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HSC Transformation
SDS Care Management Pathway
Barry Scrase Project Manager
J u l y 2 0 1 2
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
Care Direct
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
HospitalSocial Work
Team
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
Multi Agency Transitions Team
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team Short Term Services
6-week involvement
STAR Action Plan
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team Existing service users receiving
a review
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
TeamInformation for SDS
shared with individual (including SDS Questionnaire)
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
Carer’s Deflator Question asked
Carer’s Assessment offered
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
Practitioner completes assessment on PARIS including information
from carer.
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
Indicative Personal Budget
agreed with Team Manager
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
Financial assessment
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Support Planning(next slide)
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
Interim services
SDS PathwayAssessment
Care Direct
Short Term Services
6-week involvement
STAR Action Plan
Hospital
Social Work Team
Overview Assessment
eligibility
YES
NO
Eligibility Screening
NO
STAROverview
Assessment eligibility
NO
YES
YES
Carer’s Deflator Question asked
Carer’s Assessment offered
Visit from practitioner to complete assessor’s
view on SDS Questionnaire and
commence Practitioner Assessment
Information for SDS shared with
individual (including SDS Questionnaire)
Practitioner completes assessment on PARIS including information
from carer.
Existing service users receiving
a review
Copy of assessment to
service user and copy of carer’s assessment to
carer
Financial assessment
Signposting to other services and contacts
Indicative Personal Budget
agreed with Team Manager
Interim services
Eligibility for service
assessed
Review(separate process)
NO
YES
New service users Existing service users
SDS Starts
Carer’s Assessment
If taken up
Multi Agency Transitions
Team
Support Planning(next slide)
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YES
Case Discussion
ForumNO
Inform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YESNOInform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
Develop Plan
Case Discussion
Forum
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YESNOInform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
SW/ARC with funding Team
Manager discuss to agree Support
Plan
Case Discussion
Forum
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YESNOInform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
Team Manager
authorises
Case Discussion
Forum
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YESNOInform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
Review(separate process)
Case Discussion
Forum
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YESNOInform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
Risk
Over indicative budget
Differences of view
Case Discussion
Forum
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YES
Case Discussion
Forum to decide
NOInform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
Case Discussion
Forum
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YESNOInform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
Inform service
user
Case Discussion
Forum
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YESNOInform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
CDF agrees
Case Discussion
Forum
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YESNOInform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
Review(separate process)
Case Discussion
Forum
Individual
Family/Carer
Social WorkerARC/CPN
Independent Planner
Summary Plan
SW/ARC/CPN
Develop Plan
Put onto
PARIS
NO
YES
Team Manager
authorises
Risk
Not enough information
Not robust
back to plan
Risk
Over indicative budget
Differences of view
SW/ARC with funding Team
Manager discuss to agree Support
Plan
YESNOInform service
user
CASE DISCUSSION FORUM FUNCTION
Consistency
Enabling
Solutions options
Publish learning
Decisions
Risk enablement
Consider cost
CDF agrees
Review(separate process)
back to plan
SDS PathwaySupport Planning
Case Discussion
Forum
Any Questions?
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