Implementing the Single Assessment Process across the South West Peninsula Basic awareness

What is the Single Assessment Process (SAP) ? Originated from the National Service Framework (NSF)Older People Standard 2: Person Centred Care - a single agreed approach to assessment for health /social care -type of assessment is appropriate to needs -agencies do not duplicate assessment -effective contribution by range of professionals/agencies - resulting in a single holistic service or care plan -contributed to and agreed by all (including the person)  In South West Peninsula SAP will cover all adults 18+ except mental health

Who will be using SAP? All health &social staff South west peninsula partnership All organisations using same tools and eSAP system PCTs, Adult social care,acute trusts For full list of partners see SAP website

“Don’t you people talk to each other?!”

National guidance “Provides a rigorous framework that will lead to convergence of assessment methods and results over time irrespective of the tools chosen for local use”

What is an assessment? involves the gathering of information about the health and social status of the user, analysis of that data, and the making of a professional judgement to meet the user’s need Within SAP this is carried out with the service user

SAP 4 types of assessment Contact Overview Specialist Comprehensive

Contact Assessment Not every contact needs one initial contact if needs recording multi-agency referral form basic personal information difficulties, risks & significant life events any staff member who is trained not necessarily professionally qualified staff may be partially completed by one person

Overview More detailed assessment At any stage in SAP More complete picture of an individual Incorporates core information Includes information on providers/agencies Risk triggers Identifies need for further assessment

Specialist Specific difficulties identified at contact/overview One or more specialist professionals Unstable,unpredictable or complex needs Specialist tools/scales/measures -each profession Examples of specialist assessments : The SAP Health needs assessment (HNA) is the only specialist assessment in place across the SWP and on eSAP – other specialist assessments will be carried out on existing tools or using FACE second line tools but not on eSAP) – eg Care programme Approach for mental health, Housing, Speech & language etc

Comprehensive ( in the SWP a process not a tool) Contributions from different professionals / teams Co-ordinated by appropriately skilled professionals Evidence base for detailed care planning Includes all domains of overview / specialist Intensive & prolonged level of support / treatment Complex care packages - e.g. intermediate/residential care

Care Plan Care is joint agency and identifies what care or treatment is in place and who is providing this. Contingency plan for emergencies Diary Sheet

Review All care plans should have review date set A review should take place with the person and their carer The review tool is to record this and set next review date

Making the links with SAP Managing long term conditions Falls Mental health and specialties Continuing Care/Funded nursing care Intermediate Care Delayed discharge Medicines Fair access to Care (FACS) Person centred one assessment across health & social care it can impact on all this and more….

Projecting & Sharing Information Don’t you people talk to each other! Information can be shared providing the service user has given written or verbal consent and this is recorded on: “ Consent to share and protect your information form Agreed protocol across the health & social care agencies in SWP

What is eSAP? SAP can’t work without IT! eSAP enables assessment and care plan information to be stored electronically, shared with professionals across health and social care and sent to each other This is possible using your own computer and your organisation's IT system Web based browser- very safe & secure

Benefits of eSAP Reduction in delayed transfers of care -Improved communication and better access to information Reduction in unplanned admissions -Better information should lead to improved risk management decisions and unnecessary admissions to hospital Better use of workforce -Reduce duplication and staff time spent in recording. -Easier and faster transfer of information between agencies. -More appropriate use of skills Less faxing, photocopying, storage

Personal held record This is a folder ( usually yellow) held in person’s home and issued by PCT Contains SAP documentation, communication diary and useful self-care information Enables professionals to communicate Service user and carer kept informed Useful for emergencies Will be flagged on eSAP so know it is in place Anyone can suggest one is issued providing meet the criteria as follows:

Criteria for Personal held record complex care packages delivered in own home treatment and care by a number of practitioners / agencies known to request frequent unscheduled care from their GP (including out of hours services) or their district nurse have required a number of unscheduled admissions to hospital at ‘risk’ of needing emergency care managed for a ‘long term condition’ or ‘complex care pathway’ palliative diagnosis including malignant or non-malignant

Single Assessment Process For further information contact: Heather Eardley/Jude Anthonisz/Bruce o’Connor SAP Programme Team Tel: Website address: