SWSG Guidance Package Index Ref: F1

July 1998

Chief Executives, Scottish Local Authorities

General Managers, Health Boards

Chief Executives of NHS Trusts

Directors of Social Work

Chief Social Work Officers

Directors of Housing

Chief Housing Officers

Copy to: Association of Directors of Social Work

Convention of Scottish Local Authorities

Chief Executive Scottish Homes

Director, Scottish Federation of Housing Associations

General Manager, Common Services Agency

General Manager, Health Education Board for Scotland

General Manager, State Hospitals Board for Scotland

Appropriate Professional, Voluntary and Private Sector

Organisations

Holders of SWSG Guidance Package (Circular only)

Dear Sir/Madam

COMMUNITY CARE NEEDS OF FRAIL OLDER PEOPLE: INTEGRATING PROFESSIONAL ASSESSMENTS AND CARE ARRANGEMENTS

Summary

1. This circular is addressed to local authority social work and housing departments, health boards and National Health Service (NHS) Trusts. It provides guidance on how social work, housing and health professionals [ The term "health professionals" is here taken to mean doctors, generic and specialist nurses, occupational therapists, speech therapists, physiotherapists, psychologists, dieticians, chiropodists and pharmacists.] can jointly contribute more effectively to community care assessments and care arrangements of frail older people [ Frail older people includes older people with dementia, mental illness and learning disabilities.] . Many older people requiring community care services have social care and health needs. A flexible and collaborative approach, focused on a sensitive understanding of their individual needs and circumstances serves older people best. Detailed policy and practice guidance already exists on assessment and care management (SWSG 11/91, 11/96, NHS MEL(1996)22). This guidance builds on that.

Context

2. The NHS and Community Care Act 1990 introduced sections 12A and 13A into the Social Work (Scotland) Act 1968 (the 1968 Act). These sections place duties on local authorities to carry out assessments of need and provide community care services. The local authority has the lead responsibility for securing the involvement of health and housing partners in the assessment procedure. Their complementary roles in contributing to a comprehensive care plan are important. Where agencies agree to jointly [ Jointly means that the agencies provide their respective services in tandem.] provide services to meet older people’s needs, it is easier to ensure individualised care.

3. Community care services should enable people to live as normal a life as possible in their own homes or in a homely environment in their local community. A frail older person may often be able to continue living in his or her own home, possibly after it has been suitably adapted to meet changing needs. Occupational therapists and housing colleagues can advise on this. In other cases, sheltered, very sheltered or other supported accommodation may meet the older person’s needs, provided that it has the appropriate design features, and the necessary health and social work services. The care manager should only consider a permanent move to long-stay care such as a residential or nursing home where the person’s frailty requires the 24 hour care available in that type of setting [ There will be some exceptions to this where, for example, only one partner requires residential care, it might be inappropriate not to offer it to both partners, to enable them to stay together, if they wish. ] . It is particularly important to avoid, wherever possible, a move for people with dementia, since this can exacerbate confusion and disorientation and may precipitate admission to long stay care.

4. If the care manager considers that the older person may need nursing care - whether at home (including sheltered and other supported accommodation) in a residential home or in a nursing home - they must consult the medical practitioner [ The 1968 Act 12a(2) refers to "a medical practitioner". For the purposes of the Act, a "medical practitioner is a "fully registered person" as defined in the Medical Act 1983, section 55. In terms of that definition a "fully registered person" is a person on the Register of Medial Practitioners of the General Medical Council.] . The medical practitioner will, almost certainly, wish to consult appropriate hospital or community nursing colleagues before giving an opinion as to whether the nursing care need can be met by them outwith a nursing home.

5. This guidance clarifies:

• the respective roles and responsibilities of the care manager, the medical practitioner, other members of the hospital or primary care multi-disciplinary team and their contributions to the assessment of an older person’s needs for community care and health services;

• how to meet the assessed needs of the older person in their own home and avoid inappropriate admission to hospital;

• the importance of securing the necessary community services to enable a safe and timely discharge from hospital once the person’s in-patient treatment is completed.

It is vital to the well-being of the older person that all social work, health and housing professionals involved in community care assessments of frail older people share the objective of securing the best available services for that person within the resources available to them. The professionals involved in the assessment must enquire about and take account of the older person’s wishes and needs, as well as the needs and wishes of those who care for them when considering what services to provide.

Contact Point

6. Please direct any enquiries about this circular to Rosemary Bland, Social Work Services Inspectorate, Room 20, James Craig Walk, Edinburgh EH1 3BA Telephone No. 0131 244 5442).

Note

7. Holders of the SWSG Circulars and Guidance Package who wish a copy of the guidance should contact Carol-Ann Gray, Room 38, at the above address, tel 0131-244-5409.

Yours faithfully

COMMUNITY CARE NEEDS OF FRAIL OLDER PEOPLE: INTEGRATING PROFESSIONAL ASSESSMENTS AND CARE ARRANGEMENTS

Contents Paragraphs

Involvement of older people and carers 1

The rights of carers 2-3

The importance of collaborative working 4-6

Communication 7-8

The development of care management 9-18

Other contributions to assessments 16

An integrated care record 17-18

Common data sets 18

The role of the medical practitioner in assessing older 20-27

people’s community care needs and nursing care needs

Psychiatric opinion 24-25

Transfer to nursing home, hospice or hospital 26-27

Discharging older people from hospital 28-38

The role of the consultant 32-33

Responses to referrals 34

Components of good discharge arrangements 35-38

Managing confidentiality 39

Urgent assessments and admissions to care 40-43

Avoiding unnecessary hospitalisation 41-42

Postponing financial assessments 43

Funding the cost of care 44-51

Requests to modify charges 44-47

Liability of spouses 48

Local Authority Help with Fees 49-51

Rights of appeal and complaints procedures 52-54

Joint training initiatives 55-56

Annex Paragraphs in Annex

Screening for care management 1-3

Involvement of older people and carers

2. Older people and their carers can only participate fully in a process which they understand. They should be informed by the care manager about the purpose and process of community care assessments from the point of first contact. They should be involved in the assessment process and give their agreement to any confidential information being relayed on a need-to-know basis to other professionals or care providers. They need to understand the purpose of the assessment and should know that they have a right to a copy of it and the subsequent care plan. Information is most effectively conveyed to older people in person, supported by clearly presented written material. When deciding which form of care to arrange, it is vital that the care manager knows and takes account of the preferences of the older person and the person who cares for them. The cost and any likely charges to them and/or their family should be fully explained. Where the person prefers to remain at home and this is possible with support, the care manager should strive to procure the combination of services which provides best value. This may include services purchased from independent sector providers. The care manager should consult with health and housing colleagues where this seems necessary so they can make their own contribution to the care provided. Care managers should ensure that the older person is fully aware of their possible entitlement to a range of welfare benefits and help them, if they wish, to make the relevant claims to meet accommodation or service charges.

The rights of carers

3. Most older people remain in the community with the support of their families, neighbours and friends. Without this continuing support community care would be much more expensive or even impossible. This vital role of the carer has been confirmed in recent research which shows that when carer support is no longer available admission to long stay residential care can often result [ Sinclair, Ian (1988) Residential Care: the research reviewed, London HMSO, Bland, R. and Bland, R.E. (1985) Client Characteristics and Patterns of Care in Local Authority Old People’s Homes, University of Stirling mimeo.] . Carers may not have the energy to complain or appeal about the services available and a comprehensive needs assessment of the older person for whom they are caring is essential to provide the right support. The contribution of carers should be arrived at in discussion rather than assumed. Account should be taken of potential conflicts of interest between them and the older person. The older person has a right to confidentiality of information and their consent should be sought, wherever possible, before this is shared with a carer.

4. Carers (other than those under a contract of employment or as a volunteer for a voluntary organisation) have a legal right under Section 12A (3A) of the Social Work (Scotland) Act 1968 [ Section 12A (3A) was inserted into the 1968 Act by Section 2 of the Carers (Recognition and Services) Act 1995. ] to request an authority to assess their ability to provide substantial care on a regular basis. Any decision about care must take such an assessment into account. This is an important safeguard against carers themselves being overburdened. Otherwise, there could be an increase in the total care burden since carers are often elderly and not in robust health.

The importance of collaborative working

5. Older people and their carers benefit directly from good working relationships between social work and housing providers, hospital and primary health care teams. NHS guidance [ NHS MEL(1996)22] on community care emphasises the need for co-operation at every level between health, social work and housing agencies. That emphasis extends to current developments in primary care [ NHS White Paper 1997 Designed to Care ; Renewing the National Health Service in Scotland] . Good co-operation between all these agencies can enable older people to be properly supported at home. Voluntary and, increasingly, private, organisations are making a valuable contribution in providing this support and care. Research has identified the stressful effect on people of moving from one environment to another. Particular groups of people who are at greatest risk include those with "a marked degree of brain failure" (such as in moderate or severe dementia), severe physical illness, or frailty. Older people with such frailties are at high risk of not being able to adjust successfully if they have to move. Agencies should ensure that frail older people are only moved in order to get the treatment or care they require as numerous relocations can do much harm.

6. All local authority housing and social work departments, health boards and NHS Trusts should establish local operational agreements. These should clarify their respective responsibilities for the funding (both capital and revenue) and provision of community care and community health services. Disputes about eligibility for community based care, residential and nursing home care and continuing health care should not be allowed to jeopardise the wellbeing of older people. These agreements should include a mechanism for dealing speedily with any disputes and they should be referred to in the community care plan. The mechanism for dealing with disputes should be widely publicised and disseminated to staff and all other local agencies concerned in delivering community care services.

7. Some social work and health authorities have successfully pooled [ Any resources of money, staff, etc. which are ‘pooled’ or allocated to an exercise or programme must, of course, remain clearly identifiable for accounting and managerial purposes.] resources in order to provide integrated services to older people at home. Other strategies which effectively establish joint working such as joint commissioning, locating staff from different agencies beside each other at primary care level, and joint training should also be used. Different strategies will need to be adopted and adapted to suit local circumstances.

Communication

8. It is essential that service providers make every effort to listen carefully to and understand older people and their carers. Service providers should make sure that there is always clear and effective communication and understanding, especially when involving older people and their carers in planning care. Plain English should be used, rather than jargon, acronyms or technical terms when speaking or writing to older people and carers. [ See SWSI/Consumer Council Guide 1997, Informed Choices - A guide for Local Authority Social Work Departments on how to provide information for older people and those who care for them about Community Care Services.] Likewise, clear written and verbal communication between social work, health and housing staff and independent sector partners will result in better services and play an important part in ensuring a spirit of co-operation. In some areas communication has been much improved by care manager attachments to primary health care teams, and liaison nurses working between hospital and community health care teams.

9. All health staff who may be involved with the older person need up-to-date information about the range of community care and accommodation services available locally. Health staff should know how to obtain these services and how the local authority prioritises need for community care and accommodation services. Local authority staff and staff of relevant voluntary organisations should know what community health services are available locally and how these can be obtained. It is particularly important when an older person in hospital is being assessed for their community care needs that the primary care team should be asked to contribute to that assessment well before the day of discharge.

The development of care management

10. Care management is a complex and demanding role. It should be undertaken by qualified and experienced practitioners, wherever possible, able to take decisions quickly. Staff from social work, nursing or occupational therapy backgrounds working as care managers can do much to guarantee the expertise needed to deliver good services. Local authorities can contract with voluntary and private sector agencies to carry out care management on their behalf. Some voluntary agencies have expertise in specialist fields, such as sensory impairment.

11. Most older people who need services do not require care management. Some older people are able to assess their own needs accurately, such as for a basic piece of equipment [ For example, special cutlery, a hosiery aid or a raised toilet seat.] to enable them to maintain their independence. Authorities should accept self-assessment and act on it, where the request is reasonable and resources are available to meet the request. This can provide a timely solution to a minor difficulty. It can prevent possible escalation into a major problem which may be costly, both to the older person and the agency.

12. Care management is particularly relevant in meeting the more complex needs of people who require a range of different services and who cannot manage to live independently at home without considerable long term support. Where the older person has dementia, they are very likely to need care management to secure the ongoing help and support they need.

13. Authorities should develop screening and referral systems which can help to identify those referrals that should go direct to a care manager and those which should be directed elsewhere. These may consist of a simple screening or case-finding tool to identify older people with short or critical intervals of need, and situations where the person who is providing care is in urgent need of support. (See Annex).

14. Care managers have key responsibilities for:

• assessing need;

• developing the care plan;

• co-ordinating the delivery of the relevant services (including suitable accommodation); and

• monitoring the care plan of the person receiving the services.

To fulfil this role, they require both management and administrative support. Local authorities should gather together for general use information on locally available services. Care managers will need to act within the context of the local authority budget or financial plan when deciding the care that best meets the older person’s needs.

15. Research [ Petch, A., Cheetham, J., Fuller, R., MacDonald, C. And Myers, F. (1996) Delivering Community Care: Initial Implementation of Care Management in Scotland, Edinburgh: The Stationery Office.] shows that where care managers have devolved budgets and access to a wide range of resources, people who need support get better care. In Scotland, some local authorities have already successfully devolved budgets to team level or to their care managers [ Accounts Commission for Scotland: The Commissioning Maze. Commissioning Community Care Services . November 1997.] . For effective care management, it is important to locate budgetary control as close as possible to the decision-making about the care that an individual needs. All local authorities should now begin to devolve purchasing budgets to at least team level.

16. Where care managers have been given training, power to purchase support services and budgetary responsibility may be devolved to them, within an agreed budgetary framework. Local authorities should bear in mind the need to balance flexibility with adequate financial control. In order for older people to have a real choice about the kinds of support available to them, care managers must know the unit costs of existing services and resources of their own department as well as those of the services available from the voluntary and private sectors. Research has found that care managers are well placed to promote the development of new, cost-effective ways of meeting older people’s needs [ Davies, B and Challis, D (1986) Matching Resources to Needs in Community Care , Gower.] . Care managers should inform hospital and primary care as well as housing colleagues of the approach to care management used locally, including the extent of their remit and authority over resources.

Other contributions to assessments

17. A pre-requisite for successful care management is the ability of a range of experts to make a positive contribution to the assessment. They need to:

• be aware and take account of the wishes and preferences of the person being assessed and those of their carer;

• be familiar with and have been consulted about the development of any documentation, such as the personal care record, incorporating their views about the person’s needs;

• know the name of the designated care manager carrying out the assessment;

• know the timescale within which their contribution is required;

• be aware of the statutory obligations on local authorities to assess the person’s ability to contribute towards the cost of their care;

• be aware of the criteria and procedure agreed between the local authority and the health board for considering how to meet a person’s need for nursing care;

• know the procedures for allocating housing or other accommodation required;

• know the criteria and procedures in relation to residential care and home care services.

An integrated care record

18. Health and local authority occupational therapists are now accepting each other’s assessment of need in some areas [ Insofar as in making their assessment they rely largely on the work of the other.] . Some social work and community nursing staff also accept and act on each other’s assessments of need in community care. However, older people still find themselves subject to a number of assessments from different professionals (eg General Practitioners (GPs), nurses and occupational therapists as well as care managers). In order to minimise unnecessary repetition, health, social work and housing agencies should jointly agree procedures to record professional opinion and information relating to community care. This is best done at the stage the local operational agreement is developed.

19. There should be one integrated personal care record which incorporates the views of the older person, their carer and the various professional contributions to the assessment. Such a document, a copy of which should be held by the older person, the local authority and the NHS primary care trust, will help inter-agency communication and avoid wasteful collection of information and multiple assessments. Core information should be collected by the professional who sees the older person first. The record should be clear and easily understood. It should be developed on a local basis by the professionals involved in consultation with older people and carers. The care manager should review the record periodically to monitor effectiveness in identifying and meeting people’s needs. Issues of confidentiality and restricted access to sensitive information are dealt with in paragraph 39.

Common data sets

20. Health boards, NHS Trusts and GPs are working together to produce a Health Improvement Programme (HIP) for the people of each health board area. Health boards are leading the preparation of these programmes. The key stakeholders in Community Care who should share the joint production of the Community Care Plan (CCP) include social work departments, health boards, housing departments and others [ See SWSG 21/95, para. 23, Community Care Planning: Joint Planning Structures. ] . The lead agency for Community Care planning is the social work department. Local authority housing departments are responsible for preparing housing plans, which should include the housing component of community care plans. Local authorities and health boards should have common ownership of HIPs, CCP information and housing plans.

The role of the medical practitioner in assessing older people’s community care needs and nursing care needs

21. Where it appears to the care manager that an older person may need nursing care the local authority has to consult a medical practitioner [ Social Work (Scotland) Act 1968, section 12A.] . The medical practitioner, after consulting community nursing colleagues, will be able to advise whether or not the primary care team can provide this nursing care to the older person in their own home or in a residential care home or whether nursing home care is necessary. The final decision about the provision of nursing home care is for the local authority since it must meet the cost of purchasing the service. In making this decision there is currently legal authority to suggest that the local authority may take its resources into account. However, local authorities must be careful that any decision is not "unreasonable"; otherwise it might be open to legal challenge. They will also wish to keep the legal position under review [ R. v. Gloucester County Council and another ex parte Barry, Gloucester 1997 2 All ER Page 1. The House of Lords case in re T (A Minor) 1997 (20 May 1998 House 9, previously unreported) begins to make some inroads into the House of Lords’ thinking in the Gloucestershire case.] .

22. Some local authorities and health boards have agreed the criteria to be used by medical practitioners when recommending that a person should have their nursing care needs met in a nursing home. Agreed criteria reduce inter-agency disputes to the benefit of people needing services. All local authorities and health boards should agree such criteria. Local authorities should, in consultation with health, housing and other service agencies, publish these criteria along with information about assessment procedures, care management and the services available for older people and their carers. Information needs to be provided in clear, easily accessible formats and made widely available in libraries, primary health care centres, hospital out-patient departments, hospital wards and in housing and social work offices.

23. It is important that the medical practitioner is aware of the range and intensity of community health, housing and social work services able to meet care needs. Services such as physio-, speech or occupational therapy, adapted and specialist housing provision, day and respite care and sitter services, as well as other resources may be available locally to enable older people to remain in their own homes. The community nursing service or an independent nursing agency may be able to provide nursing care to keep someone at home or in supported accommodation, or in a residential care home. Care managers need to know about local community health care alternatives to nursing home care. A geriatric or psychogeriatric multi-disciplinary assessment of the older person (either domiciliary or at a day hospital) may be helpful before recommending a move to a nursing home. When considering available options with the older person, it can help the care manager if the individual components of the nursing care required are identified by the medical practitioner. The medical practitioner should agree that the arrangements to meet the person’s nursing care needs are satisfactory. No medical practitioner or other professional should recommend an admission to a nursing or residential home in which he or she has a financial interest. The locally agreed protocol should include arrangements for dealing with differences of opinion between medical practitioners and care managers which cannot otherwise be immediately resolved.

24. The care manager and the medical practitioner should take the views of the older person and their family (which may not necessarily coincide) into account when recommending how the older person’s needs should be met. If the older person wishes to be supported at home, the care manager and the medical practitioner should try to do so, within the health and social care resources available to them.

Psychiatric opinion

25. Where the older person wishes to be looked after at home but the carer is unable or unwilling to do this, even with community health service and social work support, a move to residential or nursing home may be the only available option. Where there are differences of opinion about how or where to provide the care, or the older person has dementia, the care manager should, wherever possible, offer to contact an independent advocacy service to assist the older person in expressing their views [ Scottish Health Advisory Service/The Scottish Office Department of Health 1997, Advocacy: A Guide to Good Practice] . Occasionally, the older person may insist on remaining at home or returning home, despite the joint health and social work recommendation. Where the older person is of sound mind and aware of the risks, the local authority and health services have a continuing duty to secure such care and support as the person will accept, within available resources.

26. If there are doubts about the older person’s capacity to make a reasoned and informed judgement the care manager should seek advice from the older person’s GP. The GP may consider requesting a psychiatric opinion to determine whether the older person has mental health needs which can be met and supported in the community, possibly with community psychiatric nurse involvement. Where psychiatric opinion is that the older person is not able to make sound judgements about their care and cannot have their mental health care needs met at home, the local authority should follow a locally agreed protocol. If the older person has to move into a residential or nursing home and has no carer or relative to assist them in choosing a home, the care manager should consider involving an independent advocate to help the older person make a choice.

Transfer to nursing home, hospice or hospital

27. Where an older person in a residential care home has had that care arranged by or is subsequently supported by the local authority, and the GP or hospital doctor recommends moving to a nursing home, hospice or hospital, the doctor should discuss this with the older person, their relatives, the home and the care manager. If a nursing home is recommended for other than palliative care, the care manager must review their assessment of the older person’s needs. Where it is possible to provide community nursing, palliative care or independent nursing agency care for the person in the residential home as a way of avoiding a move, this is valuable, particularly for people with dementia. Where the older person is not agreeable to a move and the residential care provider is agreeable to them remaining where they are, the primary care team will have a continuing responsibility to provide or secure such health care within the resources available to them.

28. An older person can only move into a nursing home without a full community care assessment in an emergency or if they are acting independently and are self-funding. Where an older person has been admitted to residential or nursing home care in an emergency, their social and health care needs should be jointly assessed as soon as possible and within 5 working days of their admission. Older people contemplating a move to residential or nursing home care who would be self-funding have a right to advice and assistance from health and social care agencies in relation to such a move where they request it. Urgent assessments and admissions to care are dealt with in more detail in paragraphs 40-42.

Discharging older people from hospital

29. All health boards, NHS Trusts, social work and housing authorities should agree local protocols that enable discharge from hospital when the person’s in-patient treatment is concluded. Staff in both primary and secondary care teams should be consulted. The protocols should specify target timescales for community and health care services to be provided.

30. Older people who remain in hospital longer than their medical condition warrants, are at risk of becoming institutionalised and/or demoralised. This can result in them deteriorating to a point where discharge home is no longer feasible or possible. It is important to identify on admission to hospital those older people whose discharge may prove problematic. They may be identified at pre-admission clinics or from information provided to the hospital by the primary care team on admission. For instance, a carer may find it difficult or be unable to resume caring or a move to alternative accommodation is required. In the latter case, the care manager should involve housing staff as early as possible to establish the person’s priority for suitable alternative housing (not necessarily local authority provided) or adaptations to their existing home. Where the older person has dementia, timely discharge is very important.

31. The admitting nurse should identify older people with potential discharge difficulties and make an early referral to the care manager. The care manager should carry out a preliminary assessment initiating early action, particularly if major housing adaptations or a move to sheltered or supported accommodation are likely. Occupational therapy and housing colleagues will be able to advise the older person and the care manager about getting the existing home adapted or about the availability of suitable alternative accommodation. Adaptations to houses are funded in a number of ways depending on the tenure of the household. Close liaison between housing providers and occupational therapists is crucial in order to ensure that adaptations work is carried out promptly and smoothly. A multi-professional working group has been developing good practice guidance on adaptations which should be published in the Autumn of 1998.

32. Regular liaison between health, social work, housing professionals and the older person and their carer about the likelihood of discharge is essential, especially if there are indications that the older person may not require extended hospital care. When an older person is admitted to hospital for elective surgery, their need for community care services on discharge can be identified by the GP before admission and they should be referred to the social work department for a community care assessment at that stage. SWSG 11/96 also emphasises the importance of involving relatives or friends providing care when hospital discharges or admissions for elective surgery are being planned.

The role of the consultant

33. The consultant in charge (or in some community hospitals, GPs) will decide, in consultation with other clinical, nursing and paramedical colleagues, whether the older person needs continuing in-patient care arranged and funded by the NHS, or a period of rehabilitation or recovery, or whether they can be discharged [ NHS MEL(1996)22, Appendix para. 20.] . Where continuing NHS funded care is not required, the consultant or community hospital GP should make an early referral to the local authority for a community care assessment. It is essential that the local authority receives medical information and opinion about whether the older person can live independently with adequate community based support, requires a period of interim care or needs 24 hour residential or nursing care.

34. Where the older person’s acute condition is stabilised but they have not regained sufficient independence to be discharged into the community, the consultant should consider a period of rehabilitation in a designated ward or nursing home. On no account should an older person be discharged prematurely from acute hospital care. If a period of interim care or convalescence is agreed, the care manager can arrange appropriate care and support for the older person afterwards.

Responses to referrals

35. Social work staff should acknowledge all referrals promptly and in writing unless the need is urgent. Social work departments should agree timescales for achieving community care assessments with their health and housing partners and these should be included in the jointly agreed local protocols. Older people needing small amounts of extra assistance on discharge should normally be able to have that need assessed within one working day. Assessing and planning the care of people with complex needs will take longer to achieve. This may include people who have dementia or who have high physical needs as a result of an acute illness or accident. Adaptations or allocation of alternative housing may be required and timescales should reflect this. Good practice for starting community care assessments of complex needs in hospital settings should be within 2 working days of receipt of the referral and completion normally within twenty-one calendar days.

Components of good discharge arrangements

36. Research studies have shown that successful discharge arrangements are more likely where a significant number of the following measures are employed and adapted to local circumstances:

• a named member of the nursing staff has responsibility for co-ordinating discharge planning;

• the care manager has the authority to commit resources, either long term or for the immediate post discharge period;

• direct consultation with members of the Primary Health Care Team (PHCT) takes place at an early stage of discharge planning;

• discharge liaison nurses are attached to clinical specialties to ensure the early involvement of the primary health care team in the planning;

• written discharge checklists are used by individual wards and duly forwarded to the primary health care team by fax, e-mail or first class post on the day of discharge ;

• home care discharge teams are based in the hospital;

• the older person and their carer have been involved in the planning from the beginning , have a copy of the agreed care plan and have a contact number for the care manager;

• health, social work and housing staff have access to a joint equipment store;

• discharge protocols are agreed and implemented by health, social work and housing authorities including staff at hospital ward level;

• the care manager meets a member of the unit’s multi-disciplinary team to reach discharge decisions speedily;

• housing needs are assessed before discharge;

• intensive home support packages are available to help individuals for the critical period immediately following discharge from hospital.

37. If the residential or nursing home of the older person’s choice is unlikely to be available in the near future (8 weeks) [ NHS MEL(1996)22, Appendix para. 26.] the care manager should discuss acceptable alternatives with them. Health and social work agencies should consider the realistic personal and financial costs of this in discussion with the older person and their relatives. If the person is moving to long stay care, one option might be to ask them to make a second choice of home, with the prospect of moving into the home of first choice in due course. Alternatively, the prospect of a temporary period of jointly commissioned intensive support at home to meet predictable needs should be considered. The need for intensive support should be reviewed at regular intervals and where the person is not recovering sufficient independence to be able to manage with less support, long term residential or nursing home care may need to be reconsidered.

38. Older people find the decision to give up their home and move into care hard to make. Moving directly from hospital into long term care without returning home even briefly to make the necessary arrangements and decisions can make that move more difficult and jeopardise its success. Discharge schemes able to provide intensive 24 hour support to meet predictable and unpredictable needs may enable some older people who would otherwise go directly into residential or nursing home care to have the opportunity to go home in the short term, if they so wish. This will enable them to review their situation and to consider the options realistically open to them. If the older person subsequently expresses a preference to remain at home, the local authority should consider this, taking into account the level of resources it would otherwise commit to support the person in long term residential or nursing home care.

39. Health boards, NHS Trusts and local authorities have a joint responsibility to ensure that their staff know what the criteria for continuing health care are [ NHS MEL(1996)22] . Staff should:

• understand the support available and the criteria for receiving different community care services;

• be familiar with the procedures and any jointly agreed policy and protocol documents - a jointly produced or commissioned leaflet for patients and family carers is useful;

• be aware of the pre-discharge appeal process available to patients who disagree with the decision to discharge them [ Ibid.] ;

• not implement discharge procedures if the planned care, support and accommodation are not in place.

Older people’s right to appeal against discharge from hospital is explained in paragraph 52.

Managing confidentiality

40. Under the Patients’ Charter 1991 every citizen has the right of access to their health record and to know that those working for the NHS will keep the contents confidential, unless the patient gives permission for information to be shared with other professionals on a need to know basis. People who use social work services have the right to all personal information held by local authorities in any manually recorded form from which he or she can be identified as being the subject, [ Access to Personal Files (Social Work (Scotland)) Regulations made under Section III of the Access to Personal Files Act (1987)] and to know that staff are bound by the same rules of confidentiality as people working in the health service. In exceptional circumstances, where the local authority considers that access may result in serious harm to a person’s physical or mental health or emotional condition, it may restrict that access [ Access to Personal Files (Social Work (Scotland)) Regulations (1987), Regulations 8, 9 and 10.] . Similarly, public sector tenants, or those who are applying to be a public sector tenant, must be given access to information held about them and their tenancy by a landlord, subject to certain conditions [ Access to Personal Files (|Housing) (Scotland) Regulations 1992.] . The older person’s permission should be obtained, wherever possible, when confidential information provided by a third party needs to be shared with another agency to enable their community care assessment and care plan to be completed. The older person and, with that person’s agreement, their carer, should be given a copy of the completed care plan. They should be kept informed by the care manager of progress in implementing the plan. When a patient is admitted to hospital, they give implied consent to the sharing of information among the multi-disciplinary team involved in their care and treatment. Other agencies involved in supporting the older person, such as home care or residential or nursing homes, should be given only the information needed to help them do their particular task.

Urgent assessments and admissions to care

41. From time to time, a local authority may have to arrange community care for a person urgently before assessing their needs [ Social Work (Scotland) Act 1968, section 12A, subsection 5.] . Guidance on urgent admission to residential or nursing home care or to hostels was issued in 1991 [ SWSG 11/91.] . The local authority is only exempt from the requirement to consult a medical practitioner when considering arranging for an older person to move into a nursing home where the need is urgent.

Avoiding unnecessary hospitalisation

42. Sometimes older people at home may need an urgent assessment to prevent unnecessary hospitalisation or collapse of their informal support arrangements. Often it is the PHCT who is alerted in the first instance. Health boards, NHS Trusts and local authorities must jointly agree arrangements to prevent unnecessary hospitalisation, with clear agreement about the specific contribution that each can make. The process of joint working in primary care requires trust and perseverance to make it succeed. A number of arrangements e.g. co-location of care managers and/or occupational therapists with PHCTs or a named liaison care manager for each PHCT can assist the process. It is essential that care managers have the authority to procure quickly the community care services that meet the person’s needs. Occupational therapists located in PHCTs are particularly well placed to undertake urgent functional assessments and arrange services such as adaptations to a person’s home. The establishment of joint equipment centres which health, housing and social work staff can access (possibly using an authorised prescriber system) helps to integrate services, eliminate duplication of assessment and speed up solutions for people.

43. Social work departments vary in their arrangements to provide services to people outwith normal working hours and in emergencies. Some councils have dedicated emergency duty teams, while others have staff working ‘on call’ or ‘standby’ arrangements. In some areas, PHCTs have direct access to ‘on call’ home care staff who can meet urgent need for domiciliary support over 24 hours. The local, jointly agreed protocol between health boards, NHS Trusts and local authorities should include specific arrangements for PHCTs to access community care services over 24 hours to cover emergencies. In some areas, PHCTs and the local authority are jointly providing out-of-hours cover using GP ‘on call’ arrangements and facilities and community nursing services. Out-of-hours arrangements which cater for emergencies should not be left as the only cover for community care services for prolonged periods (ie more than 72 hours). On those occasions when public holidays result in social work departments being closed for longer periods, a residual complement of key staff should be available to meet the full range of assessed need.

Postponing financial assessments

44. The older person’s physical or mental inability or refusal to provide information about their financial position should only delay their discharge in exceptional circumstances. Social work departments are required to assess older people’s ability to contribute to the cost of their post hospital care. It is important that the local authority ensures that older people and carers have up-to-date information about the community care services they will be charged for and the likely cost. If the older person moves out of hospital before the financial assessment is completed, they and their carers should agree the likely charges with the local authority, and how these charges will be met. Where the person has dementia and has no relative or lawyer able to act legally on their behalf, the local authority should ensure appropriate arrangements are in place to protect and manage the person’s interests before their discharge into residential or nursing home care.

Funding the cost of care

Requests to modify charges

45. One of the difficulties in providing community care services jointly between health and local authorities is that of service charges. NHS care is free at the point of delivery but there are charges for local authority social work services. Where services are to be provided jointly, local agreement on definitions of health and social care must be reached so that agencies and people receiving services are clear which services are chargeable. Local authorities have discretionary powers to charge for day and domiciliary services [ SWSG 1/97.] . Authorities cannot charge for advice or guidance about the availability of services, the assessment of an individual’s community care needs or for care management. The legislation requires local authorities not to charge more than a person can reasonably afford to pay, taking account of other financial commitments and the person’s overall financial means [ "Means" may include the resources of a third party such as a spouse where the person has reliable access to their funds.] . In particular, authorities should have regard to any extra expenditure incurred because of the older person’s disability or frailty. It is for the authority to decide what is reasonable in each case. No one who has insufficient means to pay a charge should be denied an essential service because of their inability to contribute towards its cost. Where a person considers that he or she cannot pay the charge, they have the right to ask the authority to reduce or waive it [ Section 87(1A) of the Social Work (Scotland) Act 1968.] .

46. A person who refuses any support services may have a tendency to self-neglect. Nevertheless, people have a right to choose whether or not they will accept any services offered to them. Once a person has been assessed as requiring a service but they refuse to pay for it, the service should not be withheld or withdrawn where it is clear that the service is essential to that person’s well-being. It is, however, open to a local authority to pursue the debt while continuing to provide the service. Local authorities should, amongst other things, weigh up considerations about risk to individuals, fairness to others, and capacity to pay, in reaching decisions about withdrawal of service. The final decision about reasonableness and equity of charging rests with the local authority.

47. When arranging services to meet an individual’s community care needs, authorities should ensure that the charges made do not result in the person being left without the means to pay for any other necessary personal care. Authorities must make information about their charging policies and procedures widely available. This should use written and other media and be in available, accessible and readily understood styles to people who already use services, people who are in hospital and others who may use services in the future. This includes people from ethnic minority backgrounds and people with sensory impairment. When a service is offered to them, people should receive up-to-date information about any charges they will be liable to pay, including billing periods and payment arrangements. Everyone using a service should know how to challenge assessments and any charging decision with which they disagree.

48. Regulations lay down the framework for local authorities to calculate how much a person should contribute towards the cost of their residential (including registered supported housing) or nursing home care [ The National Assistance (Assessment of Resources) Regulations 1992 as amended.] . If an older person living at home has care or nursing needs which are best met in a residential or nursing home, and they require assistance with fees, the local authority must carry out a community care assessment which includes the person’s ability to contribute to the care costs. This assessment is based on income, including pensions and social security benefits, and any savings, investment or property (capital) the older person may have. As long as the older person has sufficient income, capital or earnings, they will be expected to pay the full cost of care themselves. When their capital is reduced to £10,000 the local authority will disregard it when calculating the person’s contribution to the cost of their care.

Liability of spouses

49. Where a person’s accommodation (including registered supported housing) is arranged by a local authority, the local authority may ask the spouse (i.e. the liable relative) to refund all or part of the cost of the accommodation [ In terms of section 42 of the National Assistance Act (1948) which applies in Scotland by virtue of Section 87(3) of the Social Work (Scotland) Act 1968, a man is liable to maintain his wife and a woman is liable to maintain her husband.] . If the request is refused, a court order may be obtained imposing a legally enforceable liability to pay the amount set by the court. However, spouse liability does not apply to non-residential services. When the older person’s capital or savings fall below £10,000, these are ignored for financial assessment purposes. This is known as the Capital Disregard. Where an older person needs to move into a residential or nursing home and their husband, wife, partner, or a relative who is aged 60 or over, or who is disabled still lives in their house or flat, the local authority may not take the value of the property into account when calculating the older person’s financial contribution to their care. People who are thinking of moving into a care home can get details about the financial implications of this from the local authority, from the Scottish Office booklet ‘Thinking about moving into a care home?’ or from Age Concern Scotland.

Local authority help with fees

50. In some circumstances, the needs of the older person may exceed the local authority’s ability to pay for them. For instance, where an older person has entered an independent residential or nursing home at their own expense and their funds are exhausted, the local authority may be asked to assume financial responsibility. If the person is assessed as needing that level of care and the fees are at a level the local authority is willing to pay, it may meet its share of these costs or make alternative arrangements to provide the appropriate level of care. The local authority may ask the older person to move to a less expensive home, or it may approach relatives to contribute to the shortfall. Local authorities should provide registered homes with written information about help with fees to pass on to their residents. They should also encourage homes to request at an early stage, a community care assessment of older residents who only have funds to meet their full care costs for a limited period (twelve months or less).

51. Local authorities may carry out a financial assessment [ National Assistance (Assessment of Resources) Regulations 1992 cited in para. 42 of SWSG10/96] within the first 8 weeks of an older person’s stay for respite or short term care in a residential or nursing home. If no assessment is made, the authority should charge such an amount as it considers reasonable for the resident to pay. When an assessment is made, special provisions cover the treatment of capital and income. A resident’s normal dwelling is disregarded [ SWSG 10/96.] .

52. It is for the local authority to assess the needs of its population and plan to meet those needs in the way that provides best value within the resources available to it. Patterns of need change from time to time and authorities should reflect these changing pressures in the use and distribution of their resources. Individuals with the same needs should have similar levels of priority attaching to them, irrespective of whether they are at home or in hospital. In some areas, the demand for financial help with care fees may exceed the sums available. Local authorities may have regard to their own financial resources in considering the need of individuals for services. They should comply with any capital disregards in force in providing a person with residential accommodation [ SWSG Letter 20.11.97. Community Care: Implications of recent legal judgements in England and Wales, para 6.] . Councils must continue to pursue best value in respect of the services which they both provide and purchase. A Royal Commission is examining the future nature and funding of long-term care for older people.

Rights of appeal and complaints procedures

53. Older people being assessed for health, social care and housing services have separate rights of appeal against the outcomes of these assessments. Arrangements to review clinical recommendations for the continuing health care of individual hospital patients were established in April 1996. [ NHS MEL(1996)22] Patients may now appeal against the clinician’s decision that they can be discharged from NHS hospital care. It is the responsibility of the NHS Trust to ensure that information on how to appeal should be contained within documentation provided to all patients. The NHS has other complaints procedures for patients and complaints can ultimately be taken to the Health Service Commissioner for Scotland [ Wherever possible, a complaint should be resolved locally with the person close to the cause of the complaint. If this is not successful, the Complaints Officer of the NHS Trust or health board should be contacted. If the complainant remains dissatisfied, the Health Service Commissioner may investigate the case.] .

54. All local authority social work departments have established complaints procedures [ SWSG5/96.] . Where an older person or the person who cares for them is unhappy with the decision reached about their long term support, they should raise this informally in the first instance, with their care manager or the local community care services manager. If they remain dissatisfied, they should make representations using the complaints procedure. They can make representations or complaints about any service, refusal of a service, or any aspect of assessment or care management with which they are unhappy. They can seek further advice, if necessary, from their GP, local councillors, member of parliament, local health council or an independent advocacy service.

55. Complaints about the housing service (which may include adaptations work which is to be carried out) should be addressed to the landlord - the local authority, housing association or Scottish Homes - in the first instance. If the complaint remains unresolved then it can be referred to either the Local Government Ombudsman who will investigate whether an injustice has been caused by maladministration or to the Housing Association Ombudsman, who will investigate individual complaints against housing associations and co-operatives, and against other participating landlords.

Joint training initiatives

56. Joint training initiatives have been used successfully to develop better understanding and working together between different professional groups. Joint training enables unhelpful and destructive stereotypes to be challenged and an informed and shared understanding of respective roles allows more effective communication and collaboration to take place. Local authorities, health boards, NHS Trusts, housing agencies and their independent sector partners should develop local training strategies for multi-professional groups who already work together, using their experience of efforts to collaborate as learning material. Training in the workplace can be more practical and effective, both in terms of cost and time. Some suitable locations may include primary health care centres, day hospitals and local authority area offices.

57. In order to develop services which are more focused on the people who use them, consideration should also be given to involving them in training initiatives, to draw on their experiences. The constraints and obstacles to effective working can then be considered constructively and ways to eliminate or minimise them be found. Trust and openness and a flexible approach are essential for good multidisciplinary relationships to develop. Joint training initiatives at pre-qualifying and post qualifying levels can foster a spirit of inter-professional respect and collaboration from the outset. Accreditation of post-qualifying training by the relevant professional training bodies will provide an important incentive for all relevant professional groups to participate.

SCREENING FOR CARE MANAGEMENT - POSSIBLE TOOLS

In order to avoid inappropriate involvement of care managers in all referrals of older people needing services, a screening tool may be useful. Such a tool may be used by professional staff to assist them in exercising their professional judgement. There is no substitute for professional experience in reaching decisions about whether an older person should have a comprehensive community care assessment. A number of screening tools have been developed, mostly for use in community settings.

One of the following may be of use to social work departments in identifying older people needing care management:

58. Intervals of Need (Isaacs & Neville 1976)

Isaacs was asked to develop a method for measuring the needs of older people for ‘residential and domiciliary services’. He interpreted needs to be for ‘basic care’, that is the provision of food, warmth, cleanliness and security. He used Time - specifically the period for which a person could manage on their own without help and yet still have these basic needs met - as the indicator of Need in older people. Isaacs classified people into 3 ‘Need’ groups:

1. People who have constant or unpredictable need for help or attention at any time of the day or night have Critical Interval Needs. People who are bed or chairbound and unable to use the toilet safely without help, people who are incontinent or who have a moderate or severe degree of dementia have Critical Interval Needs. These people require 24 hour care and should be referred for a community care assessment and care management.

2. People who cannot, for whatever reason (whether mental or physical), make themselves a meal or a hot drink have Short Interval Needs. These people require services several times a day but at predictable intervals. They should be referred for a community care assessment by a care manager.

3. People who cannot perform one or more domestic activities such as house cleaning, shopping or laundry without help have Long Interval Needs. These needs can be met by services provided on one or two days per week and may not need a community care assessment.

Intervals of Need have since been used by the Personal Social Services Research Unit at the University of Kent when evaluating success in matching needs and resources in various care management projects for older people set up in different areas of England. SWSI used Isaacs’ Intervals of Need in their inspections of the home care service in Scotland and of community care services in Angus, Dundee City and Perth and Kinross.

59. The Elderly at Risk (Taylor, Ford and Barber 1983)

Research in Aberdeen identified four factors which put older people at greatest risk of going into long stay care. They were:

• people who had recently moved home

• people who had recently been discharged from hospital

• people who were divorced or separated

• very old people - aged 80 and over

The researchers developed a screening letter which was sent to 100 elderly patients, asking the following 9 questions:

1. Do you live on your own?

2. Do you have a relative whom you can rely on for help?

3. Do you need regular help with housework or shopping?

4. Are there days when you are unable to prepare a hot meal for yourself?

5. Are you confined to the house through ill health?

6. Is there any difficulty or worry about your health that you still need to see about?

7. Do you have any problem with your eyes or eyesight?

8. Do you have any difficulty with your hearing?

9. Have you been in hospital during the past year?

People reporting difficulties in response to the letter were followed up by GP and health visitor assessments. A comparison of the 100 patients’ situation 8 months’ later, showed clear reductions in unmet needs and in symptoms requiring action.

60. The EPIC (Elderly People in the Community) or Stirling Screening Tool (Lutz et al. 1989)

This screening tool which built on the Aberdeen and other research, was developed at Stirling University for use by social work department and primary health care staff in deciding which of their existing elderly patients or clients and new referrals should be referred to the Stirling EPIC Care Management Project. This project sought to identify older people at risk of long stay care who wished to remain at home, and to provide support to do so cost effectively.

The screening tool was subsequently used and tested in two area teams in another local authority. In one of these areas, the questions were added to the 75+ GP assessment and were used as a joint tool by social work and primary care for identifying and referring older people at risk. In the other area, the tool was used by the social services team. A follow-up of 100 older people living in the areas covered by the two teams who had been screened for care management found an association between high scores on the screening tool and morbidity/mortality.

The screening tool is, however, only an addition to, not a replacement for, professional judgement. A high frailty score for the older person is not the sole indicator that a speedy and comprehensive assessment is required. Where the person giving care is finding their role stressful, this is a similarly urgent situation needing prompt attention. In some situations the only positive response to the screening questions may be related to the carer finding their role stressful.

1. Is the person without anyone living nearby they can rely on for help in an emergency?

2. Does the person have a history or falls or a well founded fear of falling?

3. If there a friend/relative who makes a substantial contribution to care, is this person under physical or emotional strain?

4. Within the last 2 years has the person:

a. lost someone close to them through death, moving house or into residential or other long term care?

b. been in hospital?

c. given up their home and moved in with family/friends or others?

5. Is the person unable to get about outdoors on his/her own?

6. Is the person seriously confused or very forgetful about things?

7. Does the person have problems with incontinence?

8. Is the person neglecting themselves in important ways, such as failing to eat properly, to keep warm, or attend to their personal care?

9. Does the person need more help than they are currently receiving during the day, evening or night?

The social services department and the community health care unit jointly developed a carbonised version of the screening form which included the following permission statement for the older person to sign, allowing information to be passed to the relevant agency where appropriate.

Data Protection Act 1984/Access to Personal Files Act 1987/Access to Health Records Act 1990

The person should be made aware that the information supplied on this form may be computerised and will only be disclosed on a confidential basis.

........................................................has agreed that this information may be shared with the SWD, Housing Department, GP, or Community Health Service if appropriate.

Signature......................................................................... Screener’s Signature....................................................................................

Screener’s Designation................................Name....................................Base......................................Tel. No......................

Agency represented...Social Work Dept &127; .Housing Dept ..&127; Community Health..&127;...GP Practice.... &127; Other &127;......................................

Office Use Only: Received from.............................................................Date...........................................

Sent to......................................................................Date..................