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

_f.--------------Some issues have been raised for us within the project in relation to the Care Organiser role.Dependency can build up between the client and the Care Organiser or a particular care teammember. Family dynamics, related to social issues within the family, can emerge that are outside therole of the Care Organiser and that impact on the implementation of the client's Care Plan. Thecommunication and n'2tworking dimensions of the role of Care Organiser can be very timeconsuming.We under estimated the time needed for these functions at the outset and the amount oftime that the Care Organiser would have to give to each client.-'----------------The aim of the Care Plan is to detail the action to be taken in each case to meet the needs andobjectives identified in the assessment. The Care Plan should identify:• the assessed need• overall objectives of the plan• specific objectives of each service input/outcomes to be achieved• when services are to be providedunmet needs• monitoring and reviewing arrangements. The means of measuring the outcome will include theability of the older person to remain at home, reduced hospitalisation and quality of life for olderpeople and carers.Current Status of Home First ClientsThirty-nine clients have been involved in the Home First Project. Of those, eighteen are at home,five are awaiting discharge home, three are in nursing homes, two are awaiting assessment, two arecurrently hospital in-patients and nine have died.Key Service RequirementsThe service requirements that are necessary to optimise the value of Home First for clients are as follows:• comprehensive home packages of care which can provide home support around the clock, sevendays a week• flexible working hours• staff with transport to keep in touch with older people• support for family and informal carers• flexible respite• the involvement of the General Practitioner• services tailored to each individual's needs with personal preferences and choice to be taken into account• involvement of all agencies and professionals from community services and Beaumont Hospital inthe assessment procedure, as appropriate.Conference Proceedings