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Integrated Care for drug users: Principles and practice
ANNEX 4A
Outline Framework for an Assessment Process for Drug Users
This framework has been adapted from the outline framework for assessment set out in the Beattie Report 'Implementing Inclusiveness' (Scottish Executive, 1999). While it covers some of the ground already set out in the main body of the Chapter, its aim is to
provide more detail on the key principles and components of the assessment process. It also sets out the specific items that would be covered in the three levels of assessment set out in Section 2 of the Chapter.
Principles of Assessment:
It must be open.
It must be fair and accurate.
It must be focused on the individual and not designed to accommodate the organisational structures or administrative practices of an agency.
It must respect confidentiality.
It must encourage full participation and ownership by the individual.
It must aid progression.
It should also:
Be continuous but not repetitive
Be given adequate time and care
Be carried out by competent and well-trained staff
Be designed to allow the transfer of accurate, relevant and up-to-date information
The objectives of the assessment process:
Identification of the type and level of need and the attributes and aspirations of the individual.
Agreement jointly with the individual, and other service providers as appropriate, of an action plan for treatment, care and support.
Agreed goals and arrangements for review and reassessment.
Communication of the outcome of the assessment process to the appropriate providers and the arrangement of matching provision.
The elements of the assessment process:
The assessment exercise.
The profile.
The action plan.
An assessment should be carried out:
What should it cover?
Simple assessment should cover:
The 21 items included in the Personal Information core data set.
Comprehensive assessment should cover:
The 12 sub-headings listed under the Assessed Need core data set, including detailed assessment of:
Presenting problem
Primary drug profile
Secondary drug profile
Injecting behaviour
Signs and symptoms of oversedation or withdrawal
Risk to self or others, including dependant children
Specialist assessment should cover
Detailed assessment of all data items included under the 12 sub headings of the Assessed need core data set.
Outcome of the assessment
(a) The Profile
From the assessment process, a profile of the individual could be created to cover:
The type and level of needs; drug treatment, social support, life skills
Particular circumstances e.g. family problems, emotional and behavioural problems, debt, likely to create barriers to progress
The aspirations and attributes, with particular attention to positive experiences in the past
Goals - short term and longer term
(b) Action Plan
The Action Plan draws together the outcomes of the various stages of the assessment process. It should be produced after discussion between the individual and staff who have worked with him/her and, where possible, service providers who could provide treatment, care and support. It should draw on the outcome of assessment tool(s); self-assessment by the individual; the judgement of staff; and the profile.
The Action Plan should recognise the needs, attributes and aspirations of the individual. It should offer a systematic way to support the individual to make progress towards agreed goals at a pace suitable for him/her; and to enable service provider(s) to design and deliver the appropriate treatment, care and support "package".
The action plan should specify:
The goals
The agreed treatment approach for drug use and the service provider
The actions to address other problems e.g. housing, family support, offending behaviour, personal and social skills, education and training needs
What will constitute progress and how it will be measured
Dates for reviewing progress, who will be involved and the format
The main contact
(c) Ongoing assessment and review
This should cover progress made by the individual towards goals including:
Improvements in health
Improvements in family and social functioning
Reducing criminal behaviour
Reduction in drug use
Improvements in self esteem and motivation
Movement towards employability
The individual should be offered the opportunity for self-assessment where possible as well as taking into account the use of assessment tools and professional judgement (
see Chapter 5, Planning and Delivery of Care).
A planned review should take place at regular intervals to ensure that the care plan is revised to take account of changing needs and circumstances and that service providers are meeting needs appropriately and the agreed quality standards.
(d) Training
Staff should have access to regular training in the competencies appropriate to the level of assessment that they are engaged in. There should be opportunities for multi-disciplinary training at national and local level to support the development of joint working and information sharing.
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