Hertfordshire Single Assessment Process

Briefing Sessions

For

Residential and Nursing Homes

Purpose of Briefing SessionPurpose of Briefing Session

Understand the relevance of the Single Assessment Process to residential

and nursing homes1. 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

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The Cautionary Tales of The Cautionary Tales of unintegrated assessment and unintegrated assessment and

services 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 notes3. 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 What is Person Centred Care – Standard 2 of National Service Frameworkof National Service Framework

• ‘‘Listen to older people’Listen to older people’• ‘‘Involve and support carers when necessary’Involve and support carers when necessary’• Enable Enable older people/carers to make informed older people/carers to make informed

decisions through adequate information decisions through adequate information • Provide ‘proper assessment …. and prompt Provide ‘proper assessment …. and prompt

provision of care ….. to reduce emergency provision of care ….. to reduce emergency hospital admission and premature admission hospital admission and premature admission to a residential care setting’to a residential care setting’

• Older people should determine the level of Older people should determine the level of personal risk they are prepared to take personal risk they are prepared to take

• Carers need information/advice about the Carers need information/advice about the condition of the person they are caring for, condition of the person they are caring for, what they can do, and the services availablewhat they can do, and the services available

What is the Single Assessment ProcessWhat 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 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 RNCC6. Coordinated summary of needs & care plan

Making the links with the minimum Making the links with the minimum care standards for Care Homes (1)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 The minimum care standards for Care Homes (2)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 The minimum care standards for Care Homes (3)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

1.1. Care coordinator to oversee that comprehensive Care coordinator to oversee that comprehensive assessment includes all the necessary specialistsassessment includes all the necessary specialists

2.2. Ensure various assessments are integrated in Ensure various assessments are integrated in Single Assessment Summary and Care PlanSingle Assessment Summary and Care Plan

3.3. Ensure user & carer understand the position re Ensure user & carer understand the position re res/nursing homeres/nursing home

4.4. Facilitate user/carer to make informed choice re Facilitate user/carer to make informed choice re choice of homechoice of home

5.5. Encourage visitEncourage visit

6.6. Ensure home is given SA Summary and Care Plan Ensure home is given SA Summary and Care Plan and the detailed assessments so can judge and the detailed assessments so can judge whether can deliver what is requiredwhether 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 RecordService User Held Record

1.1. To develop open partnership with service user, To develop open partnership with service user, putting them and carers at centre of careputting them and carers at centre of care

2.2. To enable the user to share their information To enable the user to share their information with other serviceswith other services

3.3. To ensure a coordinated approach to planning To ensure a coordinated approach to planning and service deliveryand service delivery

4.4. To enable all professionals involved to To enable all professionals involved to contribute their expertise in an integrated contribute their expertise in an integrated mannermanner

5.5. For all visiting professionals to record their For all visiting professionals to record their inputinput

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 hospital4. Change in circumstances requiring

reassessment5. 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 Plans2. Up to date Service User Record for use at time of

referral or contact with other agencies3. Involvement of resident & relatives in any changes4. 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

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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?