Key points

  • Your care plan is a written record of your goals, needs, and the services you will receive
  • You must be involved in creating and reviewing it
  • Care plans must be reviewed at least every 12 months
  • A care plan is different from a service agreement
  • You can request changes at any time
  • If you disagree with your plan, you have formal options to resolve it

What is a Support at Home care plan?

Under the Support at Home program, every participant must have an individual care plan. This is a written document that records your assessed needs, your personal goals, and the services you will receive to meet those needs.

The care plan is not a static document that sits in a filing cabinet. It should be a living plan that changes as your circumstances change. It belongs to you, and your provider is required to give you a copy.

For a full overview of the Support at Home program, including how assessments and classification levels work, see our complete guide to the Support at Home program.

What goes into a care plan?

A good care plan covers several areas:

Your goals and preferences

This is the most important section. Your care plan should state what you want to achieve. That might be something like staying independent at home, recovering from a fall, maintaining social connections, or managing a chronic health condition. Goals should be specific to you, not generic.

Your assessed needs

Based on your Support at Home classification level, your care plan records the areas where you need support. This could include personal care, nursing, allied health, home modifications, transport, social support, or respite.

The services you will receive

The plan lists which services you will actually use, how often, and who will deliver them. For example, it might state that you receive personal care three mornings a week and physiotherapy fortnightly.

Your budget and funding

Your care plan should show your quarterly funding allocation across the three service categories (clinical care, independence, and everyday living) and how that funding will be spent. This gives you a clear picture of what is available and where it is going. If you want to work out the numbers before your plan is finalised, you can estimate your Support at Home budget and contributions based on your classification level.

Your preferences

This includes things like preferred times of day for visits, whether you prefer male or female support workers, cultural or language needs, dietary requirements, and anything else that matters to your day-to-day experience.

Risk management

If there are any risks identified during your assessment (falls risk, medication management issues, skin integrity concerns), your care plan should include strategies to manage them.

Emergency contacts and key information

Your GP details, next of kin, any advance care directives, and relevant medical information.

Who creates the care plan?

Your care plan is developed by your approved aged care provider, but it is not something done to you. The Aged Care Act requires providers to work with you to develop your plan. That means:

  • You should be asked about your goals, preferences, and priorities
  • You can have a family member, friend, or advocate present during the planning process
  • The provider coordinates the clinical and practical aspects, but your input drives the plan
  • You must agree to the plan before it is finalised

If English is not your first language, you are entitled to interpreter services. If you have cognitive impairment, your nominated representative can participate on your behalf.

Who else might be involved?

Depending on your needs, your care plan might involve input from:

  • Your GP
  • Allied health professionals (physiotherapist, occupational therapist, speech pathologist)
  • Nursing staff
  • Social workers
  • Specialist dementia or palliative care advisors

The provider coordinates all of this, but you remain at the centre of the process.

Care plan vs service agreement: what is the difference?

These two documents are often confused, but they serve very different purposes.

The care plan is about your care. It records your goals, needs, and the services you will receive. It is a clinical and personal document.

The service agreement is a legal contract between you and your provider. It covers:

  • The fees you will pay (co-contributions)
  • What the provider will deliver
  • Notice periods for ending the agreement
  • The provider’s responsibilities
  • Your responsibilities
  • How to make a complaint
  • How disputes will be resolved
  • What happens if either party wants to end the arrangement

You need both documents. The care plan tells you what services you are getting and why. The service agreement tells you what it costs, what the rules are, and what your rights are.

Important: Read your service agreement carefully before signing. If anything is unclear, ask the provider to explain it. You can also contact the Older Persons Advocacy Network (OPAN) on 1800 700 600 for free, independent advice before signing.

How often is your care plan reviewed?

Your provider must formally review your care plan at least once every 12 months. However, a review can and should happen more often if:

  • Your health changes significantly (a hospital admission, a fall, a new diagnosis)
  • Your goals change
  • You are not happy with the services you are receiving
  • Your classification level changes after a reassessment
  • Your living situation changes (a spouse enters residential care, you move house)
  • You request a review

You do not need a reason to ask for a care plan review. If something is not working, say so. A good provider will welcome this feedback.

What happens during a review?

A care plan review typically involves:

  1. A conversation between you (and your family or representative if you wish) and your care coordinator
  2. A check on whether your current services are meeting your goals
  3. Discussion of any new needs or changed circumstances
  4. Adjustments to services, schedules, or providers as needed
  5. An updated written care plan

The review should not be a rushed phone call. It should be a proper conversation where you have time to raise concerns and discuss what is and is not working.

Your rights around your care plan

Under the Support at Home program, you have clear rights:

The right to be involved. No one should create a care plan without your input. If your provider drafts a plan without consulting you, that is not acceptable.

The right to a copy. You must receive a written copy of your care plan and any updates. If you have not been given one, ask for it.

The right to change it. Your care plan is not set in stone. You can request changes at any time.

The right to understand it. If your care plan uses jargon or is confusing, ask your provider to explain it in plain language.

The right to disagree. If you think your care plan does not reflect your needs or goals, you can raise this with your provider. If that does not resolve the issue, you have escalation options (see below).

The right to access your records. You can request access to your full care records at any time.

What to do if you disagree with your care plan

Disagreements happen. Maybe you feel your provider is not listening to your preferences. Maybe you have been assessed at a level that does not reflect your actual needs. Here is what to do:

Step 1: Talk to your provider

Start with a direct conversation. Explain what you disagree with and what you would prefer. Many issues can be resolved at this stage. Put your concerns in writing if a verbal conversation does not lead to action.

Step 2: Ask for a formal care plan review

You have the right to request a review at any time. Your provider must conduct one when you ask.

Step 3: Contact an advocate

The Older Persons Advocacy Network (OPAN) provides free, independent advocacy for people receiving aged care. Call 1800 700 600. An advocate can attend meetings with you and help you communicate your concerns.

Step 4: Lodge a complaint

If your provider is not responding to reasonable requests, you can lodge a complaint with the Aged Care Quality and Safety Commission:

  • Phone: 1800 951 822
  • Online: agedcarequality.gov.au

Complaints are confidential. Your provider is not allowed to retaliate against you for making a complaint.

Step 5: Change providers

If the relationship with your provider has broken down, you can switch to a different provider at any time. Under Support at Home, there are no exit fees, and your unspent funding transfers with you.

What if your classification level does not match your needs?

Your care plan is based on your Support at Home classification level, which determines your funding. If you believe your classification level is too low, you can:

  1. Request a reassessment through My Aged Care (1800 200 422)
  2. Ask your GP or specialist to provide supporting documentation
  3. Contact OPAN for advocacy support during the reassessment process

A reassessment may result in a higher classification level and more funding, which would then flow into an updated care plan.

What a good care plan looks like vs a bad one

Not all care plans are created equal. Here is how to tell the difference:

A good care plan:

  • States your goals in your own words, not clinical jargon
  • Lists specific services with frequencies (e.g. “personal care 3 mornings per week, Tuesday/Thursday/Saturday, 7:30am to 8:30am”)
  • Shows your budget allocation and how it is being spent
  • Includes your preferences (preferred worker gender, language, cultural needs)
  • Has a clear risk management section
  • Is reviewed and updated when things change
  • Was created with your direct input

A poor care plan:

  • Uses vague language like “assist with activities of daily living as required”
  • Does not mention your goals or mentions generic ones that could apply to anyone
  • Has no budget information or spending breakdown
  • Was created without consulting you
  • Has not been updated in over a year despite changes in your needs
  • Does not include your preferences or ignores them

If your care plan looks more like the second list, it is time to request a review and insist on a plan that actually reflects your situation.

Care plans for people with specific needs

Some people need additional considerations in their care plan:

People with dementia: The care plan should address safety strategies (wandering prevention, medication management, kitchen safety), routine consistency, and communication approaches. It should name specific dementia-trained workers where possible.

People from culturally and linguistically diverse backgrounds: The care plan should record language preferences, cultural and religious requirements (dietary needs, gender preferences for personal care, observances), and any interpreter requirements.

Aboriginal and Torres Strait Islander people: The care plan should reflect cultural needs, connection to community, and any preferences around traditional healing practices alongside clinical care.

People with complex health conditions: If you have multiple conditions (diabetes, heart failure, COPD, chronic pain), your care plan should show how different services work together. For example, nursing visits for wound care, dietetic input for diabetes management, and physiotherapy for mobility should all be coordinated rather than operating in silos.

Tips for getting the most out of your care plan

Be specific about your goals. “I want to stay at home” is fine as a starting point, but “I want to be able to walk to the shops independently again” or “I want to manage my diabetes so I can avoid hospital admissions” gives your provider something concrete to work towards.

Keep a list of concerns between reviews. When something is not working, write it down. It is easy to forget small issues in a formal review. A running list helps you cover everything.

Bring someone you trust to reviews. A family member or friend can help you remember what was discussed and raise points you might not think of in the moment.

Ask questions. If your provider suggests a service you do not understand, ask why they are recommending it and what the alternative is. You are not obligated to accept every recommendation.

Review your budget regularly. Your care plan should align with your funding. If you are spending your budget faster than expected, or if funds are sitting unused, raise it with your provider so they can adjust.

Check your service agreement matches your care plan. If your care plan says you receive three hours of personal care a week, your service agreement and invoices should reflect that. Discrepancies are worth querying.

How Carevo can help

Carevo is a connection platform that helps you find vetted aged care providers who match your needs. Carevo lists 2,131 aged care providers across 1,568 suburbs, so you can compare options close to home. Whether you are looking for a new provider, comparing options, or need help understanding your care plan options, Carevo connects you with experienced professionals who can guide you through the process.

If you are unsure about your current care plan or want a second opinion, reaching out to a different provider through Carevo can give you a fresh perspective on what is possible with your funding.

Summary

Your Support at Home care plan is your roadmap for the services and support you receive at home. You have a right to be involved in creating it, to understand it, to change it, and to disagree with it. A good care plan reflects your goals and priorities, not just a list of services.

Review your care plan regularly, keep your provider accountable, and do not hesitate to ask for help from advocacy services if something is not right. The system is designed to work for you, and knowing your rights is the first step to making sure it does.