ࡱ>   6bjbjFF *$$ V___ssss8 s$oK"l ,,,,/0<1PmmmmmmmqJtm_1*/^/11m6,,sn6661,_,m61m66b)6_f Z`s&4t_d(fn0$odDt6tPf6_f111 i:   Care Coordination Plan For consumers with complex and/or multiple issues, tosupport a coordinated approach. It shows who is involved in a consumers care, the main issues, agreed goals developed together, planned actions and who is responsible for each action.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label hereConsumer Consent to Share Information Before developing this plan, ensure consent to share information has been obtained using the  Consumer Consent to Share Information tool template. Reason for Plan.  FORMTEXT      Participants in Care List known persons currently contributing to the consumer s care, including the individual and the carer/advocate and the key worker /care plan coordinator/facilitator, (e.g. GP, health/community care providers, substitute decision maker, family members, volunteers or friends who provide assistance.) Append sheet to specify any additional persons. NameRole or area ofsupportContact phone number/sOther relevant contact details (e.g. agency, email)Participant inplanning process (yes/no)Copy ofplan provided (yes/no) FORMTEXT      Consumer  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Carer FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Key Worker FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      GP FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Supporting Documentation This may include social profile, assessments, service plans, support plans, GP plans, advance care plans, emergency management plans, screening or risk alerts. List appropriate documents and source or location.  FORMTEXT       Produced by the Victorian Department of Human Services, 2009This information collected by:CCP Page 1 of 3Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign: Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       Care Coordination Plan For consumers with complex and/or multiple issues, tosupport a coordinated approach. It shows who is involved in a consumer s care, the main issues, agreed goals developed together, planned actions and who is responsible for each action.Consumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label here Issues/problems (list in order of priority)Agreed goal (measurable)Action/s to be taken & by whomTarget date1  FORMTEXT      1.1  FORMTEXT       FORMTEXT       FORMTEXT      1.2  FORMTEXT       FORMTEXT       FORMTEXT      2  FORMTEXT      2.1  FORMTEXT       FORMTEXT       FORMTEXT      2.2  FORMTEXT       FORMTEXT       FORMTEXT      3  FORMTEXT      3.1  FORMTEXT       FORMTEXT       FORMTEXT      3.2  FORMTEXT       FORMTEXT       FORMTEXT      4  FORMTEXT      4.1  FORMTEXT       FORMTEXT       FORMTEXT      4.2  FORMTEXT       FORMTEXT       FORMTEXT      Plan developed:  FORMTEXT    /  FORMTEXT    / FORMTEXT      Target Review date:  FORMTEXT    /  FORMTEXT    / FORMTEXT      Case Conference:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Consumer understands and agrees to this plan:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Signature if applicable: Date:  FORMTEXT    /  FORMTEXT    / FORMTEXT      Append more sheets as necessary. Produced by the Victorian Department of Human Services, 2009This information collected by:CCP Page 2 of 3Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign:Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT       Review of CareCoordination Plan For use when the Care Coordination Plan is reviewed. It shows the outcomes/progress of agreed goals and planned actionsConsumer Name:  FORMTEXT       Date of Birth: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT      Sex:  FORMTEXT       UR Number:  FORMTEXT       or affix label here Issue & Goal Reference (Refer to Care Coordination Plan):ProgressSource of information FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Supporting Documentation  FORMTEXT      Review date:  FORMTEXT    /  FORMTEXT    / FORMTEXT      Case Conference:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Produced by the Victorian Department of Human Services, 2009This information collected by:CCP Page 3 of 3Name:  FORMTEXT      Position/Agency:  FORMTEXT      Sign:Date: dd/mm/yyyy  FORMTEXT    /  FORMTEXT    / FORMTEXT     Contact number:  FORMTEXT           Care Coordination Plan Care Coordination Plan Review of Care Coordination Plan    $ % * , D F Z \ d n p     ( R T t x hH$huCS h huCS hhuCShuCSj>huCSU_HjhuCSU_Hj`huCSU_HjhuCSU_HjthuCSU_H huCS5_HjhuCSU_HjhuCSU_HhuCSOJQJ_H huCS_H.   * R -$$Ifa$l -$Ifl ,$Ifl $1$5$7$8$9DH$Ifl $Ifl $Ifl  R T  TOJO:$Ifl gduCSgduCSkd$$Ifl Fd'd%  t 0'    2q2 l44n4lalp         "$8:HJL`bprt᭩|j||X||F|"jhuCSB*U_Hph"jDhuCSB*U_Hph"jhuCSB*U_HphhuCSB*_HphjhuCSB*U_HphhuCSB*phhuCS5B*_HphhuCSh*huCSB*phf'jhuCSB*U_HmHnHphfu(jh*huCSB*U_Hphfh*huCSB*_Hphf"jh*huCSB*U_Hphf  @ 2fxxxxxx$IfgduCSl dgduCSgkd.$$IflS'u( t0'6494 lal "J6$$$$Ifl kd$$If*ֈ4#'46 0'4494a9Jr$Ifl t "68FHJ^`nprr`"j huCSB*U_Hph"j huCSB*U_Hph"j$ huCSB*U_Hph"j huCSB*U_Hph"j8 huCSB*U_HphhuCSB*ph"jhuCSB*U_HphjhuCSB*U_Hph"j0huCSB*U_HphhuCSB*_Hph%2 $Ifl kd$$If*ֈ4#'46 0'294494a9 Hp$Ifl 2 $Ifl kd $$If*ֈ4#'46 0'294494a9&(*>@NPRfhvxz|r`"jhuCSB*U_Hph"j huCSB*U_HphhuCSB*ph"jzhuCSB*U_Hph"jhuCSB*U_Hph"j huCSB*U_Hph"j huCSB*U_HphjhuCSB*U_Hph"j huCSB*U_HphhuCSB*_Hph%(Px$Ifl xz2 $Ifl kd$$If*ֈ4#'46 0'294494a9 H$Ifl  "68FHJL`bprtձթ՗Յsa"jhuCSB*U_Hph"jbhuCSB*U_Hph"jhuCSB*U_Hph"jvhuCSB*U_HphhuCSB*ph"jhuCSB*U_Hph"jnhuCSB*U_HphhuCSB*_HphjhuCSB*U_Hph"jhuCSB*U_Hph$HJr2 $Ifl kdZ$$If*ֈ4#'46 0'294494a9:$Ifl (*8:<>RTbdfz|ջթ՗Յsa"j.huCSB*U_Hph"jhuCSB*U_Hph"jBhuCSB*U_Hph"jhuCSB*U_Hph"jVhuCSB*U_HphhuCSB*ph"jhuCSB*U_HphhuCSB*_HphjhuCSB*U_Hph"jNhuCSB*U_Hph$:<d2 $Ifl kd:$$If*ֈ4#'46 0'294494a9,$Ifl *,.0DFTVXln|~  "6ջթ՗Յsa"jhuCSB*U_Hph"jhuCSB*U_Hph"jhuCSB*U_Hph"j"huCSB*U_Hph"jhuCSB*U_Hph"j6huCSB*U_HphhuCSB*phhuCSB*_HphjhuCSB*U_Hph"jhuCSB*U_Hph%,.V~2 $Ifl kd$$If*ֈ4#'46 0'294494a9~$Ifl  Hp2 $Ifl kd$$If*ֈ4#'46 0'294494a968FHJ^`nprDձ՟Ս{sohaWjhuCSU_H hhuCS h?huCShuCShuCSB*ph"jd!huCSB*U_Hph"j huCSB*U_Hph"jx huCSB*U_Hph"j huCSB*U_Hph"jhuCSB*U_HphhuCSB*_HphjhuCSB*U_Hph"jhuCSB*U_Hph!p$Ifl D2)$gduCS,gduCSkd!$$If*ֈ4#'46 0'294494a9*,PRfhvxzȷ{㕨qdj'huCSU_HhuCSOJQJ_HjB&huCSU_Hj%huCSU_HhuCS5OJQJ_HhuCS0J_HhuCS5CJOJQJmH sH !huCS5CJOJQJ_HmH sH !huCS5CJOJQJ_HmH sH  huCSCJ huCSjhuCSU_Hj"huCSU_H huCS_H%{gN>$$Ifl $ r  U"$Ifa$l  9r $Ifl  ddgduCSikdn#$$Ifl'' t0'6494 lal$Ifl {k[%$Ifl #$Ifl kd#$$IflF ' 0'6    4 lal,xo__"$Ifl kd$$$Ifl0'  0'624 lalpxz*tk[[["$Ifl kd&$$Ifl0 '  0'62U24 lalp(*LNbdrtvx  (24HJRXZn賧xkj+huCSU_Hj(+huCSU_H huCS5_Hj*huCSU_HhuCSOJQJ_HhuCShuCSOJQJmH sH huCSOJQJ_Hj)huCSU_HhuCS5OJQJ_Hj(huCSU_H huCS_HjhuCSU_Hj((huCSU_H'tvxMK;+$Ifl $Ifl  kd~)$$IflF '    0'6    2U24 lalp~-$$Ifa$l -$Ifl ,$Ifl $1$5$7$8$9DH$Ifl np|8^nr     & ( * 0 4 6 J ĺ|k!jhchuCSOJQJU_Hj8/hchuCSU_HjhchuCSU_HhchuCSOJQJhchuCS_HmH sH hchuCS_HhchuCS5_HhuCSj,huCSU_Hj~,huCSU_H huCS_HjhuCSU_Hj,huCSU_H(rVTDDDD$Ifl kdj-$$Ifl Fd'd%  t 0'    2q2 l44n4lalp * \ `NNNN$Ifl kdi.$$Ifl\F "'   t0'494 lalJ L N X Z \ ^ r t v !! 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