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 2Person-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:Solution:A unified way of doing assessments and care planning

Problem: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 PROCESSWho is

involved?Users and CarersVoluntary Sector

Primary Care, Acute Trusts, mental health

Adults & Community Care Services

Borough Councils Housing & Community Services

Ambulance Service

SAP – making it work

shared valuescommon terminology & tools

accepting other staffs assessmentskey worker responsibility

understanding servicesperson-centred approach

3. Specialist Assessments

SAP – structure4 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 - ConclusionSAP is:

a co-ordinated single structure for Assessment & Care Planning

patient - centred care (NSF Standard 2)

SAP - ConclusionSAP will improve patients’ experience:

less duplication and confusion

better co-ordination between agencies

SAP - ConclusionSAP means better use of resources:

less duplication of work through sharing and communication

“more care, less paperwork”

Before Introduction of SAPOlder

Person

Health Problem

Significant Health Episode

Crisis Health Episode

GP Advice & MedicationPatientNotes

GP Referral To OutpatientsPatientNotes

GP Refer To District NursePatientNotes

AdvisoryOfficerFACs

ContactAssessment

Refer to care manager eligible?

CareManagerCommunity

CareAssessment

Refer to Borough Council

DayCentre

Manager

HousingOfficer

HousingAssessment

Day CentreAssessment

DistrictNurseVisits

Nursing Needs

Assessment

Refer To Social Care Team

After Introduction of SAPOlder

Person

Health Problem

Significant Health Episode

GP Advice & MedicationPatientNotes

DistrictNurseVisits

CONTACT ASSESSMENTOVERVIEW ASSESSMENT

SPECIALIST Nursing Assessment

GP Referral To OutpatientsPatientNotes

Referral To District NurseFor CONTACT ASSESSMENT

Care ManagerVisits

SPECIALISTCommunity

CareAssessment

AdvisoryOfficer

Borough CouncilDay

CentreManager

FACsContact

Assessment

HousingOfficer

SPECIALISTHousing

Assessment

SPECIALISTDay Centre

Assessment

Before Introduction of SAPOlder

Person

Health Problem

Significant Health Episode

Crisis Health Episode

GP Advice & MedicationPatientNotes

GP Referral To OutpatientsPatientNotes

GP Refer To District NursePatientNotes

AdvisoryOfficerFACs

ContactAssessment

Refer to care manager eligible?

CareManagerCommunity

CareAssessment

Refer to Borough Council

DayCentre

Manager

HousingOfficer

HousingAssessment

Day CentreAssessment

DistrictNurseVisits

Nursing Needs

Assessment

Refer To Social Care Team

Thanks For Listening!