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Implementing the single assessment for older people.

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The National Service Framework for Older People (Department of Health, 2001) envisages that the single assessment process (SAP) will act as a key driver in the improvement of older people’s services. The challenge to health and social care organisations was subsequently set out more specifically (DoH, 2002): ‘To ensure that older people receive appropriate, effective and timely responses to their health and social care needs, and that professional resources are used effectively.’

Abstract

VOL: 101, ISSUE: 25, PAGE NO: 32

Keith V. Wilson, MMedSci, BSc, is professor in primary and community care, University of Sheffield

Angie Clegg, HSC, RGN, is nurse consultant, Leeds Teaching Hospitals NHS Trust; Frances Fairclough, RGN, is EasyCARE user liaison, Centre for Healthy Ageing, University of Sheffield; Susanne Jones, BA, RGN, is patient pathways development manager, Leeds Teaching Hospitals NHS Trust

The National Service Framework for Older People (Department of Health, 2001) envisages that the single assessment process (SAP) will act as a key driver in the improvement of older people’s services. The challenge to health and social care organisations was subsequently set out more specifically (DoH, 2002): ‘To ensure that older people receive appropriate, effective and timely responses to their health and social care needs, and that professional resources are used effectively.’

 

 

Optimised assessment (that would be person-centred and avoid duplicate assessments), should lead to optimum interventions and optimum outcomes.

 

 

However, the extent to which implementing SAP would require change across staff groups and organisations, including hospitals, may not have been as clearly envisaged. The challenge has been amplified by the need to respond to emerging national and local policies and IT strategies, such as the hospital discharge reimbursement legislation and the management of long-term conditions.

 

 

Successful implementation of SAP requires local agencies to develop effective approaches to the delivery of integrated care (Wilson, 2002) and whole-system working (Wilson, 2003). Little seems to have been learnt about what makes integrated care work best since the late 1980s (Cameron and Lart, 2003). However, in the implementation of SAP, improvements in joint working arrangements have been observed where commitment and strong project leadership are present.

 

 

Progress with implementation is variable. It has been most evident in community health and social services, with less activity reported in hospitals. However, a whole-system approach cannot be achieved without full participation of local hospitals.

 

 

General features of SAP
Organisational requirements

 

 

To implement SAP in a health and social care community, all agencies need to agree to:

 

 

- Replace existing local assessment procedures (but not specialist assessments) with a standardised, unified assessment;

 

 

- Develop staff skills in person-centred assessment;

 

 

- Put systems in place to facilitate secure and timely sharing of information.

 

 

To support standardisation across a whole system of care, standardised instruments have been introduced for contact and overview assessments (see below). This has been achieved by developing a local instrument or adopting one accredited by the DoH.

 

 

Types of assessment

 

 

The DoH (2002) identified four types of assessment:

 

 

- Contact: SAP requires all staff to use a common means of recording basic patient data - a minimum data set collected no matter where assessment is undertaken. This is known as the ‘contact assessment’;

 

 

- Overview: in a fully implemented SAP a standard approach would also be used by staff undertaking a holistic assessment - typically in the community setting. Any qualified member of health or social services staff who has attended approved SAP training should be able to undertake this holistic assessment known as the ‘overview assessment’;

 

 

- Specialist: a detailed analysis of a patient’s physiological, psychological and/or social well-being undertaken by one or more professionals with expertise in their field of practice. Typically but not exclusively this would involve a multidisciplinary assessment in a hospital setting;

 

 

- Comprehensive: a holistic assessment of older people with complex needs that compromise independence and require the intervention of more than one specialist to promote well-being. The assessment would typically be undertaken by a specialist multidisciplinary older persons’ care team.

 

 

The different types of assessment need not take place in a linear fashion but do need to be linked to by protocols and procedures as part of a care pathway.

 

 

Hospitals - the general situation
Reports on successful implementation in hospital are scarce. Where implemented the contact assessment has been introduced in the nursing assessment on admission to hospital or at preadmission assessment for elective admissions. The experience has been that some essential details that are necessary in hospital are not part of the minimum data set of the contact assessment used in the community. This has resulted in unsatisfactory procedures for the ward staff. Alternative solutions that have been considered include:

 

 

- A separate hospital contact assessment (against the principles of SAP);

 

 

- Parallel systems (causing further duplication for ward staff);

 

 

- Amendments to the contact assessment to make it more acceptable and useful for hospital staff, particularly nurses (a balance has to be maintained to preserve acceptability to community staff).

 

 

The latter approach, which is supported by the Centre for Healthy Ageing at the University of Sheffield, was taken in Leeds and many barriers that previously hindered SAP implementation in hospital have subsequently been addressed.

 

 

The Leeds experience
Leeds Teaching Hospitals NHS Trust (LTHT) worked with the city’s social services department, Leeds Mental Health Trust, voluntary and independent-sector organisations (Fig 1) and the developers of a nationally accredited assessment instrument (EASYCare, University of Sheffield; available at: www.shef.ac.uk/sisa/easycare/html/home/home_text.html) to arrive at a form of contact assessment that works in both hospital and community settings.

 

 

We opted to use EASYCare assessment because of its credibility for staff experienced in patient assessment, and comprehensive approach to contact and overview assessments.

 

 

EASYCare assessment tools are available in both paper and electronic formats. The project groups introduced a patient-held record and paper system because most areas involved do not yet have the necessary IT equipment.

 

 

Implementation structure
Strong project leadership was key to the project’s success. A trust SAP implementation assurance group was established in October 2003. Chaired by a nurse consultant, its purpose was to ensure that SAP was introduced across the trust’s adult services by April 2004. Membership of this group included assistant directors of nursing and operations, heads of professional groups, and a cross-section of matrons, managers and professional development staff.

 

 

Implementation milestones
Year 1 (2003):

 

 

- Identifying project leadership;

 

 

- Creating interest and ownership of the development;

 

 

- Developing a project plan;

 

 

- Securing corporate support and funding;

 

 

- Developing a comprehensive teaching programme;

 

 

- Agreeing the infrastructure;

 

 

- Gaining momentum.

 

 

Year 2 (2004):

 

 

- Launch of the project;

 

 

- Roll-out across elderly care and orthopaedics (April);

 

 

- Six-month evaluation - recognising the pitfalls (October);

 

 

- Introduction of operational leadership (November);

 

 

- Redesign of process and documentation (December).

 

 

Year 3 (2005):

 

 

- Trial and audit of the new process and documentation (January);

 

 

- Negotiate changes with the city-wide groups/discussions with EasyCARE (January);

 

 

- Relaunch and roll-out across the trust (February).

 

 

Six-month evaluation
In order to inform a planned city-wide evaluation, the trust undertook its own evaluation of SAP using two methods. First, 100 staff were interviewed in focus groups as part of two afternoon evaluation events, then matrons were invited to complete an SAP implementation progress report for their localities.

 

 

Focus group responses ranged from the positive: ‘It gives me the opportunity to really get to know my patients,’ to the negative: ‘It’s great in principle, a nightmare in practice.’

 

 

There was a general concern at the time required to complete contact and overview assessments, and that the task had fallen entirely on nurses.

 

 

Despite the difficulties, staff remained committed to the principle of SAP and wanted to persevere with implementation. They did, however, expect their concerns to be addressed quickly and were not prepared to wait for the results of a city-wide review.

 

 

The evaluation identified the need for urgent action if the trust staff support for the SAP was to be maintained. Some issues identified had significant corporate risk. For example, key information such as reason for admission, past medical history and emergency contact numbers was difficult to access quickly in an emergency. This prompted formation of a working group to propose amendments to the original contact assessment document.

 

 

The purpose of the document prompted much discussion. Could and should it be a means of referral to other agencies, and if so, could it also record reimbursement information? In order to reduce duplication, everyone involved agreed to use the contact assessment as the main referral mechanism between agencies and the means of recording reimbursement information.

 

 

Because Leeds used a paper-based system, assessments were transmitted to other agencies by fax with the patient’s consent. The number of pages in the original contact assessment document posed problems for the fax machines. The document was therefore reformatted to reduce the number of pages without significantly changing the content. The amount of ‘white space’ was reduced, small but significant changes were made to the ordering of information and some pertinent hospital information was added, such as date and time of admission, without detracting from the existing content.

 

 

The role of the EASYCare developers
A distinctive feature of EASYCare has been that users’ views contribute to its continuing development. Changes to the standard tool are only made when emerging scientific evidence dictates or there is an overwhelming consensus of opinion from experienced assessors in everyday practice. Regular user meetings are arranged, supported by a website chat room. Consultancy, provided in association with the University of Sheffield, is available to support SAP project managers and gain feedback from them.

 

 

Overview assessment
The EasyCARE overview assessment is designed principally for use in a community setting. However, in order to maximise continuity between hospital and community assessments, the trust explored its use by nurses as part of the discharge planning process. However, this proved too big a challenge and compliance was low as duplication between the contact, specialist and overview assessments made the amount of time required untenable.

 

 

Overview assessments are now undertaken by case managers (a joint care manager or social worker) to support complex discharge plans. Hospital staff use a bespoke, two-page specialist nursing assessment, designed in conjunction with primary care and social services, for completion by hospital staff discharging older adults with complex needs.

 

 

The overview assessment has, however, been retained for use in conjunction with a range of specialist assessments to provide a comprehensive older people’s assessment and this approach is under development and review.

 

 

Operating the SAP
The SAP process is now operating in Leeds, as follows (Fig 2):

 

 

- All patients over the age of 18 (with the exception of women using maternity services) have a four-page contact assessment completed on admission to the trust (contact assessments have completely replaced hospital admission documentation);

 

 

- Adults with complex needs are assigned a joint care manager or social worker (overview and specialist assessments are combined for comprehensive assessment - this approach is under continuous review);

 

 

- A two-page specialist nursing assessment is used by hospital staff discharging older adults with complex needs;

 

 

- Adults over the age of 65 are given a copy of the contact assessment (and overview assessment if completed) to take home on discharge.

 

 

Positive outcomes
The assessment project has resulted in a number of positive outcomes:

 

 

- Ownership of the implementation process: despite the problems encountered, nurses at the trust never lost sight of the principle of SAP and worked hard to achieve a successful process with effective documentation. The ‘stages of change’ model (Prochaska and DiClemente, 1992) was an inclusive theoretical framework for the management of change;

 

 

- Better communication with patients: the assessment provides a broad base of information on patients’/clients’ home circumstances and aspirations. The framing of the questions prompts staff to spend more time talking to patients and relatives. Positive interaction with staff improves patient experience of care (Webster, 2004; Clegg, 2003);

 

 

- Improved standardised assessment documentation: before SAP implementation the trust identified the range and quality of documentation as an issue. An audit of patient records in January 2005 found that the quality of information collected had improved using the new contact assessment. Patient experience of assessment is yet to be tested, but there is ample evidence in the literature of a positive correlation between effective health needs assessment and positive outcomes of care (Clegg and Doherty, 2001);

 

 

- Communication: communication between wards has improved now that assessment methods are evidence-based and prescribed;

 

 

- Improved patient information on admission: SAP is in the early stages of implementation but the hospital is already experiencing admission of patients with existing EASYCare contact and overview assessments. This reduces duplication and significantly improves communication while reducing the time taken to complete paperwork as part of a hospital admission;

 

 

- Improved information for primary care: feedback from primary care is very positive as district nurses and intermediate care teams receive comprehensive patient information for the first time.

 

 

There is still a significant amount of work to be done in the trust but a good start has been made, with the support of partners in primary care and social services and a responsive and supportive approach taken by the EASYCare developers at University of Sheffield.

 

 

Conclusion
Overall conclusions from the implementation of SAP, which may be applied generally to other organisations, are summarised below:

 

 

- SAP implementation within a single organisation is enhanced by adopting a whole-system approach that includes strong project leadership;

 

 

- It is feasible to have a contact assessment approach that fits the needs of patients both in hospital and in the community context;

 

 

- Implementing the single assessment process in hospital should prompt a radical review of existing systems and result in a simplified and standardised approach;

 

 

- Contact assessment can replace the initial part of the admission assessment;

 

 

- Assessment information should, wherever possible, follow the patient into hospital and form the baseline for assessments that take place during the hospital stay;

 

 

- Overview assessments are most effectively used along the hospital pathway when they form part of the discharge planning process for complex cases;

 

 

- Overview assessments do not add value when they are used as part of the admission assessment;

 

 

- As a result of introducing SAP, improved person-centred information follows the patient on discharge;

 

 

- While awaiting the arrival of the NHS IT strategy (or a local interim SAP software solution), a window of opportunity exists for staff to ensure the principles of the SAP are well-established and practised among staff teams before the additional and challenging requirement to learn a new software application becomes necessary.

 

 

This article has been double-blind peer-reviewed.

 

 

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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