Assessment of Older People's Health and Social Care Needs and ...

The Assessment ProcessThe assessment process in Home First, which is illustrated in Figure 2, incorporates a number of keyelements. These are:• collection of baseline information including psycho-social and functional assessments, along withstandardised assessments such as Barthel, Easycare, Mini Mental Test Score andmobility/disability assessment• multi-disciplinary assessment of clinical need as appropriate, with user involvement. (A basicassumption of many standardised measurement tools is the idea of improvement as an outcomemeasure. However, for many clients in Home First, maintenance of their current level of functionand prevention of deterioration are valid goals. This area of assessment remains an ongoingchallenge to the teamdischarge planning, including the production of a care plan, and the collection of qualitative information• monitoring patient progress and identifying barriers that may impede choice• matching patient experience to realistic expectations• ongoing assessment by the team to reflect changing needs and to allow adaptations to the careplan as needed• mechanism for direct referral for reassessment to the fortnightly Home First clinic in Beaumont Hospital.Assessment of Older People's Health and Social Care Needs and Preferences