Scottish Government

Chapter One: Care Management Aberdeen

Aberdeen City Council: Social Work Service Care Management Standards 2002

Contents

Introduction
Community Care and Care Management
Care Management - Values and Objectives
The Process of Care Management

Standards
Public Information
Referral
Emergency Response
Screening
Assessment
Care Planning
Implementing the Care Plan
Monitoring
Review and Closure
Monitoring and Reviewing the Care Management Standards

Acknowledgement
This document was produced by a small Working Group which included:
Alistair MacDonald, Head of Quality Assurance
Bill Stokoe, Senior Social Care Manager
Murray Hourston, Senior Social Care Manager
Judith Munday, Social Care Manager
Susan McKechnie, Social Care Manager
Janice Gorman, Social Work Manager

Ref CC 048
April 2002

Care Management Standards 2002 - Introduction

Community Care and Care Management

This document sets out the Standards which apply to Care Management within Aberdeen City Council Social Work Service.

The National Health Service and Community Care Act 1990 gave Local Authorities the lead role in enabling the development of Community Care services. In addition, Aberdeen City Council is fully committed to the Scottish Executive's "Joint Futures" Initiative and "Modernising Community Care", both of which will have a major impact on how community care services are delivered.

The Aberdeen City Joint Community Care Plan identifies the main service user groups as:

• older people
• people with dementia
• people with mental illness
• people with physical or sensory disabilities
• people with learning disabilities
• people with head injury
• children and young people with disabilities
• people with an alcohol or drug problem
• people with HIV/ AIDS
• cancer care
• carers.

Care Management (or "intensive Care Management") is a term describing:

"Any strategy for managing and co-ordinating services for an individual service user in a way that provides for continuity of care and accountability to both user and agency. It comprises core tasks of identification of need, screening, assessment, care planning, monitoring and reviewing." The approach within Aberdeen also includes the provision of certain care services, including counselling.

Care Management - Values and Objectives

The objectives of Aberdeen City Council Social Work Service in relation to Community Care include:

• To promote the development of domiciliary, day and respite services to enable people to live in their own homes wherever feasible and sensible
• To make sure that service providers make practical support for carers a high priority
• To make proper assessment of need and good care management the cornerstone of high quality care
• To promote the development of a flourishing independent sector alongside good quality public services
• To clarify the responsibilities of agencies and so to make it easier to hold them to account for their performance
• To ensure good value for money
• To provide choice
• To allow patients from long stay hospitals to move back into a community setting when it is where their care needs can best be met.
• l To prevent inappropriate admissions to hospital.

(Social Work Service Plan 2000-03)

At the heart of community care are the people who require support and assistance. Care Management should enable care arrangements to be made according to the needs and preferences of individuals. In turn, the following values underpin Care Management:

• respect for the privacy and confidentiality of the individual;
• respect for the individual's dignity and self worth;
• the right of individuals and families to exercise choice;
• the right to protection for those who are at risk of abuse;
• the provision of a comprehensive range of quality services;
• the provision of a positive health promotion strategy;
• equality of access to relevant information, support and care;
• equality of opportunity to develop individual interests and skills;
• user and carer support without undue dependence, or exploitation;
• user and carer participation in the Care Planning process.

Eligibility Criteria have been introduced to try to ensure that those considered most in need of a Care Management service are able to receive one.

1. The Process of Care Management

Care Management depends upon the collaborative working of Care Managers, service users, carers, care providers, health care professionals and other essential contributors to the care process.

This document describes Standards associated with each step in the Care Management process.

• the Key Result is the desired outcome of each stage in the process.
• the Standards specify the Service's expected standards of performance at each stage.

This document could be taken to imply that the process of Care Management is always a clear step by step process. In reality, this is often not the case as there is usually overlap between the steps and some may need to be taken out of their logical sequence.

Actions at all stages of the Care Management process should be recorded on the standard forms prescribed by the Social Work Service and as required within the careFirst system.

The different processes within Care Management should operate consistently across the city.

The main stages of Care Management are illustrated in fig. 1 below.

Fig.1 The Process of Care Management

Standards

1. Public Information

Key result 1: The Social work Service publishes appropriate advice and information about Care Management to all those involved, including service users, relatives, professionals and the general public.

1a) The Social Work Service publishes a leaflet and/or other information on Care Management, which includes:

• The objectives and values of Care Management
• Who is entitled to Care Management, where to get it and how it works
• The types of service available across the statutory and independent sector
• The Eligibility Criteria for receiving services
• The referral, assessment and review procedures
• The standards by which Care Management will be measured local and national charging policies.

1b) The Social Work Service publishes a Community Care Plan which includes developments in Care Management.

1c) Information is clearly produced in a style, language and medium appropriate to those who require it.

1d) Information is appropriately disseminated and is accessible to those who require it. Care Managers are involved in facilitating this process and enabling people to understand the information.

1e) Information on representations, comments and complaints is given to the service user.

2. Referral

Key result 2: Anyone can make a referral for Care Management. The referral process is open, simple and straightforward.

2a) There are no restrictions on who can make a referral.

2b) The Referral process is open, simple and straightforward. Duplication is avoided.

2c) Care Managers work in a pro-active manner towards gathering information needed to ensure service users meet Eligibility Criteria. Written referrals are requested only where necessary to ensure accurate details.

2d) The Care Manager/Team Leader checks that the referrer has made the prospective user aware of the referral and that, unless in exceptional circumstances, consent has been given.

2e) Care Managers establish effective links with potential referring agents eg consultants, GPs, voluntary bodies, etc.

3. Emergency Response

Key result 3: Emergency referrals are considered on the same day and any services necessary to reduce unacceptable risk or to prevent significant deterioration are given on an interim basis. A full Assessment and Care Plan are completed without delay and a package of care implemented as soon as.

3a) Emergency referrals are actioned on the same working day.

• If the referral is received during office working hours and is clearly an emergency request for Care Management, it is passed immediately to the Senior Care Manager who makes a decision on the appropriate response.
• Emergency referrals outside working hours receive an appropriate immediate service from the Out of Hours Service who will make an urgent referral to the appropriate Care Management Team on the next working day.

3b) Services are arranged to hold the situation until a full assessment can be undertaken.

(Special arrangements apply to immediate admissions to Albyn House.)

3c) If funding is required, appropriate authorisation is secured.

3d) A full Assessment and Care Plan are completed without delay and at least within the specified timescales for assessment (see Section 5).

4. Screening

Key result 4: Referrals are processed quickly and effectively with priority given to those in greatest need. The service user is informed of the action taken.

4a) Referrals are screened by the Team Leader/Social Care Manager to ensure that information given is as full and accurate as possible.

4b) Decision on action is taken within 5 working days.

4c) Decision is based on the Eligibility Criteria for services.

4d) Allocation takes place within:

2 weeks of receipt of high priority referral
6 weeks of receipt of medium priority referral
12 weeks of receipt of low priority referral.

4e) Where an urgent response is required, appropriate services are provided immediately on an interim basis.

4f) Where a Care Management service is not indicated, a direct referral on to an appropriate service takes place within 5 working days.

4g) The referrer and prospective service user are informed of the outcome of the referral within 5 working days of receipt of the referral.

4h) The Care Management process and likely timescales are explained to both service user and referrer.

4i) In cases of uncertainty or disagreement about whether a person should receive a Care Management Service, the matter is resolved in the first instance by the Team Leader, with cases of continued difficulty referred to the Social Work Manager (Community Care) for final resolution. This process is completed within 2 weeks of receipt of referral.

5. Assessment

Key Result 5: Needs are assessed promptly and effectively in conjunction with the service user, their carer(s) and any other relevant agency.

5a) Initial contact is made with service user within 1 week of allocation.

5b) Assessment is carried out and recorded within 4 weeks of allocation.

5c) The Social Care Manager will:

• agree the scope and timescales of the assessment with the user
• arrange for a separate assessment for carers if requested or where a conflict of interest arises
• request specialist assessments where appropriate e.g. psychologist, physiotherapist, GP, etc
• seek and record service user and carer views
• record differences of opinion relating to assessment
• make and record a clear evaluation of risk
• ensure that a financial assessment is carried out and service users are informed of the Charging Policy and its implications for them
• agree, with reference to the Eligibility Criteria, the priority needs which will be met
• ensure the assessment is recorded on a document which is clearly identified in the case file, preferably on the common assessment form, and is updated on an ongoing basis
• sign the assessment. (If assessment has been carried out by social worker in training, assessment is countersigned by Practice Teacher/Supervisor)
• ensure that the assessment is signed by the service user or their representative
• inform the service user and/or their representative of their right to a copy of the assessment, and give them a copy (excluding third party information where consent has not been given for disclosure).

6. Care planning

Key Result 6: A personalised Care Plan is discussed and agreed with the service user (and their carer where appropriate). The Care Plan meets as many of the assessed needs as possible and maximises the service user's choice.

6a) All people receiving a care managed service have a written Care Plan which conveys what will be done, by whom, when and how it will be done and at what cost.

6b) The Care Plan is drawn up within 1 week of the date of the completed Assessment or 1 week prior to a planned admission to Nursing Home/Residential Care.

6c) The Care Plan takes account of existing supports and service provision.

6d) The main components of the Care Plan are:

• Name, address and contact number of provider of care (if known at that stage)
• A shared view of the overall aim of the care being provided
• An expression of the Assessed care needs which are to be addressed, which resources are to respond to which needs and the envisaged outcome for the service user
• Frequency and time of care provision allowing for flexibility as determined by the service user's changing needs
• Service user and carer views
• Service user and carer agreement or disagreement with the Care Plan
• The cost of each care component and the total cost of the care package with contribution by service user and Social Work
• Appropriate authorisation is obtained for any planned expenditure
• A note of unmet needs and how these are being addressed
• How care components will be monitored and by whom
• Date of and arrangements for review
• Who will co-ordinate the overall care package, who will monitor and who is to be informed of any changes.

6e) A copy of the Care Plan is given to the service user and, with his/her agreement, is made available to providers involved.

7. Implementing the Care Plan

Key Result 7: Services, as identified and agreed in the Care Plan, are delivered.

7a) The Care Manager takes responsibility for negotiating the services which will be provided and for monitoring that they are actually being provided.

7b) A Service Specification is completed for each service.

7c) The Care Plan specifies the desired implementation date for each service. This is within 1 week of the agreement of the Care Plan, unless the service user's circumstances require otherwise.

7d) Wherever possible, the service user's choice is selected and independence is maximised. Where this is not the case or where there is disagreement, this is recorded.

7e) Each Service Specification is sufficiently detailed to make it clear to all parties exactly what service is to be provided. It includes, at least:

• agreement on the care needs to be met
• how the care will be provided
• details of what will be provided, when and by whom
• costs, including service user's contribution
• where Invoices should be sent
• monitoring and review - how, what, when and by whom.

7f) Services provided are the most cost effective which can be arranged to satisfactorily fulfil the Care Plan and meet the service user's wishes.

7g) Services are only purchased from providers who appear on the Social Work Service's Approved Providers List and who have been Contracted to provide the required service.

In exceptional circumstances where this is not the case, the Contracts Section is involved.

Implications of this are clearly explained to the service user and his/her representative by the Care Manager.

7h) All services purchased are recorded by the Care Manager within the agreed financial systems.

8. Monitoring

Key Result 8: Client need and service provision are regularly monitored to ensure the package of care is implemented as planned. Minor adjustments are made as necessary to meet the user's changing needs.

8a) The Care Manager takes responsibility for setting up monitoring arrangements.

8b) Service user, carers and providers know who is monitoring and how to access them if difficulties arise.

8c) The participation of service user, carers and providers in monitoring are sought wherever possible and their views are recorded.

8d) The Care Manager ensures that the monitoring process covers the following areas:

• care arrangements are in keeping with Care Plan aims and complement each other
• services are delivered according to Service Specifications
• reference is made to written standards of care and other quality assurance mechanisms
• significant changes are reported to the Care Manager and are recorded
• charges are updated in keeping with changing financial circumstances.

8e) All monitoring arrangements are recorded in the case record.

8f) All changes in private or voluntary services are recorded within the agreed financial systems.

8g) All changes to the Care Plan which may affect charges to the service user are notified to the Finance Section (Community Care).

9. Review and Closure

Key Result 9: Needs, Care Plans and packages of care are thoroughly reviewed at the times specified or if there is a significant change in circumstances.

9a) An overall review of the service user's needs and care arrangements takes place on a pre-arranged date.

9b) Reviews of community based care packages take place within 3 months of completion of the Care Plan and at least 6 monthly thereafter.

9c) Residential and Nursing Home reviews take place 6-8 weeks after admission and at least annually thereafter.

9d) The method of review is appropriate to individual circumstances (eg it may take the form of a review meeting or series of less formal meetings with individual contributors).

9e) Wherever possible, the service user is included in the review.

9f) The views of service users, carers, service providers and other professionals are sought and recorded.

9g) The review considers and records:

• the extent to which the aims of the Care Plan have been met to the service user's satisfaction
• significant changes in the service user's needs or circumstances
• whether the care arrangements have been cost effective
• the need to adjust the existing Care Plan in the light of the above.

9h) Unmet need is identified, recorded and reported as appropriate.

9i) Disagreements are brought to the attention of the Senior Care Manager.

9j) Closure:

• the service user, carer and provider are advised when the case is closed to or transferred from Care Management
• cases are closed or transferred in accordance with Social Work Service procedures.

10. Monitoring and Reviewing the Care Management Standards.

Key Result 10: The Social Work Service has monitoring and review systems to ensure that the Care Management Standards are met and are updated as required.

10a) Day-to-day responsibility for monitoring the use of the Care Management Standards lies with the appropriate Team Leader.

10b) The Social Work Manager (Community Care) regularly monitors performance against the Standards and reports to the relevant Departmental Management Team.

10c) The Social Work Service carries out an audit exercise, at least annually, in relation to the Standards.

10d) The results of any such audit exercise are reported in writing to Senior Management within the Care Management Section and the relevant Departmental Management Team.

10e) The Social Work Service reviews and updates the Standards as required and at least on a 2-yearly basis.