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

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Figure 2 Assessment Flow ChartREFERRAL SOURCESBeaumont Hospital staffCommunity-based staffGPsPsychiatry of Old Age Service"Others'"/ALTERNATIVECARE/PLACEMENT INNURSING/11CARE PLANREVIEWEDASSESSMENT BYCARE ORGANISERASSESSMENT BYMULTI-DISCIPLINARYTEAM/Conference Proceedings
How Home First is StructuredThe members of the Home First team are:• the Care Organiser• the Assistant Director of Public Health Nursing• the Domiciliary Care Manager• the Social Workerthe Senior Occupational Therapist• . the Senior Physiotherapist• Registered General Nurses• home support workers.Role of the Care OrganiserThe role of the Care Organiser; as the initial contact for the patient and his or her carers with the project,has been very significant. The Care Organiser helps the older people with the assessment of their needsby ensuring that the appropriate package of care is drawn up, monitored and reviewed regularly.The Care Organiser is the principal advocate who maintains a supportive caring relationship with theolder person and acts as a broker between the different service providers.He or she also ensures that the nature of need presented is matched to the appropriate professionalor community service.Some Reflections on the Role of the Care OrganiserWhile there are many similarities between the role of Care Organiser and the Care Managementmodel practised in the UK and Northern Ireland, there are fundamental differences that have beenkey to the success of the Home First project to date. We have found that the Care Organiser plays animportant role in:empowering the older person in the care process• ensuring that the assessment is needs-led• negotiating with service providers• working all the time as advocate for the patient, without the restrictions of having to manage abudget• acting as a link between hospital and community.While the Care Organiser maintains ongoing contact with clients, no single practitioner or type ofpractitioner, individual prOVider or group can meet the total needs of a client or owns the totalservices system.Assessment of Older People's Health and Social Care Needs and Preferences
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