Sharing Assessment in Health and Social Care: A Practical Handbook for Interprofessional Working

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Carolyn Wallace & Michelle Davies

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    Acknowledgements

    We would like to thank all those people who helped us in developing and gathering the information for this book. In particualr the Florence Nightingale Travel Scholarship (Welsh Assembly Government sponsorship), Mark Culwick, Sharon Lane, Marie Nixon (Gwent Healthcare NHS Trust; Torfean LHB and Local Authority; Monmouthshire LHB and Local Authority; Blaenau Gwent LHB and Local Authority; Caerphilly LHB and Local Authority; Newport LHB and Local Authority); Rhondda Cynon Taf Local Authority; National Leadership and Innovation Agency for Healthcare for consent to use and adapt the ‘Knowledge Barometer’.

  • Appendix 1: Comparative Grid for Standardised Assessment Frameworks

    Unified Assessment (WAG, 2002)Single Assessment Process (DoH, 2002)Single Shared Assessment (Scottish Executive, 2001a)
    Self
    • Where people identify their own needs and propose their own solutions either as a sole assessment or in conjunction with other assessments
    • They may receive professional advice or the support of an advocate.
    Enquiry
    • For information only
    • Straightforward service requests
    • Leading to contact assessment
    Contact
    • Basic Personal Information
    • 7 key issues
    • 2 domains max. from the overview
    Contact
    • Basic Personal Information
    • 7 key issues
    Simple
    • Low level response
    • May involve one or more agency
    • Some coordination may be required
    Overview – 12 domains with sub-domains
    • User's perspective
    • Disease prevention
    • Personal care/physical wellbeing
    • Senses
    • Mental health
    • Safety
    • Carer's perspective/assessment
    • Clinical background
    • Activities of daily living
    • Relationships
    • Immediate environment and resources risk assessment
    • Instrumental activities of daily living
    Overview – 9 domains with sub-domains
    • User's perspective
    • Clinical background
    • Disease prevention
    • Personal care and physical wellbeing
    • Senses
    • Mental health
    • Relationships
    • Safety
    • Immediate environment and resources
    Care-Nap, an identification of need which is a tick box indicating ‘No Need’, ‘Met Need’ and ‘Unmet Need’
    • Service user's perspective
    • Carer's perspective
    • Relationships
    • Spiritual, religious and cultural matters
    • Risk and safety
    • Immediate environment and process
    • Personal care and physical wellbeing
    • Mental health
    • Clinical background
    • Disease prevention
    • Senses
    • Communication
    Specialist/in-depth
    • As defined by individual professional models, scales and local requirements
    Specialist
    • As defined by individual professional models, scales and local requirements
    Specialist
    • May be applied to simple needs of an individual or more complex needs which require more in-depth assessment
    Comprehensive
    • Includes overview and in-depth assessments appropriate to service user need. An overall interpretation gained by the care coordinator of the assessment process required by a service user with complex needs
    Comprehensive
    • A full overview assessment
    • A range of specialist assessments with partial completion of the overview as required by service user need
    • A range of specialist assessments and scales only
    Comprehensive
    • Applies where a wider range and complexity of needs are indicated
    • Likely to involve more than one agency
    • Specialist assessment may be necessary
    • Focus on coordination of assessment contributions
    • People at risk of admission to residential or nursing home care should receive a comprehensive assessment with specialist assessment and intensive care management to explore options for rehabilitation and care at home
    Role of care coordinator – identified according to patient needRole of lead assessor, care coordinator and Complex care manager
    Fair access to care
    • Directly linked to assessment process
    Fair access to care is not direclty linked to the SAP guidanceEligibility criteria linked to assessment

    Appendix 2: Mrs Pam Griffith's Carer's Assessment

    Appendix 3: Mrs Betty Mitchell's CPA Assessment

    Older Adults' Mental Health Service

    Appendix 4: Glossary of Terms

    Autonomy‘Autonomy is an intrinsic personal quality … to be able to do … anything rather than nothing … the more autonomous a person the more a person is able to do. In this context the distinction between creating autonomy and respecting it is important’ (Seedhouse, 1998).
    BPIBasic Personal Information as described by the standardised assessment frameworks. In the unified assessment process this is described as name, address, telephone number, GP, type of accommodation, tenure of accommodation, date of birth, preferred first language, ethnicity, etc. (WAG, 2002, Annex 4).
    Care ManagementThe processes undertaken by social services to assess service user needs through care planning and provision of appropriate care packages.
    Care Programme ApproachThe formalised process for assessing and managing the needs of people with mental health problems.
    CPNCommunity Psychiatric Nurse.
    DoHDepartment of Health.
    EmpowermentBuild on strength to encourage and promote choice.
    Independent Living‘Independent Living means that we want the same control and the same choices in everyday life that our non-disabled brothers and sisters, neighbours and friends take for granted. We want to grow up in our families, go to the neighbourhood school, use the same bus, work in jobs that are in line with our education and abilities. Most importantly, just like everybody else, we need to be in charge of our own lives, think and speak for ourselves’ (European Network on Independent Living).
    Identifying Risk‘Assessing the chance or probability of a disease or condition occurring’ (Naidoo and Wills, 2005).
    Health needA health need is either subjective or objective. A subjective need is defined by an expert and is usually influenced by whether the need can be met. While an objective need is viewed as something which may be viewed as a fundamental right (Naidoo and Wills, 2005).
    Learning disability‘A significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with; a reduced ability to cope independently (impaired social functioning); which started before adulthood, with a lasting effect on development’ (DoH, 2001, p. 14).
    Learning difficultiesThe preferred term of the self advocacy movement. Often the term used to define educational difficulties, but used interchangeably with ‘learning disability’.
    National Service Framework for Older PeopleThe document which sets out the national standards for health and social care provision for older people.
    Need
    • Normative need is need which is identified according to a norm (or set standard); such norms are generally set by experts, for example, eligibility for services.
    • Comparative need concerns problems which emerge by comparison with others who are not in need.
    • Felt need is need which an individual feels, a need from the individual's perspective.
    • Expressed need is the need which an individual or a group of people say they have. An individual can feel need which s/he does not express.

      (Bradshaw, 1972)

    Overview AssessmentThe holistic assessment as integral to the Single Assessment Process which provides a synopsis of a person's health and social care needs as proportionately mapped to the relevant assessment domains.
    Person-Centred PlanningThe planning process based on inclusion and the social model of disability.
    WAGWelsh Assembly Government.

    Appendix 5: Resources

    Patient Care Record – Booklet 1; ADL Nursing Assessment; Consent to Share Information; Discharge Checklist; In Depth Nursing Assessment; Unified Assessment & Care Management Summary Record; Additional Information for Community Learning Disabilities Team; Further Personal Information – Booklet 2.

    Patient Care Record – Booklet

    ADL Nursing Assessment (To Be Completed within 24 Hours of Admission)

    Assessment Information for Discharge or Transfer

    Consent to Share Information

    Discharge Checklist

    Guide for Use of Document

    On Admission:

    • Red pages in Hospital Enquiry Booklet must be completed on admission, including initial risk assessments.

    On Assessment:

    • Yellow pages – which include the ADL Assessment & care plans must be completed within 24 hours.
    • Specialist referrals, made as appropriate.

    On Admission to Ward:

    • Hospital Enquiry Booklet 1 must be completed, information must be checked. Risk assessments and care plans to be updated. Specialist referrals, as appropriate, their summaries added to Specialist Assessment Log in Booklet 2.
    • If there are concerns re: discharge, further information in Booklet 2 must be collected, prior to discharge planning.
    • If you need to refer to social services: you will need to provide information from Booklet 1.

    On Discharge:

    • If no further intervention is required, ensure all documentation is complete & filed in the Medical Notes.
    • If further assessment or ongoing treatment is required within the community, including referral to District Nurses, ensure Booklets 1 & 2 are complete, copied and sent to the lead professional / agency on discharge.

      Consent must be obtained to share information

    On Transfer to Community Hospitals:

    • Ensure Booklet 1 is completed & Booklet 2 commenced.
    • Care plans and risk assessments will be reviewed and updated, as necessary.
    • All documentation will move with the person, to ensure a full Unified Assessment is undertaken.
    • An In Depth Nursing Assessment must be completed, as well as the Individuals and Carer Perspectives in Booklet 2. Any Specialist Assessment Summaries must be added to the Specialist Assessment Log.

    On Discharge from Community Hospitals:

    • The Summary Record (Booklets 1 and 2), plus any relevant information appropriate to continued care in the community (risk assessments) will be copied and sent to the lead professional/agency on discharge.

      Consent must be obtained to share information.

    • The In Depth Nursing Assessment and the Nursing Needs Decision Record must be completed, when starting to plan discharge. Consideration must be given to Continuing Health Care.

    Complex Needs or Trigger for Unified Assessment:

    • If person has complex needs, a full Unified Assessment is required – Booklets 1 and 2.

    Screening Triggers for a Full Unified Assessment:

    • health, social care and/or housing problems that may lead to a complex discharge
    • 3 or more hospital admissions within previous 6 months
    • people who normally reside in residential/nursing homes
    • disability, illness, mental health problems or learning disability (permanent and substantial) affecting ability with activities of daily living
    • socially isolated and/or vulnerable adults
    • history of falls
    • terminal illness

    Unified Assessment & Care Management Summary Record

    Unified Assessment Summary plus Care Plan

    Document Contents:

    • Enquiry Record
    • Additional Information for Community Learning Disabilities Team
    • Outcome of Enquiry
    • Consent
    • Additional personal details
    • Additional address information
    • Professionals involved
    • Individuals Perspective
    • Carer's Perspective
    • Domain Selection Sheet
    • Information on Domains
    • Risk Domain
    • Risk Management Plan
    • Record of specialist referrals
    • Specialist Assessment Log
    • Summary of Assessment
    • Care Co-ordinators Log
    • Mental Capacity Log
    • Care Plan
    • Review

    Additional Information for Community Learning Disabilities Team

    Outcome of Enquiry

    Consent to Share Information

    Additional Personal Details:

    Additional Address Information:

    Professionals Involved:

    Service Currently Received: Info provided by:

    Other Professionals or Agencies Used: include care co-ordinator, advocate, interpreter, dentist, optician, pharmacist etc

    UACM: Individual's Perspective

    UACM: Carer's Perspective

    UACM: Domain Selection Sheet

    UACM: Risk Domain

    UACM: Risk Management Plan

    Record of Specialist Referrals Made:

    UACM: Specialist Assessment Log

    UACM: Summary of Assessment

    Information Collected by:

    UACM: Care CO-ordinators Log

    Please give details of the current Care Co-ordinator, where the Summary Record is held, the reasons why the role of Care Co-ordinator moves to another professional, their name and contact details must be completed.

    UACM: Mental Capacity Assessment Log

    If a ‘Capacity Assessment and Best Interest Record’ has been completed for a significant decision, please summarise below:

    UACM: Statutory Review

    UACM: Individual's Perspective

    UACM: Carer's Perspective

    Medication

    In-Depth Nursing Assessment

    Use this assessment in conjunction with the relevant risk assessments.

    Consider each domain and the relevant sub domains through the assessment.

    Disease Prevention Domain:

    • Nutrition: Current diet / Swallowing ability / Difficulties chewing / Fluids / Any assistance required for eating & drinking
    • History of Blood Pressure monitoring:
    • Drinking & smoking history:
    • Exercise pattern:
    • Vaccination history: e.g., Flu
    • History of screening: e.g., Breast/cervical
    • Pattern & nature of disease/disability/illness

    Clinical Background Domain:

    • Breathing: Any difficulties with breathing / Shortness of breath, at rest or on exertion / Productive cough / Uses any equipment / Requires oxygen
    • Falls History: Any history of falls / Any injurious fall in last 1 2 months / Any fear of falling. If yes to any of these – a falls pathway will be required
    • Medical History / Diagnosis / Medication & ability to self medicate / Recent hospitalisation information should already be recorded within Booklet 1 & 2.

    Personal Care & Physical Wellbeing Domain:

    • Pain: Is there any experience of pain / Able to manage their pain / Able to express if they have pain / Does anything relieve the pain
    • Oral health: Condition of mouth – lips, gums, tongue / Own teeth / Dentures / Caps or crowns
    • Foot care: Include circulation
    • Skin condition: Pressure areas / Wounds / Ulceration / Skin rash / Oedema / Any history which could affect tissue tolerance or contribute to wound infection / Prevention – Relief of pressure.
    • Mobility: In & out of the home – level of independence / Any aids used
    • Ability to use stairs and slopes: Level of independence / Any aids used
    • Continence: Usual pattern of elimination / Urinary incontinence / Faecal incontinence
    • Sleeping patterns: Usual sleeping pattern / Difficulty sleeping / Number of pillows / Assistance required e.g., medication, special routines

    Senses Domain:

    • Speech and communication: Cognition / Understanding / Speech impaired / Any aids used
    • Sight: Glasses / Contact lenses / Visualy impaired / Blind
    • Hearing difficulties: Hearing aid / Hearing impaired / Deaf
    • Touch / Dexterity:
    • Smell / Taste:

    Activities of Daily Living Domain:

    • Washing: Hands / Face / Body
    • Bathing / Showering: Any aids used or help required
    • Grooming: Hair care / Shaving / Applying make up
    • Dressing / Undressing: Any aids used
    • Ability to access & use the toilet: Any aids used
    • Transferring: On & off toilet / On & off chair / On & off bed
    • Support needed for eating & drinking: Any aids used or help required
    • Ability & opportunity to make choices / Have control over environment:
    • Is any equipment used:

    Mental Well Domain:

    • Cognitive ability: Orientation / Memory / Wandering
    • Confusional states:
    • Depression / Worry / Anxiety / Fatigue:
    • Emotional distress / Agitation:
    • Life change: Loss / Bereavement
    • Behaviour: Inappropriate / Challenging / Aggressive – Verbal or Physical
    • Paranoia states: Unusual ideas / Delusions
    • Other emotional difficulties:
    • Circumstances in relation to substance misuse:
    • Suicide Risk: Worthing / Dices

    Safety Domain:

    • Abuse / Neglect: Risk of neglect / Abuse / Exploitation
    • Other aspects of personal safety: Ability to summon help / Awareness of danger
    • Public safety & hazards:
    • Manual Handling Assessment:
    • Vulnerable Adult / Child Protection Issues:

    Relationships Domain:

    • Carer support: Strength of caring arrangements
    • Ability to care for others: Partner / Children / Parents
    • Sex & sexuality: Personal relationships
    • Social support: Networks / Involvement in leisure, hobbies, religious groups etc.
    • Cultural awareness issues:

    Instrumental Activities of Daily Living Domain:

    • Cooking: Preparing snacks / Meals / Hot drinks
    • Heavy housework: Cleaning / Laundry
    • Shopping: For food, clothes, prescriptions etc
    • Keeping warm:
    • Care in the home: Using household appliances
    • Managing affairs: Finances / Paperwork

    Immediate Environment & Resources Domain:

    • Accommodation: Noise / heating / physical hazards / location / access
    • Level & management of finances: Need for benefit advice / Collecting pensions / Accessing cash
    • Access to local facilities & services:
    • Participating in community activities: Work / Education / Learning / Socialising
    • Transport needs: Access to car / Public transport

    Is there any other information that would be beneficial to this assessment?

    Please complete the Nursing Needs Assessment Decision Record.

    UACM: Specialist Assessment Log

    Specialists – please give details of your professional involvement, including contact details.

    UACM: Care Co-ordinators Log

    If required, please complete this log.

    On discharge, the MDT may refer to a community team for a care co-ordinator (which team will depend on presenting need). Please give details of the current Care Co-ordinator, where the Summary Record is held, the reasons why the role of Care Co-ordinator moves to another professional, their name and contact details must be completed.

    UACM: Summary of Assessment / Episode of Care

    UACM: Care Plan

    UACM: Care Plan Continuation Sheet (Number ¨ ¨)

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