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

Age Care Evaluation TeamThe next level of assessment is conducted by the age care evaluation team. Essentially, this teamcollates the assessments of the multi-disciplinary team. We also do further assessment with carers,so there is assessment of carer management, difficulties and satisfaction. The team will recommendcare options that aim to meet the needs and preferences of the older persons and their carers. Apackage of care is developed and we then liaise with the GP, the PHN, statutory bodies such as thelocal authority, and voluntary bodies, for example, the Alzheimers Association (always with theconsent of the older person) so as to ease the transition of the older person either to home or tolong-stay care.Reflections on the Assessment ModelStrengths of the ModelThe strengths of our model of assessment are:• the excellence of the inter-professional working• the fact that key staff have embraced the vision of comprehensive, integrated care for olderpeople• the contribution of the Elder Care Group, comprising heads of disciplines, which was set up tosupport the implementation of the 'Ageing with Confidence' strategy in Kerry it identifies servicedeficits and problems; and aims to find solutions to those problems• local multi-disciplinary teams which identify problems at their own level and feed information tothe Elder Care Group.IssuesIssues have arisen in our work as well. The key staff have embraced -the vision which supports ourapproach to assessment, but there are others who are reluctant collaborators. There can bedifficulties with the sharing of information, for example in relation to discharge notifications. We arepiloting a new discharge system to address that issue as I speak.Though we have a framework for a service, we have just one geriatrician and one specialist age careevaluation team, so we do need additional resources.There is a lack of appropriate resources, suchas sheltered housing, in local areas. Another issue is the predominance of the biomedical model.Older people's needs are very complex and a combined bio-social-psychological model would be moreappropriate to meet those needs.Our social structure is changing.An increasing number of older people are living alone and morewomen are working outside the home. There is increasing cultural diversity in our society and we haveto be able to respond to the needs of ethnic groups who have different approaches to ageing and death.We also have to take on the challenge of inter-agency working. Older people's needs encompasssocial needs such as housing and transport. As a health board, we have to recognise those needs andact as a catalyst to bring the services together to meet older people's needs.---Conference Proceedings