Care Planning

INW PCP Care Planning Collaborative Project

This project aligns with INW PCP Strategic Priority 2: improve system capacity to increase prevention and support people from priority populations with chronic disease and its co-morbidities.

The Inner North West Primary Care Partnership, together with its member agencies, seeks to develop a consistent, integrated approach to person centred care planning practice in Melbourne’s Inner North West, in order to enhance communication and service coordination between agencies and ultimately improve client outcomes. To achieve this, project partners will:

  • Develop a solid understanding of the key principles, systems and tools that support effective Goal Directed Care Planning.
  • Review the existing systems for care planning within local member agencies and identify the strategies required to embed a best practice approach within the context of each agency.
  • Partner agencies will each implement system improvements for care planning, guided by best practice principles outlined in the Victorian Service Coordination Practice Manual 2012 and the Goal Directed Care Planning Toolkit.
  • Collaboratively develop a local agreement with shared guiding principles for intra-agency care planning in Melbourne’s Inner North West.
  • Strengthen partnerships between the different service providers to provide a strong platform for an inter-agency shared care planning phase of the project in 2016-2017.

Care Planning Collaborative Project Evaluation

In October 2016, INW PCP commenced a small scale monitoring evaluation to monitor progress on the CPC Project and inform future directions for the project in the next strategic planning phase.

Some of the key findings included:

  • The CPC Project has improved current practice both at a practitioner level and an organisational level. This includes clinician level improvements such as use of client centred language; collaborative goal setting and quality care plans, as well as organisational improvements such as policy development.
  • The INW PCP held a number of training sessions to support agencies to make steps toward better service coordination in Goal Directed Care Planning (GDCP) and case conferencing. Over 140 people participated in the training.
  • Over 60% of respondents engaged in this project have been using the Goal Directed Care Planning Toolkit (GDCP Toolkit) as both an auditing tool at a clinician and organisational level. Additionally, approximately 50% of respondents reported organisational improvements such as policy development and ongoing evaluation and monitoring in GDCP that have been sustained after the original training sessions.

For more information view the full evaluation report.



Project Coordinator Emily Buchanan