Assessment and Care Planning

Good practice examples

Why is it important?

Managing access to services

Staffing and care management

Working with Health

Signposts to Sources

 

Good practice examples

Nottinghamshire - Interagency application of best value

Derbyshire - Managing the community care budget - a flexible pot

Why is it important?

Care managers on the frontline make the critical decisions about which services are needed on a case by case basis. Their decisions will collectively have a substantial impact on the council's pattern of expenditure. Getting them to do this well ensures the budget is spent effectively. The joint review team has found that frontline teams which control and are responsible for their own purchasing budgets are more likely to use them imaginatively to get the best solutions for service users.

Councils may take their resources into account when deciding which services will be provided but there should be no blanket policy that excludes certain groups on the basis, for example, of age or a particular service need. They should also ensure that service users with similar needs receive packages of care that produce similar outcomes, although the particular help provided may be different.

Care Managers should:

  • Identify the most cost effective service provision, and include this in care plans
  • Not enter into a significant long-term inflexible commitment unless they are sure needs will not change
  • Be aware of and, wherever possible, support existing formal and informal carers, thereby minimising disruption to the service user and reducing the cost implications for the council.
  • Be aware of transport needs related to any service provision. This should not be a hidden cost but should be a clearly stated part of the agreed care package
  • Provide a written, costed care plan, which is agreed and signed by the service user and their advocate or carer, including:
    • details of assessed needs
    • a risk assessment
    • details of the outcomes expected from the services to be provided
    • details of agreed service provision and costs of providing the service
    • details of any charges to be paid, or of direct payments arrangements if in place
    • agreed involvement of carers
    • a review date
  • Assess in partnership with other agencies. The time saved by this arrangement benefits not only the council and its partners, but also the service user, who is likely to experience the assessment process as more consistent, less stressful and possibly quicker. (Nottinghamshire good practice).
  • Remove perverse incentives such as placing people in in-house residential care when budgets for home care are under pressure. The case scenario in the commissioning module: 'You want to shift the balance of services for older people away from institutional to community-based care' may assist here.

GOOD PRACTICE TIPS

Assessment and Care Management

  • Develop staff to understand the balance between value for money and available resources and always aim to purchase cost effective best value solutions
  • Avoid the temptation to use easy to access in-house services, as they may not be the most effective way of meeting a need
  • Audit assessments and service outcomes and use the learning to inform future packages
  • Never make long term commitments where plans are developed at a time of crisis
  • Provide details of the cost of every element of a care plan and any contributions expected from users
  • Encourage staff to consider innovative packages of care as alternatives to expensive residential and domiciliary packages
  • Make sure the way your budgets are set-up does not discourage preventative packages in the community
  • Use joint posts as a tool to facilitate single assessments or, in Wales, unified assessments.
  • Develop protocols for multi-agency assessments which are realistic and familiar to staff

 

Managing access to services

Some authorities have high numbers on waiting lists for assessment and services. This can lead to draconian gatekeeping procedures in an attempt to bring expenditure down, with complex panel systems and packages being allocated on a 'one out, one in' basis.

This can prove short-sighted as users may deteriorate whilst waiting for a service and as a result enter the service with higher levels of need. It also takes responsibility for putting together a care plan away from the user, the carer and the care manager who have most knowledge of the need. Running panels is also expensive as it often involves large numbers of fairly senior members of staff from several agencies in frequent meetings.

So:

  • Use panels as short-term solutions but at the same time develop commissioning strategies to ensure that your services are responding to changing needs
  • Maximise the availability of low intervention/low cost services to reduce demand for expensive resources
  • Be open and honest with user and carer groups about the sort of choices you are having to make within available resources

Use panels as a short-term not a long-term solution

  • Use panels to develop an agreed understanding on the types of need that different tiers of service will provide
  • Use panels to agree criteria with your partners about shared funding
  • Use panels to support frontline staff and managers in putting together innovative packages and to develop confidence in taking more risk as part of promoting independence
  • Use panels where you want to shift patterns of service and develop your care managers away from traditional packages of care
  • Find out how much your panel costs to run

Once a panel has fulfilled its role, stop, and pass the responsibility back to front line or middle managers.

GOOD PRACTICE TIPS

Devolve Budgets to the front line

  • Devolve budgets so far as is possible to frontline managers and give them responsibility for bringing them in on line
  • Train frontline managers so they understand financial management
  • Revisit your budget lines to ensure there is potential for frontline staff and their mangers to develop and fund innovative packages, this will probably mean beginning to break away from budgets attached to very specific services (see Good Practice Derbyshire County Council) and Finance Module "Flexibility in Managing Budgets"
  • Make sure all care packages are costed, including the cost of in-house services

See also Financial Management.

Staffing and care management

Putting the right staff at the point of initial contact with social services will significantly impact on the quality of assessments and care plan. Getting it right can help minimise costs; on the other hand poorly trained or overstretched staff at the frontline can add considerably to overall costs.

A significant aspect of social services' expenditure goes into funding the cost of providing care management and councils need to keep an eye on this overhead. The proportion spent on care management varies considerably between services but also from council to council.

In authorities reviewed by the Joint Review Team in 2001/2 months the percentage of gross expenditure on older people spent on care management varied from just over 6 per cent to nearly 18 per cent of the total budget (see Exhibit 2).

EXHIBIT 2

Percentage of total gross expenditure for older people on care management

Image

Source: Joint Review Finance and Activity Data, 2001/2

Councils must balance the need for an effective care management service with the need to keep down costs. Experience from joint reviews shows that authorities that follow the suggestions below get the maximum benefit from the staff they have and tend to retain them longer.

GOOD PRACTICE TIPS

Keeping down the costs of care management

  • Plan ahead to match skill levels to availability and anticipate shortages
  • Use vocationally trained staff to provide screening and initial assessment services
  • Determine the level of assessment required at the point of screening and allocate according to the skills required
  • Set targets for the time required to complete assessments and monitor this on a regular basis

  • Minimise the use of agency staff by;

    • Putting in place long-term workforce plans
    • Concentrating as much on retention as on recruitment
    • Using money saved on payment of agency premiums to raise the conditions of service of established staff
    • Reducing unnecessary delays in recruiting to permanent posts
  • Maximise the use of administrative support staff and to release qualified staff time
  • Use the potential of IT to improve efficiency and reduce the burden of administration
  • Recruitment and retention staff can be a problem in some areas of adults services.

For more on this and other aspects of human resources planning go to Children's Module.

Working with Health

Effective joint planning with health will avoid unnecessary hospital admissions and facilitate speedy transfers back into the community. There are two major financial implications of doing this well; avoiding the cost of reimbursements in England and avoiding unnecessarily placing people in expensive residential or nursing home placements.

Good ways of sharing resources with partners in order to deliver your priorities better are explored in the Partnership module. For information particularly related to the potential financial benefits of partnership working see Partnership module.

In addition you may wish to consider the case scenario from the commissioning module: "You want to reduce the numbers of older people who progress from hospital to residential and nursing care" to improve your joint working.

Care Packages Which Include Health Services

There are difficulties in describing and costing care packages which include health and other services. If all parties are able to integrate data from their respective computer systems to produce a profile of users / patients who receive both social care and community health services this difficulty can be overcome.

Independent providers in some instances are willing to separate the costs of the health and care components of particular placements as some authorities are asking for these when considering shared funding.

GOOD PRACTICE TIPS

Working with health

Minimise hospital admissions

  • Undertake an audit with the PCT (Local Health Boards in Wales) to identify those hospital admissions that might have been prevented with better or earlier support in the community
  • Audit the services that are available and develop a range of services designed to keep people at home with support
  • Check your eligibility criteria to ensure that these early interventions are included
  • Prioritise a reduction in waiting times if it means people are deteriorating whilst waiting for a service
  • Focus on services that can be put in place at short notice, including outside office hours

Improve assessments in hospital

  • Sort hospital discharge protocols to ensure everyone knows what is expected of them
  • Develop shared training with health staff to ensure coherent assessment
  • Ensure hospital based staff can access information about resources that are available in the community
  • Develop services that can be put in place quickly
  • Think 'promoting independence' even when initially there may be a need for 24 hour care
  • Review all hospital discharge assessments within six weeks and regularly thereafter until you are sure that there is no potential for significant improvement
  • Where possible don't commit to long-term residential/nursing care until some time after discharge

Signposts to Sources

Additionally there is policy and practice guidance for assessment and care planning for particular groups in: