Hertfordshire Single Assessment Process Briefing Sessions For Residential and Nursing Homes

Purpose of Briefing Session Understand the relevance of the Single Assessment Process to residential and nursing homes 1.What is Single Assessment and what is Person Centred Care 2.Be clear as to what residential/nursing home can expect of external agencies/ professionals re Single Assessment 3.Be clear as to what external agencies/ professionals expect of residedntial/nursing home re Single Assessment 4.How the Service User Held Record is used

Nurses Adult Care Services GPs & Clinicians Acute based & Community Therapists Res/Nursing Homes + Other Organisations

Adult Care Services GPs & Clinicians Acute based & Community Therapists Nurses Res/Nursing Homes + Other Organisations

Nurses Acute based &Community Therapists Adult Care Services GPs & Clinicians Res/Nurse Homes + Other Orgs

The Cautionary Tales of unintegrated assessment and services 1.In small groups, tell story of recent lack of integration between res/nursing home and other agencies/professionals which made the service to user go pear-shaped 2.Write key reasons on separate post-it notes 3.Write on post-it notes the motto, prayer, slogan of the new world where the problem would have been overcome or not arisen 4.Place post-it notes on wall

What is Person Centred Care – Standard 2 of National Service Framework ‘Listen to older people’‘Listen to older people’ ‘Involve and support carers when necessary’‘Involve and support carers when necessary’ Enable older people/carers to make informed decisions through adequate informationEnable older people/carers to make informed decisions through adequate information Provide ‘proper assessment …. and prompt provision of care ….. to reduce emergency hospital admission and premature admission to a residential care setting’Provide ‘proper assessment …. and prompt provision of care ….. to reduce emergency hospital admission and premature admission to a residential care setting’ Older people should determine the level of personal risk they are prepared to takeOlder people should determine the level of personal risk they are prepared to take Carers need information/advice about the condition of the person they are caring for, what they can do, and the services availableCarers need information/advice about the condition of the person they are caring for, what they can do, and the services available

What is the Single Assessment Process National Service Framework for Older People Standard 2: Person Centred Care 1.A single approach to assessing health and social care needs 2.Starts from the service user’s perspective 3.Assessment appropriate to need 4.Professionals contribute to each others assessment 5.Culturally sensitive assessments 6.Coordinated Care Plan (agreed by individual) 7.Implementation by April 2004

Assessment “A process whereby the actual or potential needs of an individual are identified and their impact on independence, daily functioning and quality of life evaluated, so that action can be planned.” DoH

The 4 Types of Assessment in the Single Assessment Process Contact Overview Specialist Comprehensive

Contact Assessment 1.First point of contact with health or social care 2.Collection of basic personal information 3.Presenting difficulties, risks and significant life events explored 4.Emphasis on service user/carer perspective 5.Obtain explicit consent for sharing information

Overview Assessment 1.More holistic assessment when there is more than just one simple health or social care need 2.Covers 9 domains (areas of need) to ensure that treatable conditions are not missed –Disease prevention –Physical care and well being –Senses –Mental health –Relationships –Environment 3.May identify need for further in-depth assessment by specialist 4.Identifies risks in more detail

Specialist Assessment 1.Need for specialist assessment identified either at contact or overview stage 2.Way of exploring specific needs in depth by one or more professionals 3.Specialist assessor has specialist skills in the area concerned, e.g. –Nursing –Physiotherapist –Occupational therapist –Social work 4.Outcome contributes to Single Assessment Summary and Care Plan

Comprehensive Assessment 1.Required when level of support & treatment is likely to be intensive or prolonged 2.Specialist assessments in all or most of 9 domains 3.Always multi-disciplinary and multi- professional input 4.Required when older person may need permanent care or complex care packages at home 5.Should provide detail needed for RNCC 6.Coordinated summary of needs & care plan

Making the links with the minimum care standards for Care Homes (1) ‘The key must be the choice and the opportunity to exercise choice (in choosing a home). This can only be achieved if full information is provided’ ‘No service user moved into the home without having had his/her needs assessed and been assured that these will be met’ ‘New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective user …… and relevant professionals have been party’

The minimum care standards for Care Homes (2) ‘For individuals referred through Care Management arrangements, the registered person obtains a summary of the Care Management (health and social services) assessment and a copy of the Care Plan produced for care management purposes’ ‘Services users and their representatives know that they home they enter will meet their needs’ Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home’

The minimum care standards for Care Homes (3) ‘What is found during the assessment process should be put in the service user’s plan… Care must be delivered in accordance with the … plan. Thus the plan becomes the yardstick for judging whether appropriate care is delivered ….. It is a dynamic document which will change as regular assessment of the resident reveals changing need’

Care coordination & residential/ nursing care 1.Care coordinator to oversee that comprehensive assessment includes all the necessary specialists 2.Ensure various assessments are integrated in Single Assessment Summary and Care Plan 3.Ensure user & carer understand the position re res/nursing home 4.Facilitate user/carer to make informed choice re choice of home 5.Encourage visit 6.Ensure home is given SA Summary and Care Plan and the detailed assessments so can judge whether can deliver what is required

Exercise: Dependence on other agencies/professionals Discuss in small group –What do you require of Single Assessment and Person Centred Care to fulfil your minimum care standards –What currently goes wrong –What changes could be made Write findings on flip chart for plenary discussion

Information sharing Principle of information sharing with users, carers and other professionals Consent to share at contact, overview and specialist assessments User knows the repercussions of not sharing Sharing with carers

Service User Held Record 1.To develop open partnership with service user, putting them and carers at centre of care 2.To enable the user to share their information with other services 3.To ensure a coordinated approach to planning and service delivery 4.To enable all professionals involved to contribute their expertise in an integrated manner 5.For all visiting professionals to record their input

Information sharing discussion What are the issues for information sharing with users, carers and other professionals/ agencies?

Health/social involvement/reliance on your residential/nursing service THE SCENARIOS 1.Input to resident from other professionals e.g. DNs, therapists 2.Referrals to external agencies professional/clinics etc 3.Admission to hospital 4.Change in circumstances requiring reassessment 5.Discharge for complex community package or to another home

Health/social involvement/reliance on your residential/nursing service THE ACTIONS 1.Up to date Care Plans 2.Up to date Service User Record for use at time of referral or contact with other agencies 3.Involvement of resident & relatives in any changes 4.Assist with information and understanding by user/carer as to current position and the purpose of referral/change 5.Assist understanding by external professional/ agency providing service and to give relevant information

Exercise: Dependence by other agencies/professionals on Residential/ Nursing Home 1.Discuss in small group –What do you see as the requirements of the other agencies/professionals –What currently goes wrong –What changes could be made 2.Write findings on flip chart for plenary discussion

Nurses Acute based &Community Therapists Adult Care Services GPs & Clinicians Res/Nurse Homes + Other Orgs

The key learnings for residential and nursing homes from single assessment briefing What are they? How will they impact on future action within the home?