Hertfordshire Single Assessment Process

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Hertfordshire Single Assessment Process

• Briefing Sessions
• For
• Residential and Nursing Homes

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Purpose of Briefing Session

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

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

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What is Person Centred Care Standard 2 of
National Service Framework

• Listen to older people
• Involve and support carers when necessary
• Enable 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
• Older 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 available

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What is the Single Assessment Process

• National Service Framework for Older People
  Standard 2 Person Centred Care
• A single approach to assessing health and social
  care needs
• Starts from the service users perspective
• Assessment appropriate to need
• Professionals contribute to each others
  assessment
• Culturally sensitive assessments
• Coordinated Care Plan (agreed by individual)
• Implementation by April 2004

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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

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The 4 Types of Assessment in the Single
Assessment Process

• Contact
• Overview
• Specialist
• Comprehensive

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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

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Overview Assessment

• More holistic assessment when there is more than
  just one simple health or social care need
• 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
• May identify need for further in-depth assessment
  by specialist
• Identifies risks in more detail

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Specialist Assessment

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

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Comprehensive Assessment

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

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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

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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

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The minimum care standards for Care Homes (3)

• What is found during the assessment process
  should be put in the service users 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

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Care coordination residential/ nursing care

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

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Exercise Dependence on other agencies/professiona
ls

• 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

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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

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Service User Held Record

• To develop open partnership with service user,
  putting them and carers at centre of care
• To enable the user to share their information
  with other services
• To ensure a coordinated approach to planning and
  service delivery
• To enable all professionals involved to
  contribute their expertise in an integrated
  manner
• For all visiting professionals to record their
  input

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Information sharing discussion

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

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Health/social involvement/reliance on your
residential/nursing service

• THE SCENARIOS
• Input to resident from other professionals e.g.
  DNs, therapists
• Referrals to external agencies professional/clinic
  s etc
• Admission to hospital
• Change in circumstances requiring reassessment
• Discharge for complex community package or to
  another home

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Health/social involvement/reliance on your
residential/nursing service

• THE ACTIONS
• Up to date Care Plans
• Up to date Service User Record for use at time of
  referral or contact with other agencies
• Involvement of resident relatives in any
  changes
• Assist with information and understanding by
  user/carer as to current position and the purpose
  of referral/change
• Assist understanding by external professional/
  agency providing service and to give relevant
  information

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Exercise Dependence by other agencies/professiona
ls on Residential/ Nursing Home

• 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
• Write findings on flip chart for plenary
  discussion

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