This form collects personal information about you for the purpose of delivering care and services. We will not use or release your information for other purposes without your consent. Please note, however, in an emergency, we are permitted to exchange required information with relevant agencies without your consent.

It is your right to withdraw consent at any time and to obtain access to the information we hold about you.

We aim to ensure that your wishes, beliefs, cultural and spiritual values, and care decisions are respected and upheld throughout your care journey. Establishing your goals of care helps all staff involved in your care understand your decisions and provide support in accordance with them

The use of the following tools will enable the team to track the progress of interventions, improve program quality and compliance, and identify opportunities to modify your individual support plan as needed. Both tools will be used at the start and upon completion of the program. The modified Barthel Index will apply during the physiotherapy initial assessment and the during the preparation for exiting the program.

During assessment and preparation for exiting the program:

Quality of Life-Aged Care Consumers- Interviewed facilitate Version (QOL-ACC Tool-Flinders Caring Future Institute)

1. Mobility

The first question is about your mobility. Mobility is about being able to get to the places you need or want to go. This includes moving about indoors as well as outside spaces where you live or in the community.

Your mobility may be supported by the use of mobility aids such as walking sticks, walking frames, wheelchairs or mobility scooters.

The mobility statement is:

I am able to get around as much as I want to. (using mobility aids if you use them)

Before you answer, I will give you the five response options. They are:

So, which of those response options is true for you TODAY in response to “I am able to get around as much as I want to”?

(Repeat statement and response options if needed.)

2. Pain Management

The next statement is about pain management. This relates to your experience of pain and whether you feel it is well managed. Managing pain can include the provision of heat packs, medication, or other treatments from a doctor, physiotherapist or other health care professional.

The statement is:

When I experience pain, it is well managed.

The response options are:

So, which of those response options is true for you TODAY in response to “I am able to get around as much as I want to”?

(Repeat statement and response options if needed.)

3. Emotional well-being

The third question is about emotional well-being. Emotional well-being is about living your life without sadness, worry or stress. It is about whether you are generally happy and contented with your life.

The statement for emotional well-being is:

I am generally happy.

The response options are:

So, which of those response options is true for you TODAY in response to “I am able to get around as much as I want to”?

(Repeat statement and response options if needed.)

4. Independence

The next question is about independence. Independence is about living the life you choose and making your own decisions. This can be decisions about your life or day to day decisions such as how to structure your day, when you take your meals, when and how you undertake care or self-care activities, and when you go to bed.

The independence statement is:

I have as much independence as I want.

The options are:

So, which of those response options is true for you TODAY in response to “I am able to get around as much as I want to”?

(Repeat statement and response options if needed.)

5. Social Connections

The next statement is about social connections. This can include family, friends and acquaintances. If you are living in residential care social connections can also include your connections with other people living in your residential care home, staff and volunteers who you interact with regularly and have built a relationship with.

The statement for social connections is:

I have good social relationships with family and friends.

The options are:

So, which of those response options is true for you TODAY in response to “I am able to get around as much as I want to”?

(Repeat statement and response options if needed.)

6. Activities

The final question is about activities, that is, spending time doing things you enjoy and value. Activities can be those you undertake alone, such as word puzzles, reading or sudoku or activities undertaken with other people such as playing cards, craft classes, coffee mornings or going on an outing.

These might be activities organised by aged care staff or those organised with family and friends. If you are a member of a church or other community organisation, activities could also include services or other events you attend.

The statement for activities is:

I have leisure activities / hobbies I enjoy.

The options are:

So, which of those response options is true for you TODAY in response to “I am able to get around as much as I want to”?

(Repeat statement and response options if needed.)

I, 

consent to information relevant to the care I receive being made available as outlined below:

Doctor/GP/Specialist

Aged Care Assessment Service 

(ACAS)

Family Member/Next of Kin

Relevant information may be shared with other team members involved in my care

Other

(i.e. Hospitals, specialists, etc.)

Other Service Providers