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

Need for Standardised AssessmentIn developing the 'Ageing with Confidence' strategy, we recognised the need for a standardisedapproach to assessment. This was in order that we, as professionals, would speak the samelanguage, share a common understanding and, as such, meet the needs of older people. In order todo this, we had to develop a tool which would be common to all our groups, be they in the acutehospital, community hospital or community setting. This has ensured that older people receiveappropriate, effective and timely interventions to their health and social care needs, and again, Iemphasise social care needs. It has also helped the co-ordination and integration of services andinformation between acute hospital and community settings.Initial AssessmentInitial assessments are conducted by the General Practitioner or the Public Health Nurse. Theadvantage of this is that both are familiar faces to older people. They make use of the .Barthel Index,the ten Point Mental Test Score and also assess home and social circumstances.Such assessments are done only if a need is identified. We question the need to carry outassessments with older people when they are well.Community Hospital AssessmentThe next level of assessment is the community hospital assessment. Community hospitals in Kerryprovide long-stay, respite and palliative care for older people. Community hospital assessments arecarried out by a team comprising a medical officer, director of nursing, physiotherapist, PHN andcontinuing care placement co-ordinator. This team generally meets weekly or fortnightly in eachcommunity hospital to discuss patient care. Discharge plans are prepared for patients who areleaving the hospital, community supports are identified and 'at risk' older people are identified.Specialist AssessmentSpecialist assessment is carried out by the consultant in medicine for the elderly and a multidisciplinaryteam in Tralee General Hospital. Older people who receive specialist assessment arethose whose needs cannot be met in community hospitals or who have complications in terms ofdischarge and continuing care. The purpose of the specialist assessment is to provide an accuratediagnosis of the older people's problem; to arrange co-ordinated treatment from the specialist teamwhich would then try to improve their functional capacity and to examine their rehabilitativepotential. All of this is done in order to improve the autonomy of the older person and to reduce hisor her dependency.Older people are involved in the assessment process. It is not just professionals making a plan forolder people. They have to be part of that plan themselves.Assessment of Older People's Health and Social Care Needs and Preferences