CHC08 Disability Behaviour Support Skill Set
Learner Resource Suite
Learner Workbook 4
Community Services and Health Industry Skills Council Ltd
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Published by Community Services and Health Industry Skills Council Ltd
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PO Box 49
Strawberry Hills, NSW 2012
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Page 1 of 42
Workbook 4: Provide Services to Support Complex
Needs
Complex Needs ................................................................................................................... 3
Assessment of Needs........................................................................................................ 5
Role of the Carer ............................................................................................................. 17
Person Centred Planning ................................................................................................. 21
Developing an Individual Plan ......................................................................................... 25
Developing Positive Support Strategies ........................................................................... 32
Supporting Resources ..................................................................................................... 34
Delegating Services and Care Activities .......................................................................... 37
Monitoring and Evaluation ............................................................................................... 39
The Review Process........................................................................................................ 39
Feedback ........................................................................................................................ 41
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Section 1: Complex Needs
People with complex needs have multiple health, functional or social conditions where one
condition affects other conditions. For example, depression may complicate the
communication of someone who has an intellectual disability, or poverty and social isolation
may impair a person’s capacity to meet medical or physical needs. Complex needs include
a person with one or more of the following disabilities – physical, intellectual, psychiatric,
sensory and/or speech, acquired brain injury, and have one or more of the following:






Chronic health condition.
Communication difficulties.
Behaviours of concern.
Drug or alcohol use.
Lack of suitable housing.
Lack of family or other social supports.

ACTIVITY 1.1: Think of a client you work with who has complex needs. Fill in the table below
to describe how their disability impacts on their quality of life:
Disability
Cause
Impact on Body
Functions
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Complex Needs
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Chronic Health Conditions
A chronic health condition is an ongoing physical and/or mental health condition which varies
in severity. The condition is typically incurable and requires continuous or intermittent
management by professionals or carers. A chronic health condition may affect your client’s
mobility, independence, change the way they live, how they see themselves and how they
relate to others.

ACTIVITY 1.2: Research some of the common health conditions experienced by your
clients. How does it impact on their disability? What is the impact on their quality of life?
Dual/Multiple Diagnosis
A dual diagnosis in the disability sector is as one of the following:


Two disabilities are present, such as an intellectual disability and a hearing
impairment.
A disability and a health condition are present such as a cognitive disability (learning
and problem-solving) and mental illness.
A multiple diagnosis is when there are more than two disabilities and health issues, such as
an intellectual disability, autism spectrum disorder, depression and diabetes.
According to the Australian Institute of Health and Welfare Analysis more than half of all
people with a disability reported having more than one disability. The following points are of
note:




The average number of long-term health conditions associated with disabilities
ranged from 3.5 for people with two disabilities to 6.2 for people with five disabilities.
Dementia, autism, Parkinson’s disease, schizophrenia, speech problems and stroke
were more commonly associated with multiple disabilities.
The support needs of people with early-onset multiple disabilities vary depending on
the nature of their disabilities and their life stages. As they grow older, they may have
higher support needs at an earlier age than people with single or late onset disability.
A substantial proportion of care for people with multiple disabilities was provided by
their family members and friends.
Among people with four or five disabilities, 30 per cent were unable to go out as
often as they would like to participate in community activities, more than 40 per cent
were living in institutions and the majority (77 per cent) was aged 65 years or over.
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs

ACTIVITY 1.3: Think of the clients you work with. How does multiple/dual diagnosis impact
on their needs?
Assessment of Needs
When developing a plan to address complex needs with the client it is important to identify
the priority for different services and support requirements and work with the client to identify
the best fit for their needs. A person centred approach is used to ensure services fit the
client and if they do not it is the service provider who assists in finding services that do fit the
client’s needs.
Some needs are more urgent than others such as a crisis situation for a life-threatening selfharm, or acute chest pain and severe bleeding in a person’s left side around their heart.
These people have a greater priority for emergency services before addressing their
complex needs. A person who is homeless, has an intellectual disability, severe depression,
alcohol addiction , is hungry and tired has a greater priority for accommodation that provides
food and a bed, before stabilising their medication and looking at their addiction.
Besides health and physical needs, consider the client’s ability to travel and willingness to
access a service. Cost and availability of services is also a factor.

ACTIVITY 1.4: Think about the clients you support. What needs do they view as a priority?
ACTIVITY 1.5: Consider Agnes who is a 34-year-old woman with Multiple Sclerosis, Agnes
uses a wheelchair for mobility and has been diagnosed with clinical depression and
incontinence.
One on occasion Agnes soils her bed but does not want to get out of the bed. She is not
talking to anyone and has begun to pull at her hair and rock herself. How would you prioritise
Agnes’ needs?
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
There are a number of formal assessment tools which assess, refer and identify broader
needs.

ACTIVITY 1.6: Research the functional screening tools used in your State/territory. How do
these compare to the forms used in your Workplace?
While purpose designed tools can assist you to assess the needs of your client, you also
need to remember that formal tools may not always be relevant because symptoms can
often present in hugely varied ways.
Therefore, your knowledge and skills provide informal assessments through:
•
•
•
•
•
Looking at reports from carers and the client’s history and reputation.
Observing changes.
Being able to exclude physical problems by organising a comprehensive health
assessment.
Recognising if there is a stigma attached to a certain diagnosis.
Seeking a diagnosis from qualified professionals from a range of disciplines to
determine a prognosis and treatment.

ACTIVITY 1.7: Identifying the interests, abilities and requirements of a person with a
disability who has complex needs can be undertaken in a variety of ways. What are some of
the assessment tools and less formal ways that can be used to do this?
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Your Role in the Assessment of Complex Needs
Your role as a support worker is to provide a service within the scope of your service
provider, which is delivered within the framework of legislation, funding, the society your
client belongs to and historical factors. You work within your service provider’s philosophy,
mission and goals and are guided by them in the following ways:



Your work role is to be a direct support to the client to maximise their quality of life, to
ensure their physical and mental wellbeing as you work with other professionals.
These may include health professionals such as speech pathologists and therapists,
physiotherapists, occupational therapists, general practitioners, the client’s workplace
managers and supervisors, interpreters or other government and non-government
agencies that can assist them with funding and financial matters. You provide an
indirect support to your client’s carers.
You monitor the setting the client is in to ensure you balance your duty of care and
manage the risks of what they do as they learn new tasks and skills. You consider
the people and environment they interact with such as where they live, who they visit
and if they participate in work and leisure activities
Collecting data and supporting the implementation of your client’s Individual Plan within
your work role. This will include consulting with others and giving indirect support to your
client’s carers.
As a disability services worker you are not expected or able to diagnose complex needs in
your clients, or assess relevant data on your own. Instead you should seek advice from
health professionals and personnel, relevant to your client’s needs and disability.

ACTIVITY 1.8: Who is involved in the assessment of complex needs in your workplace?
ACTIVITY 1.9: Use the following Functional Assessment Tool to identify the needs and
behaviours of your clients.
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Functional Assessment Tool
Name (surname)
Date of Assessment
(first)
(middle)
Gender
Date of Birth
Date/s of prior assessments (if applicable): _______________________________________________________
Person completing this assessment: _______________________________________________________________
Communication skills (tick all that apply):
Verbal
Hearing impairment
Non-verbal
Uses hearing aids
Signs
Uses communication board
Other relevant information: ________________________________________________________________________
___________________________________________________________________________________________________________
Personal medical history: ___________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Current medications (note* if this is a recent change):
Medication
Dose
Frequency
Reason drug prescribed
Family medical history (parents, siblings, eg. Heart disease, hypothyroidism, cancer,
psychiatric illness, depression): ______________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Mobility:
Independent, no assistance needed
Independently uses assistive devices (wheelchair, walker)
Needs assistance (no adaptive device)
Needs assistance (with adaptive device)
Is dependent for mobility
Comments:
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Dressing:
Independent
Independent with verbal prompts
Minimal physical assistance (zipper, button)
Significant physical assistance (include comments)
Is dependent for dressing needs
Comments:
Bathing:
Independent
Independent with verbal prompts
Minimal assistance required (water temperature)
Significant physical assistance (include comments)
Is dependent for bathing needs
Comments:
Personal hygiene (toothbrush, deodorant, grooming, menses):
Independent
Independent with verbal prompts
Minimal assistance required
Significant physical assistance (include comments)
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Is dependent for hygiene needs
Comments:
Routine – memory (s/he remembers the location of commonly used items – clothes, bathing
articles, dishes):
Always (rare exceptions)
Frequently
Occasionally
Rarely
Never
Comments:
Wandering (s/he leaves residence or workplace without notice):
Never (rare exceptions)
Rarely (monthly)
Occasionally (weekly)
Frequently (daily)
Always (rare exceptions)
Can the person be easily redirected by simply calling their name?
Yes
No
Comments:
Incontinence, urine:
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Always (more than once a day)
Frequently (more than twice per week)
Occasionally (once or twice per week)
Rarely (less than once a month)
Never (rare exceptions)
Is the person on a toileting program?
Yes
No
Yes
No
Comments:
Incontinence, faeces:
Always (more than once a day)
Frequently (more than twice per week)
Occasionally (once or twice per week)
Rarely (less than once a month)
Never (rare exceptions)
Is the person on a toileting program?
Comments:
Orientation (can s/he find the bathroom?):
Always (rare exceptions)
Frequently
Occasionally
Rarely
Never
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Is the person able to communicate the need to use the toilet?
Yes
No
Comments:
Leisure time:
Always active
Usually active
Needs prompting to participate
Rarely participates, even with prompts
Never participates, even with prompts
Comments:
Routine performance (is s/he able to perform tasks on a routine basis?):
Always (rare exceptions)
Frequently
Occasionally, with prompts
Rarely, even with prompts
Is dependent on others for guidance
Comments:
Gait (has there been a change in the way s/he walks?):
No
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Yes, minimal changes (explain)
Yes, major changes (explain)
Comments:
Time (is s/he aware of the day, week, month, year and seasons?):
Never knew them
Always (rare exceptions)
Frequently
Occasionally
Never
Comments:
Behaviour of concern (does s/he express excessive anger or unreasonable demands?):
Never (rare exceptions)
Rarely
Occasionally
Frequently
Consistently
Does this person have Individual Plan?
Date of last review:
Can this person’s anger/behaviour be easily redirected?
Yes
No
Comments:
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Danger to self/others (does this person behave in ways likely to be injurious to self/others?):
Never (rare exceptions)
Rarely
Occasionally
Frequently
Consistently
Does this person have an Individual Plan?
Date of last review:
Can this person’s anger/behaviour be easily redirected?
Yes
No
Comments:
Memory – recall (can the person easily recognise and recall everyday items?):
Always
Most of the time
Never
Not able to communicate
Comments:
Eating (have there been changes in the person’s eating patterns unrelated to known reasons?):
No
Yes, needs prompting
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Eating poorly, even with prompts
Comments:
Sleep (have there been changes in the person’s sleep pattern?):
No
Yes, minor changes (explain)
Yes, major changes (explain)
Comments:
Personality (have there been changes in the person’s interaction with others, or changes in
mood?):
No
Yes, minor changes (explain)
Yes, major changes (explain)
Comments:
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Role of the Carer
A carer is a family member and/or significant other who supports a person with a disability in
their daily living. Carers might be the children whose parents have a disability and they can
also be the siblings of clients with disabilities. It has been recognised by governments that
carers make a significant contribution to the health and wellbeing of our community. Unlike
child care caring, or other caring responsibilities with unpaid work, caring for someone with a
disability, a mental illness or who is aged is not necessarily seen as care carried out during
an ordinary life transition. The lack of certainty and choice around caring for a person with a
disability and the likelihood of the role intensifying as time goes by impacts on other
relationships. Carers often do not receive adequate recognition or understanding from the
government, community and family.
There are approximately 13% of Australian households which provide care for people who
have a disability, who are ageing, or both. The Australian Institute of Family Studies, in 2007
in a collaborative project between the Australian Government and the Department of
Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) summarised the
impact on carers of providing this care. This study showed that carers:




Were 1.46 times more likely than the general population to have low face to face
social contact with friends and relatives living outside the household.
Social isolation, financial hardship and their level of general health are linked. There
is a need for policies and services to enhance the lives of carers and consider carers’
needs for more intensive supported assistance.
Are reluctant to reveal their own health and support needs because they feel their
needs are secondary to those they assist and studies show they have a higher risk of
health issues than non-carers.
Have the greatest barrier to the workforce as there are a lack of services and
understanding in the community Research shows the benefits of staying connected
to the workforce gives carers a sense of identity, breaks from caring and financial
benefits.
The Centre for Public Policy, 2007 showed that carers, particularly young carers, are
disadvantaged in terms of education and entry into the workforce and that a caring role
early in life affects many decisions made by that person later in life. This can lead to social
exclusion, lack of communication skills and opportunities of furthering their work skills and
this can negatively impact on a carer who has not had a chance to prove their capabilities.
For all carers the range of issues regarding caring and the workforce include:




Inflexible employment conditions
Perceived disadvantage in the workforce due to absence from the workforce
Lack of recognition of skills obtained during the caring role that have relevance in the
workplace such as complex care tasks, advocacy skills, patience, reliance,
perseverance and communication skills
Concern that receiving benefits such as carers allowance might be jeopardised if
they take up work hours.
Carers have a need to be affirmed, reconsidered, educated and informed about referral
services for those they care for as well as services that cater for their needs. As a disability
services worker you have control over where you work, which clients you work with and are
protected by workplace policies surrounding WHS and fair workplace conditions. Carers
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
never clock off and go home – they are always on-call, and are required to attend to the full
range of complex needs around the clock. As a worker you can affirm them by:




Recognising what they do and how they support the client.
Reminding them of the importance of their involvement in designing and
implementing Individual Plans for the person needing support.
Suggesting options for respite from their caring role.
Identifying support groups such as peer support and community recreation
involvement in developing Individual Plans.

ACTIVITY 1.10: Think about the carers of your clients. How can you support them to feel
their role is important for those they care for?
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
ACTIVITY 1.11: What mechanisms are there in your organisation for providing feedback to
carers about activities of the organisation?
Impact on Those Who Care
The impact of behaviours of concern on carers can be upsetting, frightening and sometimes
even harmful; the clients engaging in the behaviour may feel the same way..
Providing Support and Respite for the Carer/s
Families and carers are the most important support to people with a disability. The role of
families and carers in providing this support will be assisted by:
•
•
•
•
Providing services that meet the changing needs of people with disabilities, their
families and carers, including improved access to flexible respite options
Recognising the specific needs of older carers at Commonwealth and State levels,
which provides funding through disability services for eligible carers to receive up to
four weeks respite a year
Supporting and protecting both people with a disability and their carers where one or
both people in the relationship provide domestic support and personal care to the
other
Working to develop specific, targeted and responsive early intervention services,
particularly for children with disabilities, to ensure that existing networks and support
structures provided by families and carers are maintained, coordinated and
enhanced.

ACTIVITY 1.12: What services can the carers of your client’s access?
ACTIVITY 1.13: How would you find more information about the needs of your client’s carers
to seek respite support?
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
ACTIVITY 1.14: Massey is the mother and full-time carer for Ellie, her daughter. Ellie has an
intellectual disability, cerebral palsy and has bouts of depression which are managed with
medication. Ellie needs daily assistance with personal care, medications, meals, transport,
appointments and her finances.
Your role is as one of a team of respite workers supporting Ellie to live at home with her
mother. You have noticed that Massey’s arthritis is getting worse and making it more difficult
for her to care for Ellie.
One morning you arrive and Massey and Ellie are still in bed.
a) What would you do?
b) Identify Massey’s issues:
c) Identify Ellie’s issues:
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Section 2: Person Centred Planning
Your role and the role of all staff working in the disability sector is to constantly look for
opportunities to involve clients in the things happening around them, so they gain more
control over their lives, become more included in their community, pursue their own interests
and gain independence.
This person centred approach is about:
•
•
•
Increasing the levels of everyday engagement and interactions between staff and
people with disabilities living in group homes or accessing disability services
organisations, and documenting this via a planning process which records and
monitors activities, allocates staff time to ensure activities occur, and regularly
reviews a person’s progress.
Ensuring people with a disability enjoy spending time participating in different
activities.
Challenging disengagement which sometimes happens in people with a disability
where staff do most things for them and clients become non-participating spectators
in their own lives, resulting in a loss of skills, confidence and motivation.
The approach is planned, provided and regularly reviewed and includes the following
components:
•
•
•
•
Staff involving the client in proactively planning opportunities for the client.
Staff documenting the activities to be pursued, their responsibilities and allocating
time to support activities.
Staff supporting participation (where required) by supplementing verbal instruction
with gestures or physical prompts, demonstrating how to undertake the tasks or
activity and providing physical guidance.
Staff regularly monitoring and reviewing the opportunities provided.
A person centred approach is based on the premise that all of us enjoy spending time
participating in different activities and participating in social, personal, household, leisure or
other pursuits typical of everyday living, as opposed to having little to do, being passive or
engaged in aimless activity; this is a measure of quality of life.
A person centred approach is not concerned with forcing or coercing people to undertake
chores or household tasks they do not want to be involved with, but involves gathering
information about the activities they wish to pursue (at home and in the local community),
and having in place a structured way to ensure engagement with such activities occurs.

ACTIVITY 2.1: With these strategies and principles in mind, how well do you think you:
a) proactively plan opportunities for your clients?
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
b) document the activities to be pursued, their responsibilities and allocating time to
support activities?
c) support participation (where required) by supplementing verbal instruction with
gestures or physical prompts, demonstrating how to undertake the tasks or activity,
or providing physical guidance?
d) regularly monitor and review the opportunities provided?
Case Management Framework
Case management is a collaborative process of assessment, planning, facilitation and
advocacy to meet an individual’s holistic needs. The framework for case management
focuses on a collaborative, person centred and strengths-based approach. The focus is on
the client’s quality of life and includes the maintenance of support structures in their
Individual Plan in accordance with the service provider’s agreement.
This is an ongoing process and should occur at least every 12 months, or when the needs of
the client change.

ACTIVITY 2.2: What are the steps in the Case Management Framework?
How does this relate to your workplace procedure for developing, monitoring and reviewing
Individual Plans?
Individual Plans
An Individual Plan is a detailed document which must be developed in conjunction with the
client so the plan remains client-focused, as well as involving the client’s family, primary
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
carers and other significant people to ensure the plan is realistic. The purpose of an
Individual Plan is to achieve an outcome for the client which may include:




Changes to the environment. This involves an understanding of relevant
environmental factors that may be contributing to the behaviour of concern. Working
as a team to analyse the STAR charts will have identified possible factors which may
include undiagnosed medical conditions or possible side effects to medication. In
addition you need to plan how you will change the environment to ensure a smooth fit
between the individual and where they live and work.
Teaching skills. This involves selecting and implementing skill development
strategies (skills the person can be supported to learn), instead of engaging in the
behaviour of concern.
Short-term change strategies to reduce the reliance on the behaviours of
concern. These may be required for a short period of time to produce a rapid change
in behaviour. These strategies are used to facilitate a more immediate change to the
behaviour
Immediate response. Strategies implemented by workers and carers when the
person presents with behaviours of concern. These strategies are used to minimise
risk to the person and others by planning responses aimed at de-escalating or
managing a serious episode of the behaviour. These strategies provide all those
involved with a strategy for immediately responding to the behaviour as it occurs.
These strategies do not promote long-term behaviour change; they are only intended
to manage a serious episode of the behaviour.
All Individual Plans need to have realistic, measurable and person centred goals and use
positive support strategies to address these goals. It is also important that there are clearly
stated roles and responsibilities to implement the strategies.

ACTIVITY 2.3: Who is involved in the development of Individual Plans in your workplace?
ACTIVITY 2.4: Provide an example of the forms you use in your workplace for designing
Individual Plans. Do they meet the criteria above?
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Example of an Individual Plan
Individual Plan
Date
Strategies From
Meeting (those in
attendance)
Long-term Goal
Changes to the
Environment
Teaching the Client
and Others
Recommendation:
Short-term
Strategies
Immediate
Response
Strategies
Short-term Goals of Individual Plan
Client’s
views/requests/opinions
Long-term goal
Short-term goals
Strategies
Person/s
Responsible
By When
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Resources
Required
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Developing an Individual Plan
To ensure that all service providers and relevant stakeholders understand their roles and
responsibilities within an Individual Plan they should be involved in the development process
which includes the following steps.
The following flowchart outlines the steps for creating an Individual Plan:
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Individual Plan Flowchart
Primary Worker
Role
Client Services
Coordinator Role
Ensure primary workers
are familiar with the
process
Ensure family and other
stakeholders are informed
of the meeting
Request and collate
reports from external
service providers
Inform manager of upcoming plan /reviews.
Ensure primary workers
are familiar with the
process
Ensure family and other
stakeholders are informed
of the meeting
Request reports from
external service providers
Either chair the meeting if
the case is complex or
delegate to key worker.
Ensure IPs are up-to-date
and relevant through
supervision of primary
workers
Monitor effectiveness of
strategies
Monitor timeframes of IPs
Monitor the risk
assessments and
implementation of risk
reduction strategies
Monitor implementation of
crisis response and use of
psychoactive medications
Eight Weeks Prior
to Meeting
Review Meeting
IP Meeting
Talk to client regarding
meeting
Ensure Nomination of
Support Person form is in
client’s file
Review Client Risk
Assessment
Send invite to families
and other stakeholders
Appraise progress
towards goals
Develop Primary Worker
Progress Report
Chair meeting if
delegated to do so by
senior worker
Ensure all parties have
opportunity to present
information
Ensure client has
opportunities for
involvement
Ensure all parties input
into the identification of
goals and development of
strategies.
Draft the IP, ensure all
information is
documented and all
parties sign the draft.
Submit the draft IP to
manager
Implementation
Ensure all house/unit staff
have knowledge of IP
goals and strategies.
Discuss barriers to
implementation of IP with
the manager
Quarterly Report
(monitoring)
Review progress against
stated IP goals and
review strategies if
required.
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 26 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Step 1 - Prior to the Individual Planning Meeting
Before the review of the client’s Individual Plan, the manager of the disability services
organisation will discuss the planning process with the client. The discussion will cover:
•
•
•
•
•
•
The purpose of the meeting.
The opportunity for the client to choose who they want to attend the meeting based
on who can assist them with the development of their plan.
The role of each attendee.
Whether the client wants to involve a support person, disability services worker or
interpreter.
Any matters the client wants to contribute to the meeting, or any issues the client
doesn’t want discussed with all service providers and attendees.
What assessments will be conducted and why.
At least eight weeks before the Individual Plan meeting, the manager must ensure that the
appropriate people are invited to attend. This must include:
•
•
•
•
•
•
•
•
•
The client.
The client’s family.
The client’s guardian.
Friends.
The client’s advocate.
An interpreter.
The client’s therapist.
Day program staff.
The client’s primary worker.
Although it is important that the relevant people attend, there should be a limited number to
make the proceedings manageable
To maximise the participation of those at the meeting, the manager will:
•
•
•
Choose an accessible and suitable meeting location.
Use accessible communication
Create an agenda which includes opportunities for discussion and participation in
decisions, but which remains flexible enough to allow meaningful contribution from
the client at any time.
The client’s primary disability services worker must prepare a report assessing the client’s
skills and evaluating their progress towards the goals of the Individual Plan. This report must
be prepared in consultation with the client and the other workers at the organisation.
The manager must also ensure the goal suggestions from family, guardian or advocate are
shared with all attendees.
The manager will also request reports and assessments at least two weeks before the
meeting, from:
•
•
•
•
Caseworkers from other service providers.
Speech therapists.
Dieticians.
Any allied health professional staff working with the client.
The manager will then use these assessments and reports to consult with the client and
write a draft of the Individual Plan. If a draft plan is developed it should be discussed with the
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
client or their guardian where appropriate. If there are contentious issues surrounding the
draft of the plan they should be discussed with the relevant people before the meeting.
If the case is complex the meeting must be chaired by a manager of the disability services
organisation. Otherwise the manager can delegate a primary disability services worker to
chair the meeting.
If the family, guardian, advocate and/or financial administrator indicate that they are not
comfortable expressing their ideas or asking questions during the meeting, the manager will
encourage them to contribute their ideas in another way, such as over the phone or in
person before the meeting.
Where any service provider is unable to attend the meeting, the manager will request that a
report be provided and distributed to all invited stakeholders. The report should include the
following where appropriate:
•
•
•
•
•
•
•
All health, medical and dental reviews.
Nutritional and swallowing assessment checklist.
Client annual budget.
Client profile.
Client risk assessment.
Risk reduction plan.
Goal suggestions from the family guardian, advocate and/or financial administrator.

ACTIVITY 2.5: What is your role in preparing for the meeting?
ACTIVITY 2.6: What cultural protocols do you need to be aware of in the individual planning
process with people with disability?
ACTIVITY 2.7: Who is involved in the planning meetings with your clients? Fill in the table
below to include each person present.
Person
Role
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 28 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Step 2 - During the Planning Meeting
It is important that the client attends the planning meeting, and if they choose not to be
present the manager must ensure that the client’s preferences and goals are raised at the
meeting.
The client’s primary disability services worker, case worker and other service providers will
then present their reports and recommendations. All attendees will then draft an Individual
Plan which specifies the prioritised client goals and planned service activities for the coming
year.
There are four broad areas of the client’s life to consider when establishing goals and
developing intervention plans:
1.
2.
3.
4.
Lifestyle and environment requirements.
Skills development.
Health and wellbeing.
Social and recreational.
Within these four areas there are a number of sub-categories to consider:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Health.
Self-care.
Mobility.
Communication.
Domestic.
Leisure and recreation.
Vocational and educational.
Socialisation.
Personal development.
Relationships.
Behaviour support.
Financial.
Advocacy.
Family support.
Other.
When staff of the disability services organisation cannot provide a service or activity which is
required to meet a client’s goal, the manager will contact other relevant providers such as
the Behaviour Management/Mental Health Team to discuss the possibility of a referral.
All decisions made at the Individual Planning meeting are to be recorded and the client, their
family, guardian, advocate and/or financial administrator must show their agreement to the
draft Individual Plan by signing it. Twelve monthly review dates are determined and also
recorded on the draft Individual Plan.
The manager will endorse the Individual Plan when the services identified to meet the
client’s goals are written within the scope of the disability services organisation, and in
consultation with other relevant staff.
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 29 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Copies of this endorsed plan are sent to the following stakeholders, ensuring the document
is in a format each person can understand:
•
•
•
•
•
•
The client.
The client’s family.
The client’s guardian.
The client’s advocate.
The client’s financial administrator.
Relevant service providers.
The manager will record the endorsement date in the client database, along with the plan
review dates and other relevant information.

ACTIVITY 2.8: What is your role during the meeting? Who should you report to?
Step 3 - Implementing the Individual Plan
Implementing an Individual Plan involves developing and carrying out specific strategies and
client routines to assist the client to meet their goals. The primary disability services workers,
in consultation with the client, their family, their guardian, advocate and/or financial
administrator will develop strategies and routines for achieving goals. These strategies may
also be developed by case workers who provide specialist services.
If there are goals in the Individual Plan which need to be met by service activities provided
by external agencies, the manager will forward these requests to the manager of the
relevant service for inclusion in their service request register. Any information needed for the
manager to prioritise the request should also be forwarded. Where an Individual Plan goal
requires a referral to another service provider, the manager of the disability services
organisation will arrange the referral.
Once the Individual Plan is in place, it is the responsibility of the manager to inform disability
services workers about the plan, and monitor its implementation. If barriers to the
interventions being implemented are identified they must be raised with the manager.
All disability services workers must implement the client’s routines and strategies as outlined
in the Individual Plan, and complete relevant progress notes. The manager will support staff
to implement the client’s plan through quarterly supervision meetings.
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
It is the manager’s responsibility to ensure all clients have current Individual Plans and that
their plans are reviewed annually or as required. The manager will also monitor the
implementation of Behaviour Intervention Plans and the use of psychotropic medications in
accordance with the workplace’s behaviour management policy and restrictive practices
policy. The manager will review the Individual Plan goals and interventions through an audit
of intervention practice, including the use of psychotropic medication.

ACTIVITY 2.9: What is your role in implementing the Individual Plan for your clients? Who
should you report to?
ACTIVITY 2.10: Provide an example of the policies your workplace uses when assessing,
implementing and reviewing Individual Plans
Implementation of an Individual Plan or strategy begins with a trial period of around two to
three weeks where:


Any issues can be closely observed by the team and actions taken to ensure that the
client is supported consistently in the way intended by the written plan.
The capacity of the support team to monitor and address implementation issues in
accordance with the written Individual Plan or strategy in the long-term is enhanced.
After the trial period, monitoring continues in accordance with the written Individual Plan or
strategy. Long-term responsibility for monitoring implementation is also part of the support
team’s role.
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 31 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Developing Positive Support Strategies
Each state and territory has their own action plans, framework and guidelines for service providers
for people with a disability. All of these policies and frameworks give guiding principles for the
development of strategies to meet the needs of clients.
The below policies are considered current best practice in choosing strategies to address the
complex needs of your clients:
State/Territory
Best Practice Guidelines
Qld – Department of communities Qld
Government
Positive Futures
NSW – NSW Department of Ageing,
Disability and home care
Behaviour support : Policy and Practice
Manual
www.communities.qld.gov.au
www.adhc.nsw.gov.au/
Victoria – Dept of Human Services
Positive behaviour support – getting it right
from the start
www.dhs.vic.gov.au
South Australia – Dept of Families and
Communities Disability, Ageing and Carers
Promoting Independence Promoting
Independence: Disability Action Plans for
SA
www.familiesandcommunities.sa.gov.au
Western Australia – Government of WA ,
disability services commission
Western Australia- Positive Behaviour
Framework
www.disability.wa.gov.au
Tasmania – Department of Premier &
Cabinet, Tasmania
Disability Framework for Action 2005-2010:
a whole-of government framework for
Tasmanians with disabilities.
www.dpac.tas.gov.au
ACT – Department of Disability, Housing
and Community Services
Future Directions: Towards Challenge
2014
ACT Government
www.dhcs.act.gov.au
Northern Territory – Territory Health
Services
The Northern Territory Disability Service
Standards
Disability Services Program
www.health.nt.gov.au
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 32 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs

ACTIVITY 2.11: As a group, research and discuss the guidelines in your State/Territory.
What evidence based approach does your workplace use?
To ensure that strategies that have been discussed are implemented and that everyone
involved understands what is expected of them they need to be well documented. When
writing up your reports you need to ensure all the vital information is included and the detail
and presentation of the information does not pose a barrier to people understanding what
needs to be done.
When reporting on the strategies in your clients’ Individual Response Plans, your
documentation should:
•
•
•
•
•
•
•
Be time limited, that is, must be completed within 24 hours
Include a clear description of the behaviour, what happened before and what
happened after
Include all observations and actions
Report all witnesses and injuries or damage
Explain what strategies you tried and if they worked or not
Say whether yourself or the client or others need debriefing
Take the opportunity to say what might help in the future to better manage the
behaviour.

ACTIVITY 2.12: Provide an example of how your workplace promotes person responsible
strategies?
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 33 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Supporting Resources
Resources which you can use to help your clients achieve their goals include the following
financial resources, aids and equipment, and qualified health specialists.
Financial Resources
For most people with a disability, financial support and assistance comes mainly from family
and friends. However, governments provide a range of services both directly and indirectly to
help those with disabilities, and the private and community sectors also provide significant
resources in this regard.
As well as disability specific services and support, the government, private and community
sectors also provide a range of mainstream services (for example, health services) that
people with a disability have access to. As there is a mix of mainstream and disabilityspecific programs and services it is difficult to get an accurate picture of the extent of funding
and support to the disability population.

ACTIVITY 2.13: Which are the government departments and interest/welfare groups in your
state or territory which would be available for your client to access?
Aids and Equipment
Your client may be able to utilise the following aids and equipment which will help them
achieve their goals:
•
•
•
•
•
Hearing aids.
Mobility aids, for example, walkers/walking frames, wheelchairs, walking sticks or
scooters.
Communication aids such as communication pictures, photographs, communication
diaries, chat books, voice output devices, Braille, videos and audio.
Shower chairs and recliner chairs.
Cooking and eating utensils.

ACTIVITY 2.14: Give an example of aids/equipment your workplace uses to assist your
clients achieve their goals?
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 34 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Qualified Health Specialists
Health professionals who can help
your client achieve their goals may
include:
•
•
•
•
•
•
•
•
Occupational therapist.
Speech pathologist.
Doctor.
Dietician.
Psychologist.
Physiotherapist.
Music therapist.
General practitioner.

ACTIVITY 2.15: What types of health professionals do your clients access?
Other Stakeholders



Teachers. Your client may have contact with a number of teachers who facilitate
their education, or teach them new skills.
Sporting coaches. Anyone involved in the direction, instruction and training related
to a specific team or individual sport. Some sporting coaches specialise in working
with people with a disability. At other times a particular sport may be modified to meet
the needs of a group of people with a disability. For example Goalball is a sport
specifically for people with vision impairment, and the sport nicknamed Murder Ball is
a modified version of rugby designed for people in a wheelchair.
Work supervisors. Any person in a management or supervisory role who the client
spends time with in a work environment, whether in a paid, voluntary or community
position.
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 35 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Community Services
There are a range of government and non-government organisations who can be contacted
for support, including the following:










Domestic violence
Mental health
Aboriginal and/or Torres Strait Islander health
Juvenile justice
HACC
Needle exchange
Support groups
Help lines
Medical clinics
Child protection

ACTIVITY 2.16: List six different types of community services in your area that might be able
to support your clients with complex needs and the services each provides.
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 36 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Delegating Services and Care Activities
In working with people with complex needs and providing positive behaviour support for their
behaviours of concern there is a continuum for the roles and responsibilities. As you
implement their Individual Plan recognising and using the strengths of the client and others,
you support and create a positive environment in which to implement the Individual Plan.
When you are working with others to implement your client’s Individual Plan, there are the
three basic principles of delegation:
1.
2.
3.
Principle of expectations. Suggests that before delegating a task to anyone the
person delegating should be able to clearly define the goals and the expected
results. For example, if your manager delegates you to investigate the cost of a
device to help your client communicate more effectively, you will need to know
exactly what equipment is required, how many quotes are needed, preferred
suppliers, how to report the information and when it needs to be delivered.
Principle of authority in doing the task. According to this principle, if you are
given a responsibility to perform a task, then you need to be given enough
independence and power to carry out the task effectively. In the above example
you can seek the information in the way that suits you, within the guidelines of the
organisation, reporting using your own words using the suggested template.
Principle of absolute responsibility. Suggests authority can be delegated but
the ultimate responsibility remains with the person delegating the task. In this
case your manager will be responsible for ensuring the quotes are accurate,
presented in an acceptable way and meet the needs of the client and the
organisation.

ACTIVITY 2.17: When delegating work to others what are the important principles to
remember to ensure it is successful?
It is particularly important that advice and assistance from relevant health professionals is
sought when the person’s goals are not being reached; people such as doctors,
psychologists, medical specialists, pain specialists and social workers.
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
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CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs

ACTIVITY 2.18: How do you seek advice and assistance when goals are not being met?
ACTIVITY 2.19: What can you do if your organisation is no longer able to provide the level of
service required?
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 38 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Section 3: Monitor and Review
A client’s Individual Plan must be reviewed at regular intervals to ensure goals are being
met, to accommodate their changing needs and to consider their needs for the future.
Review dates must be set at the Individual Plan meeting, and reviews must be conducted in
consultation with relevant people.
Individual Plans should be reviewed every 12 months, with an Individual Plan progress
report submitted quarterly by primary disability services workers. If the Individual Plan
contains a communication objective it should be reviewed at least every six months. An
Individual Plan will also be reviewed more frequently if there is a demonstrated need, and/or
if circumstances have changed.
Strategies will also require consistent implementation and a concerted effort from all those involved.
There is little point in persisting with strategies if after a reasonable period of time there does not
appear to be any change in the behaviour nor an improvement in the person’s quality of life. This
can actually have a negative effect on the person with a disability and on the enthusiasm of staff and
their feelings of hope for the future.
When reviewing it is important to:
•
•
•
•
•
Establish a reporting system appropriate to each part of the program or strategy – all
parts of the program need to be evaluated.
While diaries may be useful a lot of important information can get lost or is not
recorded because people don’t think to keep it centrally recorded. A formal shift
record sheet can be a useful prompt, and structure the reporting to clearly define
what you hope to achieve with respect to the person’s environment, skills, support
network and specific behaviours
Plan and conduct formal review meetings. At the beginning of the program, meetings
may need to be held at least weekly and they can be scaled back later. Work through
each area systematically to avoid focusing on just the most recent or most critical
occurrence. Meeting needs to be recorded and reports given in the different areas
being developed, for example, proactive strategies or Individual Response Plans,
and these reports need to be provided to other stakeholders who are not able to
make the meeting.
Keep open channels of communication between the stakeholders, the client, family
members, workers and all agencies involved.
Plan regular review meetings.
The Review Process
The date for each Individual Plan review is agreed to at the Individual Plan meeting and
recorded on the Individual Plan and in the client database by the organisation manager.
The manager will first discuss the Individual Plan review with the client using accessible
communication, and then arrange the review meeting with the client, their family, advocate
and/or financial administrator. If the review meeting is to occur on a date other than the date
scheduled, the manager will notify the attendees. At the meeting the current goals on the
client’s Individual Plan will be reviewed.
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 39 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Three weeks before the Individual Plan review, the manager will check the status of all the
client’s goals and intervention plans, considering the following:
•
•
•
•
•
Have the primary workers developed strategies and/or routines to implement the
plans for which they are responsible?
Have services requested through external providers been allocated a caseworker?
Has the intervention commenced?
Have the identified milestones been met? If not, why not?
Do the strategies need to change? If so, how?
The manager will also review the client’s risk assessment and risk reduction plans as the
client’s risk assessment is updated at the Individual Plan review meeting to reflect any
changes.
Participating in the review meetings will be the client, their family, guardian, advocate,
financial administrator and/or any professional staff. All of those involved in the review can
participate by:
•
•
•
Attending the review meeting.
Commenting on the scheduled reports which the manager may have sent to the
client’s family, guardian, advocate and/or financial administrator.
Discussing the progress of interventions through phone calls to the organisation.
A primary disability services worker may report to their manager a priority which arises from
an Individual Plan review prior to the meeting. This item will then be considered in the
Individual Plan review, and if agreed to by the client, their family, advocate and/or financial
administrator, the manager will revise the Individual Plan accordingly. If there is any
disagreement between any parties working with the client, if an Individual Plan review
indicates the need for further requests for service activities or if the existing services are no
longer relevant, this information is provided to the higher management team of the
organisation.
After the review, the manager will discuss the results with the client, as well as forward
copies of the reviewed Individual Plan to:
•
•
The client, their family, guardian, advocate and/or financial administrator.
Relevant service providers.
The manager will also make sure the disability services organisation client database is
updated.

ACTIVITY 3.1: How do you monitor the implementation of Individual Plans in your
workplace?
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 40 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs
Strategies for Effective Meetings
Whether you are conducting planning meetings and reviews or simply attending, there are a
lot of people involved and with such a high level of organisation required you want to make
sure effective outcomes are reached as easily as possible. You can do this by:
•
•
•
•
•
•
•
Being clear about what your client wants from the meeting.
Knowing who else needs to be at the meeting and what they are offering your client.
Being clear about the objective/s of the meeting, you can ask your manager to clarify
the objectives if you are unsure.
Creating an agenda for the meeting to ensure all points are covered.
Being prepared with the necessary documentation and information before the
meeting.
Being aware of your own personal agenda or expectations and if you have concerns
about your personal position you should speak with your manager.
Thinking about whether there are things which would make it hard for you to be
objective when leading the meeting and finding ways to fix this issue such as having
someone else chair the meeting.

ACTIVITY 3.2: What strategies would you employ to make sure a planning meeting was
effective?
Feedback
Feedback is a process by which all organisations gather and receive information about
program delivery, its appropriateness and its effectiveness. This information is used to
evaluate the success of programs, address shortfalls and for future planning. It is used to
ensure that client needs and goals are correctly identified and catered for.
Feedback mechanisms include:
•
•
•
•
•
•
Face to face interviews
Questionnaires
Focus groups
Observation
Input from experts
Input from behaviour support providers
Feedback is constantly collected from a variety of sources, including clients, client families,
care workers, case coordinators external consultants, service providers and other
stakeholders.
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
Page 41 of 42
CHC08 Disability Behaviour Support Skill Set
Learner Guide Book 4: Provide Services to Support Complex Needs

ACTIVITY 3.3: What is the process for providing feedback in your workplace?
ACTIVITY 3.4: What do you do when you receive feedback?
You are able to provide feedback to your client’s carers regarding the activities of your
disability services organisation through:
•
•
•
•
•
•
AGMs.
Individual planning meetings.
Carer group meetings.
Client representative group meetings.
House meetings.
Including your client’s activities and achievements in the organisation’s newsletters.
To effectively analyse and interpret feedback from all service providers, the client and their
advocates you need to make sure that the data is current and complete, and that those
collecting the data understood the purpose of the collection and remained consistent. Always
be aware of any limitations on the data collected and feedback provided.
When analysis of feedback demonstrates that current methods or work practices are not
being successfully implemented or are unsuccessful in a client plan this indicates a need for
change, and possibly external input. The importance of regularly monitoring the implemented
strategies cannot be understated.

ACTIVITY 3.5: How could you improve the feedback process in your workplace?
© Community Services and Health Industries Skills Council Ltd www.cshisc.com.au
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