and take responsibility for their choices by fostering self-determination. This includes providing education, resources, and support to help participants navigate decision-making processes and actively engage in their community.
Consider cultural, linguistic, and communication preferences to ensure inclusivity and respect for diversity. This may involve providing interpreters, cultural liaisons, or alternative communication tools to facilitate meaningful engagement and ensure all participants feel supported and heard.

Workers will use structured assessment tools, including templates, checklists, and planning frameworks, to standardise the process and ensure accuracy. The assessment process will be transparent and collaborative, encouraging trust and engagement while aligning with participants’ expectations and aspirations.

Risk Assessment and Management

Risk assessments form an integral part of every support plan. These assessments are designed to identify potential risks to the participant’s safety, wellbeing, or daily living requirements and implement effective strategies to mitigate these risks. Key actions include:

Conducting thorough risk assessments that identify possible threats related to participant safety, health, and service disruptions. Risks will be categorised (e.g., environmental, behavioural, or systemic) to ensure targeted interventions.
Documenting detailed risk mitigation strategies that outline contingency measures, proactive planning, and specific actions to address identified risks. For example, participants with mobility challenges may require personalised evacuation plans in case of emergencies.
Engaging participants in open discussions about risks and collaboratively developing strategies to manage these risks. Workers will ensure that participants understand the potential consequences and benefits of each strategy, empowering them to make informed decisions (Indicator 2).

Risk management strategies will be regularly reviewed and updated to reflect changes in participant circumstances, regulatory requirements, or external conditions. Participants will be consulted during reviews to ensure strategies remain relevant and effective.

Periodic Reviews and Goal Monitoring

Regular reviews, at least annually are essential to ensure support plans remain aligned with participant needs, goals, and evolving circumstances. The review process includes:

Conducting structured evaluations of progress toward participant goals and outcomes, identifying areas of success and any deviations from expectations. Workers will use measurable indicators to assess progress, ensuring objectivity and accuracy.
Facilitating collaborative discussions with the participant to explore any required changes to the plan. These discussions will be participant-led, with workers providing professional insights and suggestions where appropriate (Indicators 5 and 6).
Documenting changes comprehensively, including the reasons for updates, agreed-upon actions, and timelines for implementation. This ensures transparency and accountability in the support planning process.

Goal monitoring will also involve regular feedback sessions where workers provide participants with updates on their progress and acknowledge achievements. This reinforces motivation and fosters a sense of empowerment.

Communication and Accessibility

Support plans will be communicated in formats that participants can easily understand and access. Key steps include:

Providing support plans in participant-preferred formats, such as plain language documents, braille, large print, or digital files compatible with assistive technologies (Indicator 7).
Ensuring workers clearly explain the contents of the support plan, addressing any questions or concerns raised by the participant. Workers will also provide follow-up support as needed to clarify complex information.
Sharing support plans with relevant stakeholders, such as family members, healthcare providers, or external agencies, only with the participant’s consent. This ensures a consistent approach to support delivery while maintaining participant privacy (Indicator 8).

Workers will undergo training on effective communication techniques to enhance their ability to engage with participants, particularly those with unique communication needs.

Preventative Health Measures and Emergency Responses

Support plans will include proactive arrangements to safeguard participant health and wellbeing and address emergencies. Actions include:

Incorporating strategies for preventative health measures, such as facilitating access to vaccinations, routine health assessments, and allied health services. Workers will coordinate appointments and follow-ups to ensure participants receive timely care.
Developing emergency response plans tailored to each participant’s needs. These plans will outline specific actions to be taken during natural disasters, health crises, or other emergencies to ensure continuity of care and participant safety (Indicators 9 and 10). Plans will be reviewed regularly to incorporate new health guidelines, participant feedback, and lessons learned from past emergencies.

Roles and Responsibilities

Ref No	Roles	Responsibilities
1	Board and Senior Management	Oversee the development, implementation, and review of support planning policies and procedures. Ensure sufficient resources, tools, and training are available for effective support planning. Monitor compliance with regulatory requirements and organisational objectives.
2	Workers	Conduct detailed assessments and collaboratively develop support plans with participants. Implement support plans in line with organisational policies and participant preferences. Identify and address risks proactively, ensuring participant safety and wellbeing. Document and communicate any changes to support plans promptly and transparently.
3	Participants and Support Networks	Actively participate in assessments and discussions related to support planning. Provide feedback on the implementation and effectiveness of support plans. Collaborate with workers to address any challenges or changes in their needs.

Record Keeping

Support Plans: Maintain comprehensive records of all assessments, plans, and updates. These records must be securely stored and accessible to authorised personnel to ensure privacy and transparency.
Risk Assessments: Document all identified risks, mitigation strategies, and periodic reviews. This ensures an audit trail of proactive risk management.
Consent Records: Keep signed consent forms and detailed communication logs related to the sharing and updating of support plans.
Progress Monitoring: Maintain detailed records of participant progress, achievements, and any updates made to support plans. These records inform future planning and ensure alignment with participant goals.

References

NDIS Practice Standards and Quality Indicators
National Disability Insurance Scheme Act 2013
Relevant State and Territory Legislation

Policy Review

This policy will be reviewed annually or as required to ensure it remains aligned with best practices, regulatory changes, and organisational goals. Feedback from participants, workers, and stakeholders will inform updates.