| Single Assessment Process - training materials hospital discharge The following listing is subject to ongoing review and revision... Ever ready [pilot of "Evercare nurses" in the UK by 10 PCTs] [author: Carol Lewis] (8 January 2004) Article in: Health Service Journal, vol 113, no 5886, pp26-27. A model of care for older people which has helped nurse practitioners to cut hospital admissions and prescriptions through improved risk management is being piloted in the UK by 10 primary care trusts (PCTs), and has been well received. "Evercare nurses" are based on a US model of an expanded clinical role. The pilots report good results in increasing quality of social care. However, there has been criticism of diverted resources and an unthinking importing of US ideas. This article reports on Evercare projects in Airedale, Bristol South and West, Bristol North, and South Gloucestershire PCTs. Contact Details: Tel: | Fax: E–mail: | Web links: http://www.hsj.co.uk | Target group: PCT | Type / Format: article Availability / Price: | ISBN/ISSN: 0952-2271 Notes: Age Concern and Help the Aged Prevention in practice service models, methods and impact [author: Katharine Orellana] (April 2009) The consultation, 'The case for change' (Department of Health, 2008) describes social care services as "the activities, services and relationships that help people to be independent, active and healthy throughout their lives". This publication (100 pp) aims to demonstrate the range of positive outcomes that are possible for older people, organisations and systems when there is investment in preventive services. It is by way of a services directory which is also relevant to the Putting People First agenda. It includes examples of services provided by Age Concern in different localities on information and advice, practical support, support to remain as independent as possible, and support at difficult times and for carers. Three of the case studies relate to the varying effectiveness of the Single Assessment Process (SAP): Waltham Forest Age Concern's Case Finding Service aims to identify vulnerable older people within the community at risk of increased dependency. The Waltham Forest Early Detection Model of Intervention is system for identifying older people with previously unrecognised health and social care needs . GPs in Waltham Forest send a Cardiff-Newport questionnaire to older patients whop are on four or more medications. The questionnaire covers depression, memory, continence, functional decline, social interaction and falls risk. Of 8949 questionnaires distributed between May 2002 and March 2008, 4207 questionnaires were returned to ACWF; 2204 people were referred for single assessment. Concludes that this method more cost-effective than single assessment provision in the statutory sector". Age Concern Cheshire is a partner in SAP and a licence holder under SAP, allowing access to assessment forms and to give feedback to the statutory services online. ACC provides an independent Support Brokerage Service across Cheshire and towards Individual Budgets (IBs) to increase numbers receiving Direct Payments. ACC has been involved in the County Council's Self Directed Support pilot. An Accident and Emergency Diversion and Discharge Support Service is provided in seven hospitals across South Staffordshire. Most of the referrals are from Social Care and Health through their access teams. The service was developed to reduce emergency admissions to hospital, to support older people on discharge from hospital, and to prevent unnecessary admissions to hospital, respite or care homes. Among services provided is an initial assessment, linked to SAP and including risk of falling. Contact Details: Katharine Orellana, Social Care and Support Officer, Age Concern and Help the Aged, Astral House, 1268 London Road, London SW16 4ERT. Tel: 020 8765 7485 | Fax: E–mail: Katharine.Orellana@ace.org.uk | Web links: http://www.ageconcern.org.uk/AgeConcern/bigq-preventioninpractice-report.asp | Target group: All staff, users and carers | Type / Format: case studies Availability / Price: From the address given, or as dowwnload. | ISBN/ISSN: Notes: Age Concern Waltham Forest The future of social care for older people A case study of Waltham Forest [Sheena Scott Dunbar and Jorge Lagos] [30 January 2006] Age Concern Waltham Forest (WF) works in partnership with the LBWF Social Services, WF PCT, Whipps Cross University Hospital NHS Trust , NE London Mental Health Trust and WF Older People's Voluntary Sector Partnership to deliver services for older people across the borough. This presentation to the National Council on Ageing on 30 January 2006 details the various collaborative projects and integrated services developed within the framework of the Single Assessment Process. The projects are: the Waltham Forest model of early detection, prevention and healthy ageing. WF older people's voluntary sector partnership. The WF healthy ageing programme. The WF falls collaborative. Age Concern WF presence at Whipps Cross University Hospital Trust (A&E escorted discharge; welcome home service; discharge lounge and ward project). Age Concern WF link-up project (befriending service; teleconferencing; volunteers). Older people's safety campaign. Age Concern WF information, advice and advocacy service. View presentation Contact Details: Sheena Dunbar, Director, Age Concern Waltham Forest, Ground Floor, Zenith House, 210 Church Road, Leyton E10 7JQ Tel: 020 8558 5512 | Fax: 020 8558 0383 E–mail: s.dunbar@ageconcernwf.org.uk | Web links: http://www.ageconcernwf.org.uk | http://www.wfolderpeople.com/ Target group: | Type / Format: powerpoint Availability / Price: | ISBN/ISSN: Notes: BGS Policy Committee The discharge or transfer of care of frail older people for community health and social support BGS compendium updates : Policy and practice [author: British Geriatric Society (BGS) Policy Committee] (May 2006) An article in the BGS Newsletter, July 2006, issue 6, pp 14-16. One of the primary objectives of the BGS Policy Committee is to respond to the need for statements of policy and good practice which are published as updates in their Newsletter, as well as available on the BGS website, as part of the BGS Compendium (select publications). This update then is directed towards consultant geriatricians but does have relevance to all those involved in the process of discharge or transfer of care of frail older people for community health and social support purposes. It covers the eight Principles involved in the process and then details the Practical Aspects of Discharge Planning. These involve: Local arrangements; patient and Carer Involvement; Referral; Where discharges are straightforward; Accident and Emergency Departments and Medical Admissions units; Care planning; role of the Consultant in geriatric medicine; and, the Discharge Coordinator. It concludes that "... Without careful coordination this process can disintegrate to the detriment of the patient and his/her family." This BGS update is available from the website link given below. Readers are also referred to consult the document "Discharge from hospital pathway, process and practice issued by the Health and Social Care Joint Unit and Change Agent Team, Department of Health in 2003 (ref: 30473) and an accompanying toolkit (Achieving timely simple discharge from hospital: A toolkit for the multi-disciplinary team) issued in 2004; also available from the DH website. Contact Details: BGS Marjory Warren House 31 St John's Square London EC1M 4DN Tel: +44 (0)20 7608 1369 | Fax: E–mail: | Web links: http://www.bgs.org.uk/publications/compendium | http://www.doh.gov.uk/jointunit Target group: SHAs | Type / Format: article/guidance Availability / Price: | ISBN/ISSN: Notes: Camden Primary Care Trust [Camden PCT SAP workshop training materials] (2003) A set of training materials used at a series of workshops in 2003 around how SAP might operate within various situations such as patient discharge and bathing services might be developed. The training materials are as follows: ''Bathing beauties'' ; SAP Case Scenarios: Medicines, support at home, and accessing equipment; SAP Medication scenario; SAP overview report, July 2003; SAP Workshop resources guide; SAP NH placement scenario; Case Scenarios from Monica Riberos. Sandy Keen & Associates produced the overview report, 'Single Assessmnet Process (SAP) in Camden: main points from the workshops on 11 & 29 April; 7, 9, 14, 20,21, 22, 29 May 2003', The report's content is based on notes taken at the workshops by independent consultant/observer Margaret Martin. The workshops were facilitated by Sandy Keen and Christy Austin. The report sets out the key learning points identified by participants; identifies key issues and challenges; provides a resource for senior managers in Camden to promote person-centred care and implement SAP by 2004; and provides a contact list for further activities on SAP. View documents: bathing beauties | Medicines, support at home, and accessing equipment | Medication scenario | overview report | Workshop resources guide | NH placement scenario | Case Scenarios from Monica Riberos Contact Details: Graham MacDougall, SAP Project Manager, Camden PCT, St Pancras Hospital, St Pancras Way, London NW1 0PE Tel: +44 (0)20 7530 3212 | Fax: +44 (0)20 7530 3104 E–mail: Graham.MacDougall@camdenpct.nhs.uk | Web links: http://www.camdenpct.nhs.uk | Target group: PCT/SSD staff | Type / Format: training material Availability / Price: | ISBN/ISSN: Notes: Devon County Council Social Services Delayed discharge supplement Devon, Plymouth and Torbay Health and Social Care Single Assessment Process notification (Nov 2003) Assessment form (4 pp) to be used relating to delayed discharge for the Devon, Plymouth and Torbay Health and Social Care Single Assessment Process. Contact Details: Mike Brooks - SAP Programme Manager; Wendy Brewer, SAP Project Manager Devon County Council, County Hall, Topsham Road, Exeter EX2 4QD Tel: +44 (0)1392 205205 (switch) +44 (0)1392 687141 (direct brooks and brewer) | Fax: E–mail: michael.brooks@exeter-pct.nhs.uk | wendy.brewer@exeter-pct.nhs.uk Web links: http://www.swdhis.nhs.uk:8080/SAP | http://www.devon.gov.uk/socserve/sap/ Target group: PCT/SSD staff | Type / Format: assessment tool Availability / Price: | ISBN/ISSN: Notes: (Website password on application) Other contact: Wendy Brewer, SAP Project Manager. Health and Social Care Change Agent Team, Department of Health Changing times: improving services for older people report on the work of the Health and Social Care Change Agent Team, 2003/04 (September 2004) The purpose of this second annual report of the Health and Social Care Change Agent Team (CAT) is to present best practice guidance and examples of good practice. The Team's broad remit is to support implementation of wider aspects of the National Service Framework for Older People (NSF). The report covers: assessing needs: the care process and pathway; improving capacity and matching needs to services; better commissioning and securing capacity through collaborative working; and partnerships and delivering change through a whole systems approach. Examples of good practice illustrate work on: the single assessment process (SAP); discharge planning; reimbursement (for delayed discharges); intermediate care; mental health services for older people; and housing and assistive technology. The Change Agent Team's first annual report, "Changing places" and covering 2002/2003 focused on some areas of the NSF, but not SAP. View document. Contact Details: Judy McCallum, Finance and Office Manager, Department of Health, Health and Social Care Change Agent Team, Wellington House, Room LG33, 135-155 Waterloo Road, London, SE1 8UG. Tel: 020 7972 1330 | Fax: 020 7972 4349 E–mail: Judy.McCallum@dh.gsi.gov.uk | Web links: http://www.changeagentteam.org.uk | http://www.changeagentteam.org.uk/_library/changing_times.pdf Target group: All staff | Type / Format: policy Availability / Price: FOC (quote 40078 and the tiitle) from DH Publications Orderline, PO Box 777, London SE1 6XH. Tel 08701 555 455. e-mail: dh@prolog.uk.com Also available on request in Braille, on audio-cassette tape, on disk and in large print. | ISBN/ISSN: Notes: |