Customer Pathway Case Management Guide

Transcription

1 Adult Social Care Customer Pathway Case Management Guide 1

2 This guide has been produced as a reference document to support team members from across the customer pathway to ensure work is handled consistently for older people and service users with a physical disability. It covers the remit for Access, Enablement, Hospital Team, Care Management (including Scheduled Review Team) and Brokerage. Customer Journey Overview Access Hospital Screening Assessment Signpost out ICT Health Quickheart RAS No Enablement Potential? Yes Enablement Support Plan Brokerage Yes Specialist Assessment and Complex RAS if required Ongoing care needed? 6 Week Review Procurement to arrange residential packages No Close & set annual review Signpost out Close

3 Customer Pathway Principles These statements are intended to act as a guide to ensure work is correctly actioned at the most effective point: If a worker feels that a query/referral has passed to the wrong team, the case should be fed back to the correct team through an ATM or higher from team to team. Building the integrity and consistency of the pathway is key and work should be routed without delay to the relevant team and should not be actioned by the incorrect team. Cases should be closed promptly and the closing summary completed on CareFirst to aid effective management of any follow up contacts. If you are uncertain as to how to redirect a referral/query for action, phone the relevant team first and gain agreement/location to refer on to, this will prevent cases pinging through the pathway. Unplanned or emergency respite requests are managed by Access team, if the support plan/review does not make provision for the respite then Access will assess as necessary, gain approval and advise brokerage to set up the service. Brokerage can only accept pre-approved/authorised requests for support. Support plans or packages of care must have been approved before activities issued to Brokerage to action. A change in circumstances or change in need is not the same as a statutory scheduled review. The Scheduled Review team within Care Management Services handle planned statutory annual reviews and whole home safeguarding reviews. If a service users circumstances or needs change this is initially handled in Access/Enablement by a combination of stabilising the emergency and re-assessment/delivery of enablement/updating the support plan to incorporate the new circumstances then 6 week review. At this point it may be appropriate to contact the statutory review team to indicate the priority that should be placed on any pending annual review. 1

4 Access Overview To provide information, advice and guidance to residents, carers, health and social care professionals across all client groups, including learning disability and mental health (covering new and existing SU s). This includes signposting to external organisations/services/ Independent Living Resource Centre and directing service users to the web e.g. Advice and Information and Marketplace Determine eligibility Screening assessments, to support effective transition of the referral to Enablement, sensory impairment worker or CMS as appropriate Identifying and actioning urgent safeguarding issues, within 24 hours Assessment (assisted self assessment Quickheart RAS) and associated follow up to stabilise emergency/crisis situations Undertaking assessments for simple equipment and minor adaptations Timeframes Priority 1 within 48 hours: urgent manual handling and palliative, urgent respite All others assessed within 7 days 2

5 Activities Arranging crisis intervention care, Occupational Therapist and Social Worker as required by the presenting issue Short term intervention high need/high manual handling risks/ot (Priority 1) Simple equipment and minor adaptations provision through ILRC Assessment and approval for emergency and unplanned respite Signpost or invite to ILRC tutorial equipment for non FACS eligible enquiries Direct provision of services via screening tool e.g. provision of basic equipment, day care, issuing prescriptions and ICES requests Determine whether alerts should be managed within the Safeguarding process, completion of initial fact finding, implementation of interim protection plan within 24 hours, onward referral to CMS Change in circumstances and change in need, screen for urgency, stablise the case then consider potential for enablement referral or referral to CMS for ongoing intervention Manual handling assessments Assessments for palliative care where there is an urgent need (Priority 1) Assessment and specialist support for people with visual and hearing impairment which includes provision of simple equipment, employment support and mobility training 6 week reviews for SU s who receive support planning from Access team worker 3

6 Hospital Team (Social Work) Overview Access point for adult social care within the hospital Responsible for assessment and signposting to ensure right support is in place post discharge Timeframes Working within Section 2 (notification that an individual has been admitted to hospital) and Section 5 (notification of discharge) timeframes. The hospital has to give minimum of 24 hours notice of discharge. 4

7 Activities In-patient assessment for SU s ongoing social care needs Referrals to Enablement for community discharges Assessment to support individuals who need residential or nursing home support following hospital admission Safeguarding, raising the alert for safeguarding issues originating outside of hospital, completing the full safeguarding process for safeguarding issues arising during hospital stay Engagement with allocated social workers across the pathway about individual SU s needs Completion of Continuing Care Assessments 5

8 Enablement Overview Short term intervention (typically four but up to six weeks support) to maximise an individual s ability to live independently Functional assessment to identify types, levels and expected timeline of interventions completed and progress closely monitored throughout the service Identifying and actioning urgent safeguarding issues within 24 hours Timeframes Assessment within 7 days Enablement Worker support to commence as soon as required 6

9 Activities Enablement Workers deliver service as guided by Enablement Plans, work in conjunction with OTs, Enablement Officers and SWs to enable service user to do as much as they can for themselves Community referral received from Access (completed screening tool) followed by an assessment by Enablement, OT, SW, EO as appropriate Hospital discharge referrals received directly from Hospital team with social worker or OT assessment Change of circumstances or change in need referrals from other Pathway Teams or Brokerage (requests for increase to care package) Service users with an ongoing care need, Enablement will complete assisted Self Assessment (Quickheart RAS), support plan with handoff to brokerage Service users with no ongoing care need, review completed and service ended 6 week reviews for SU s who receive support plan from Enablement team and the hospital teams Residential/nursing placements for service users discharged from the Magnolia Unit Determine whether alerts should be managed within the Safeguarding process, completion of initial fact finding, implementation of interim protection plan within 24 hours, onward referral to CMS 7

10 Care Management including the Scheduled Review Team Overview Specialist OT, SW and review team to provide support for older people and physically disabled service users requiring ongoing SW/OT input to meet their assessment and review needs. Remit of team includes: Safeguarding investigation and action Continuing Health Care Acquired brain injury Sensory (complex) Complex dementia Legal Challenge/Judicial Review Appointeeship Complex family circumstances Transition (children/adults) OT Major Adaptations Paediatric OT MCA/DOLS, Court of Protection Residential/nursing care placements Multiple conditions/diagnosis HIV Disabled parents No recourse to public funds Complex vulnerable adults Declined care package Statutory annual reviews for SU s in residential/nursing home placements and with community support plans 8

11 Timeframes Safeguarding, 5 days to complete initial strategy meeting or discussion New client assessment 28 days Activities Complex support planning Long term placement into residential/nursing care home and self funders in residential care requiring financial support OT major adaptations/major equipment Provision of ongoing professional input into complex cases, in these instances a case will remain open to an allocated social worker No recourse to public funds and assessment of needs Scheduled statutory reviews Safeguarding process including whole home investigations/reviews Care Management will complete assisted Self Assessment (Quickheart RAS), specialist assessment/complex RAS as required and support plan with handoff to brokerage 6 week reviews for SU s who receive support plan from CMS team Implementing the moving on procedures for Transition cases 9

12 Brokerage Overview Negotiate between individuals and service providers, purchase services, monitor capacity, quality and price, identify providers who may assist customers with recruiting PAs and other relevant support Broker and Practitioner work together to manage risk and put in place appropriate services to meet outcomes Team has knowledge and awareness of wide range of community services to support service users needs, drawing on tools e.g. Marketplace as required Provide brokerage advice and information to self funders on request Support service user to set up Direct Payment arrangements Timeframes Support plans implemented within 5 working days Referrals from Brokerage completed within 48 hours 10

13 Activities Implement support plans All service provision except for residential and nursing care is made through Brokerage Implementing approved/planned respite i.e. 4 weeks in a year as part of a support plan Bespoke packages commissioned through DP process to give choice to users Advice to self-funders and signposting and Marketplace Administration to set up direct payments for service users with their preferred payment mechanism 11

14 Glossary of Terms Term Authorisation/ Approval CareFirst Activity CareFirst Message ILRC Observations Description Support plans, personal budgets and placement requests must be approved before being finalised, this is normally competed by a Team Manager or panel process depending on the team and costs involved. Activities are used to record that a task has been undertaken or provide a reminder to do a task and a date it is required by. Activities should be used for all requests for action or authorisation for another team, individual or manager. Messages are sent internally to other Workers or Teams in CareFirst. Messages can be systemgenerated e.g. when an Activity or Event is reassigned. Manually produced messages should be used rarely as they can easily be missed by the intended recipient. Activities should be used when reassigning or referring work. Independent Living Resource Centre, for individuals assessed as requiring equipment. They can try it out before installation/purchase to make sure they get the correct equipment for their needs in the demonstration kitchen, bedroom and bathroom areas, including the latest assistive technology and Telecare. A chronological record of events on a clients CareFirst record. This should not duplicate activities or assessment information but should confirm key events/decisions/evidence/supervision notes and must be completed on the same day. Observations are like a file front sheet, highlighting the stage/ decision and referencing other documents for more detail e.g. assessment. 12

15 Term Panel Prescription RAS Resource Allocation System Referral Screening Tool Specialist Assessment Description Authorisation process to approve a support plan and personal budget for a service user, will involve Team Manager or above depending on costs involved. Issued by Trusted Assessor or OT to enable service user to collect a prescribed simple aid to daily living (piece of low level equipment) from an approved supplier. LBE has two different RAS s. The main one used by Access and Enablement teams is the Quickheart online self assessment tool and RAS. This is used in an assisted self assessment between the service user and assessing officer as the main assessment tool for clients who need an on going service. This tool produces the indicative budget to commence support planning. If a clients needs are not able to be identified by this tool, a specialist assessment and complex RAS will be completed. It is normally only service users being supported by CMS that would trigger this process. Request for social care support or services. Anyone wanting to make a referral to social care will need to complete a Screening Tool over the phone with a member of the Access Team. The questionnaire completed by an Access Screening officer at point of referral/contact to gather sufficient information to know how best to progress the individuals request. To be completed if the Quickheart RAS is unable to cover all of a service users needs. Once complete the worker will complete the Complex RAS to calculate the individual s personal budget. 13

16 HHASC452 Contact Enfield Council Civic Centre Silver Street Enfield EN1 3XY Tel: