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INTEGRATED CARE PATHWAYS GUIDE 9: SINGLE SHARED ASSESSMENT FOR DRUG USERS

Effective Interventions Unit
Substance Misuse Division
Scottish Executive
St Andrew's House
Edinburgh EH1 3DG
Tel: 0131 244 5117 Fax: 0131 244 3311
EIU@scotland.gsi.gov.uk
http://www.drugmisuse.isdscotland.org/eiu

WHAT IS THE PURPOSE OF THIS GUIDE?

This is the ninth in a series of guides on developing and implementing Integrated Care Pathways (ICPs). This guide has been produced to assist practitioners, managers and commissioners in reviewing the way that they design, record and deliver screening and assessment services to people with drug problems. It will assist local groups to analyse current practice in their area, identify areas for improvements, and re-design parts of the pathway which do not meet identified standards.

WHO SHOULD READ IT?

Everyone involved in the design and delivery of care and treatment services to people with drug problems. It might also be of interest to service users and carers.

Background

One of the key drivers for development of the assessment process for people with drug misuse problems is the Scottish Executive's Joint Future agenda. The aim of Joint Future is to improve partnership working between agencies (through joint resourcing and joint management) and to secure better outcomes for service users and their carers.

The Joint Future Group identified the need to improve assessment systems and results. It concluded that the assessment systems, far from being the cornerstone of community care, were neither consistent, nor effective, nor efficient. They were bureaucratic, engaged with the individual on too many occasions, and were often repeated because of professionals' reluctance to accept the views of others. Moreover, their content and results were inconsistent.

The Assessment Review Co-ordinating Group (ARCG) was set up in response to practitioners' request for consistent definitions for single shared assessment (SSA) across agencies and across Scotland to support local and national Joint Future developments, particularly in the context of information sharing. Following a national seminar to promote greater integration, the ARCG began to co-ordinate the systematic preparation, dissemination and implementation of national standards that will cover all care groups and processes relating to assessment and care management. The minimum information standards for older people were published in December 2004 Circular CCD 15/2004. The circular is available on http://www.scds.org.uk/scds/files/ARCGOlderPeopleMinimumStdV1.doc.

What is assessment?

Effective assessment is an ongoing process, not a one-off event. It seeks to identify the range and level of needs of the individual, not only problems with drug misuse but also health, social and economic circumstances (where appropriate). It explores the individual's attributes and aspirations. The outcome should be informed decisions about treatment, care and support that are regularly reviewed and revised as necessary. Single shared assessment creates a single point of entry to community care services and will lead to better use of resources and more effective outcomes for people in need. The Joint Future Unit (JFU) states that in order to achieve this, "Agencies should put in place single shared assessment processes and a single shared assessment tool. This should be done through the development of joint protocols to ensure agreement locally in the systems for and ownership of assessments and the provision of joint training for staff in assessment practice" ¹.

WHY AN ICP?

ICPs can ensure the care process is better monitored and streamlined for the majority of people in a given client population. ICPs provide clients with more consistent care/service, by minimising variations in practice. Since ICPs are based in part on previous cases, providers are better equipped to predict aspects of the care process (including milestones, complications and outcomes), and improve the quality of care provided to the next service user with the same problems. This guide sets out a number of key issues that should be considered when developing an ICP for single shared assessment.

Working with others

Single shared assessment is a multi-disciplinary, multi-agency process. Developing this ICP requires local services providers to consider the roles and potential roles of other providers. Previous guides in this series have stressed the importance of ensuring that all those who have, or could have a role, in the assessment, care planning and delivery of care are involved at the earliest opportunity. These stakeholders would include service users and carers as well as practitioners and service managers.

Early discussions should focus on exploring each other's roles and remits, including statutory responsibilities and limitations. It is important to acknowledge that, in some cases, an agency may be unable to participate or contribute because of philosophical differences or funding restrictions. This acknowledgement is an important outcome at this stage of the process.

All service providers should be aware of who else may be involved in the pathway, understand their position with regards to their background, philosophy of care and any limitations on when and how they could respond; for example, minimum age restrictions, only work with ex-prisoners, not able to take people who are still using illicit drugs.

Similarly, services will need to be willing to trust the judgement of partner agencies and respect the decisions that they take. They should identify shared or common values and ensure that the language (or jargon) that they use is acceptable to all and does not alienate others, such as users and carers, from the discussions.

Earlier guides have stressed the importance of having ICP champions. These are individuals who emerge as having the drive, enthusiasm, knowledge and respect of others required to drive forward the change process. This is particularly important in a multi-agency process such as SSA.

PROCESS MAPPING AND PATHWAY RE-DESIGN

ICP Guide 2 sets out the reasons why it is important to review current practice and explains the function of process mapping. For single shared assessment it is important that agencies can identify areas where the client's journey could run smoother than it currently does. One such area might be the referral and screening system, agencies should explore the way in which referrals are made, examine the appropriateness of current referrals and understand the decision-making processes of referrers.

The result should be an agreed referral and screening system, which gets the client to where they need to be by the shortest possible route. This should set out the different levels and types of assessment identified by JFU; namely Simple, Comprehensive and Specialist, with identified protocols stating how and when these should be utilised.

As peoples' circumstances or level of motivation change, their care plan should be flexible enough to accommodate changes to the way treatment and care is provided e.g. crisis intervention. The SSA ICP should have identified entry and exit points, from and to other pathways as identified in ICP Guide 4.

Re-design should ensure that the shared assessment process facilitates access to appropriate services. Protocols should be developed to clarify the relationship between assessment and care management, for example, criteria for authorising access to high cost interventions such as access to residential rehabilitation programmes.

INFORMATION SHARING

The local ICP development group should establish what information is required at each point of the assessment process. Core data sets for drug users were developed by the Effective Interventions Unit (EIU) in 2002 in collaboration with JFU and published in Integrated Care. These cover socio-demographic information, health, housing, employment history, income/benefits as well as the nature and scale of drug misuse. These provide a minimum standard for the collection of data as part of the assessment process.

If such information were available to all the relevant parties, it would benefit clients who would not experience the frustration of answering the same question on several occasions. It would also offer reassurance that the 'system' knows about them and is actively pursuing their care. Agencies should consider developing information sharing protocols which will let practitioners and service users know exactly what can be shared, with whom and when.

ASSESSMENT TOOLS

Assessment tools are used in a range of sectors to aid the assessment process. They are instruments developed by practitioners or academic institutions that facilitate the collection of information in a systematic fashion. Outcomes of assessment can be measured, contrasted and compared in order to assist the practitioner and the client in identifying the nature and extent of problems and measure the 'distance travelled'.

In 2003, the EIU published Digest of tools used in the assessment process and core data sets. This document provides detailed information on a range of assessment tools and their potential use in simple, comprehensive and specialist assessments. It sets out the purpose of each tool along with its client group, administrative issues including copyright, training requirements and research evidence.

The local ICP development group should identify what assessment tools should be adopted or adapted as part of the single shared assessment for drug users. This may include a combination of locally developed tools and validated tools. These should be fit for purpose and provide useful measures of the nature and extent of problems, the client's perception of problems, their readiness to change and the identification and reduction of risk to the client and to others. Depending on what tools are chosen, the group should consider the need for a training plan to help practitioners familiarise and understand how to use and score the instrument.

MONITORING AND EVALUATION

The variance tracking and recording section of ICP Guide 4 explains the rationale behind recording the reasons why an individual's care does not follow. This information can be used, not only to evaluate the care of the service user but also to analyse how well the pathway is functioning.

Local services should consider the need for a protocol for monitoring cases where the care needs identified through the SSA process are not available, resulting in unmet need(s).

The table below sets out the minimum standards for the assessment process contained in the JFU guidance on single shared assessment in community care. These are designed to ensure that local SSA arrangements are meeting the required national standard. Partnership's tools and processes will be evaluated against the Minimum Information Standards by ARCG. The timeframe for specialist drug and alcohol services has yet to be agreed.

SELF ASSESSMENT OF PROGRESS

In order to help agencies plan implementation, JFU have drawn up a self-assessment checklist. The essence is to map out the expected pattern of information for local use. It should record how key steps have been achieved, how progress to date has been developed, and how it is planned to address key steps not yet underway.

Joint health and local authority bodies across Scotland are at different stages of implementing single shared assessment for drug (and alcohol) users to meet national requirements. Different tools, processes and models are being developed and have been implemented to suit local area needs and circumstances.

USEFUL LINKS

Integrated Care for Drug Users: Principles and Practice
http://www.drugmisuse.isdscotland.org/eiu/intcare/intcare.htm

Digest of tools used in the assessment process and core data sets
http://www.scotland.gov.uk/library5/health/dtap-00.asp

Joint Future Agenda: Single shared assessment
http://www.scotland.gov.uk/Topics/Health/care/17673/9484

Footnote

1 Scottish Executive Circular CCD 8/2000, Single shared assessment of community care needs

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