Older People’s Services The Single Assessment Process

WHY? Ageing population - over 65’s doubled in last 25 years Government Older People’s NSF - improve quality of care - improve consistency of care Older People use nearly half of Health and Social Care resources

NSF Standard 2 Person-centred Care Older people treated as individuals Enabled to make choices about their own care Achieved through: - the Single Assessment Process - integrated commissioning arrangements - integrated provision of services

SINGLE ASSESSMENT PROCESS Solution: A unified way of doing assessments and care planning Problem: “Don’t you people talk to each other, it wastes everyone’s time!”

SINGLE ASSESSMENT PROCESS Coordinated assessment & integrated working among agencies supports: Independence Fewer emergency hospital admissions Fewer delayed transfers of care and helps avoid premature admission to a...residential care setting

SINGLE ASSESSMENT PROCESS SAP means: a single approach to assessing health and..social care needs assessment is proportional to needs agencies don’t duplicate assessments a single holistic service or care plan all agencies contribute the views of the older person and their carers are central

SINGLE ASSESSMENT PROCESS Who is involved? Users and Carers Voluntary Sector Primary Care, Acute Trusts, mental health Adults & Community Care Services Borough Councils Housing & Community Services Ambulance Service

SAP – making it work shared values common terminology & tools accepting other staffs assessments key worker responsibility understanding services person-centred approach

3. Specialist Assessments SAP – structure 4 stages of assessment, plus summary 2. Overview Assessment 4. Comprehensive Assessment 1 Contact Assessment (including Basic Personal Information)

SAP – Information structure

SAP – Contact Assessment not every contact needs one include basic personal information initial contact where significant needs are first described or suspected current difficulties, risks & significant life events by any trained staff member, not necessarily professionally qualified informed consent to share results

SAP – Contact Assessment Basic Personal Information Seven key aspects of the persons ….needs recorded in their own words 1. What is the main need?. 2. How significant? 3. How long? 4. Possible solutions? 5. Other needs? 6. Recent life events? 7. The perceptions of family members …& carers?

SAP - Overview Assessment risk triggers identifies need for further assessment by front line professionals from Health, Social Care and Borough Councils health ‘domains’ assessed by health professionals More detailed assessment - more complete picture of an individual at any stage in SAP

SAP - Overview Assessment Domains User’s perspective Clinical Background Disease prevention Personal care and physical well-being Senses Mental Health Relationships Safety Immediate environment and resources

SAP Specialist Assessment Specific difficulties identified at Contact or Overview, or via other referral Unstable, unpredictable or complex needs Specialist tools / scales / measures - each profession’s own e.g. therapy, nursing, MH, social care, housing

SAP Comprehensive Assessment when Specialist Assessments are indicated in most domains Overview Assessment may be done as well co-ordinated by appropriately skilled professional - led by consultants when intensive & prolonged level of support or treatment is likely complex packages, care home or intermediate care

SAP – Single Assessment Summary An agreed single summary for the collection of information on older people Completion whether services provided or not after each assessment 3 components: - basic personal information - needs and health summary - summary of care plan

SAP - Implementation joint responsibility of Health & Social Care datasets (forms) integrated working practices computer systems information governance training

SAP - Conclusion SAP is: a co-ordinated single structure for Assessment & Care Planning patient - centred care (NSF Standard 2)

SAP - Conclusion SAP will improve patients’ experience: less duplication and confusion better co-ordination between agencies

SAP - Conclusion SAP means better use of resources: less duplication of work through sharing and communication “more care, less paperwork”

Before Introduction of SAP Older Person Health Problem Significant Health EpisodeCrisis Health Episode GP Advice & Medication Patient Notes GP Referral To Outpatients Patient Notes GP Refer To District Nurse Patient Notes Advisory Officer FACs Contact Assessment Refer to care manager eligible? Care Manager Community Care Assessment Refer to Borough Council Day Centre Manager Housing Officer Housing Assessment Day Centre Assessment District Nurse Visits Nursing Needs Assessment Refer To Social Care Team

After Introduction of SAP Older Person Health Problem Significant Health Episode GP Advice & Medication Patient Notes District Nurse Visits CONTACT ASSESSMENT OVERVIEW ASSESSMENT SPECIALIST Nursing Assessment GP Referral To Outpatients Patient Notes Referral To District Nurse For CONTACT ASSESSMENT Care Manager Visits SPECIALIST Community Care Assessment Advisory Officer Borough Council Day Centre Manager FACs Contact Assessment Housing Officer SPECIALIST Housing Assessment SPECIALIST Day Centre Assessment

Before Introduction of SAP Older Person Health Problem Significant Health EpisodeCrisis Health Episode GP Advice & Medication Patient Notes GP Referral To Outpatients Patient Notes GP Refer To District Nurse Patient Notes Advisory Officer FACs Contact Assessment Refer to care manager eligible? Care Manager Community Care Assessment Refer to Borough Council Day Centre Manager Housing Officer Housing Assessment Day Centre Assessment District Nurse Visits Nursing Needs Assessment Refer To Social Care Team

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