WELSH HEALTH CIRCULAR

Transcription

1 WHC (2005) 035 WELSH HEALTH CIRCULAR Parc Cathays Caerdydd CF10 3NQ Cathays Park Cardiff CF10 3NQ Title: Issue Date: 13 th May 2005 Status: Action For Action by: Chief Executives, Local Health Boards and NHS Trusts, Directors of Social Services Action required See paragraphs : 6 to 8 For Information to: see attached list Sender: John Hill-Tout, Director of Performance and Operations, Health and Social care Department National Assembly contact(s) : Gaynor Williams, Directorate of Performance and Operations Pat Vogt, Deputy Chief Inspector, Social Services Inspectorate for Wales Enclosure(s): Guidance attached Tel: GTN: 1208 Llinell union/direct line: Ffacs/Fax: Minicom:

2 Distribution List Chief Executives Chief Executives Director Chief Officer Directors Director Dean Chief Executive Chief Executive Secretary Postgraduate Dean Director information services Secretary Regional Head of Health Board Secretary Welsh Council Representative Wales Secretary Wales Secretary Regional Secretary Regional Secretary Chair Chair General Secretary Assistant Director Officer for Wales IR Officer Regional Secretary Board Secretary for Wales Officer for Wales Regional Secretary Welsh Executive Information Officer National Member for Wales Business manager Chief Executive Librarian Director General Director Patch Managers Secretariat Regional Directors Chief Executive Chief Executive Librarian Chief Executive Librarian Chief Executive NHS Trusts Local Health Boards NHS Confederation in Wales Association of Welsh Community Health Councils Local Authority Social Services Departments Welsh Local Government Association University of Wales, Bangor Commission for Racial Equality Centre for Health Leadership British Dental Association in Wales University of Wales College of Medicine University of Wales College of Medicine British Medical Association (Wales) UNISON Royal College of Nursing (Wales) British Dietetic Association British Orthoptic Society AMICUS MSF The GMB Transport & General Workers Union Community Pharmacy Wales Royal College of General Practitioners Wales TUC Chartered Society of Physiotherapists Society of Radiographers Society of Chiropodists and Podiatrists Union of Construction Allied Trades and Technicians Royal College of Midwives AMICUS Electrical & Engineering Staff Association AMICUS Amalgamated Electrical and Engineering Union Royal Pharmaceutical Society of Great Britain Wales Council for Voluntary Action AMICUS - Guild of Health Care Pharmacists Institute of Health Care Management Welsh Division Association of Optometrists British College of Optometrists Audit Commission (Wales) Business Service Centre Business Service Centres across Wales (6 copies each) Statutory Committees NHS Wales Regional Offices Health Commission Wales (Specialist Services) Health Professions Wales National Public Health Service Welsh Language Board / Bwrdd yr Iaith Gymraeg Health Promotion Library Healthcare Inspectorate Wales

3 HOSPITAL DISCHARGE PLANNING GUIDANCE Summary 1. This Guidance replaces previous Guidance WHC(90)1: Discharge of Patients from Hospital, taking account of the new commissioning arrangements and statutory requirements for partnership working between the NHS and local authorities operating from April It reflects changes following the full implementation of NHS funded nursing care (April 2004), updated Continuing NHS Health Care Guidance and Framework for Implementation (August 2004), updated Guidance on Choice (September 2004), and also refers to the ongoing introduction of Unified Assessment. Full details of all the guidance referred to above are included in paragraph 10 of this Guidance. 2. It asks Local Health Boards to ensure that all NHS trusts have clear procedures to be followed to discharge patients from hospital to the next stage of care, and sets out a number of requirements that local policies should include. 3. Much of this Guidance will not be new but updates the previous circular and restates the key requirements of local multi-agency discharge planning policies and protocols. Where Local Health Boards, NHS trusts and Local Authorities are confident that the requirements of this Guidance are already being met, it is not expected that major changes will be required to such policies by the production of this Guidance. Annex A provides a checklist to assist local health and social care communities in determining the need, if any, for further work. 4. Good Practice Guidance developed and issued by Innovations in Care in October 2004 will further support and inform implementation of the requirements of this Guidance, providing practical advice and support. Purpose of the Guidance 5. The purpose of this Guidance is to: provide revised Guidance on hospital discharge planning in Wales to reflect the new commissioning and partnership arrangements in place since April 2003; set the Guidance within the context of recent policy developments such as Unified Assessment, NHS Funded Nursing Care, and updated Continuing NHS Health Care Guidance; require that Local Health Boards ensure NHS trusts have discharge policies in place that reflect the requirements of this Guidance; 1

4 outline the necessary requirements of local discharge policies, within the context of Unified Assessment. Actions 6. Local Health Boards, working with partner local authorities and all relevant NHS trusts are required to ensure that: as commissioners they have assured themselves that NHS trusts comply with the requirements of this Guidance; local hospital discharge policies have been developed in collaboration with all partners. This will include the Welsh Ambulance Services NHS Trust, local authority and voluntary/non statutory partners; local hospital discharge policies are developed on a multi-agency basis with full engagement and input from partners, and reflect the implementation of policy developments outlined in this Guidance; Unified Assessment is used as the main instrument to deliver effective and responsive assessments; multi-agency systems are in place to monitor, audit and review local hospital discharge policies; and all primary care practitioners, including General Practitioners and members of primary health care teams are aware of both their role in ensuring effective, timely discharge arrangements, and of the requirements of this Guidance. 7. NHS Trusts, working closely with all relevant local authorities, commissioners, and the Welsh Ambulance Services NHS Trust, and in liaison with voluntary and non statutory partners, are required to ensure that: current local policies related to discharge planning comply with the requirements of this Guidance and reflect multi-agency and multiprofessional planning, development and implementation. Explicit implementation and monitoring strategies should support this requirement; multi-agency policies and supporting protocols utilise and reinforce the Unified Assessment process as the main instrument to deliver effective discharge assessments and subsequent arrangements to meet ongoing care needs; all relevant staff are fully conversant with both the requirements of this Guidance and the operation of local multi-agency discharge policies and supporting protocols; 2

5 front line staff are regularly updated and receive training appropriate to their needs related to assessment and the discharge planning process in order to deliver effective discharge planning arrangements; information in an appropriate format is developed and provided specifically aimed at patients, carers, relatives and those staff who will be providing ongoing care on discharge from hospital, to explain the operation of local discharge planning arrangements; and they confirm the above with the appropriate Regional Office of the Welsh Assembly Government by 30 th September The Regional Office will monitor ongoing compliance via trust clinical governance development plans to ensure all relevant commissioners are informed of progress. 8. Local Authorities, working closely with partner agencies are asked to: engage in the development and operation of local multi agency discharge policies and any supporting protocols; inform all relevant staff of both the requirements of this Guidance and the operation of local multi agency discharge policies and any supporting protocols; utilise and reinforce the Unified Assessment process as the main instrument to deliver effective discharge arrangements and subsequent arrangements to meet ongoing care needs; enable front line staff, including care staff whose care services they commission, to be regularly updated and receive training appropriate to their needs related to the assessment and discharge planning process in order to deliver effective discharge planning arrangements; and ensure that they contribute to the development of information in an appropriate format specifically aimed at patients, carers and relatives to explain the operation of local hospital discharge planning arrangements. Definitions 9. Definitions of all key terms are contained within Annex B. 3

6 Scope of the Guidance 10. This Guidance covers all adults. The circular supersedes the previous Guidance WHC(90)1: Discharge of Patients from Hospital and should be read and implemented in union with all other Guidance relevant to assessment and discharge planning, and guidance specific to service groups such as mental health and learning disabilities. Particular consideration should be given to: WHC(2004)024/NAFWC 25/2004: NHS Funded Nursing Care in Care Homes Guidance WHC(2004)54 / NAFWC 41/2004: Continuing NHS Health Care: Guidance and Framework for Implementation in Wales WHC(2002)32/NAFWC 09/2002: Creating a Unified and Fair System for Assessing and Managing Care WHC(2004)066/NAFWC46/2004: Guidance on National Assistance Act 1948 (Choice of Accommodation Directions 1993) Mental Health Policy Guidance: The Care Programme Approach for Mental Health Service Users, A Unified and Fair System for Managing Care, February Learning Disability Strategy: Welsh Office Guidance 1994; Section 7 Guidance on Service Principles and Responses, August WHC(2005)013: Standard Procedure for the handover of Elderly Mentally Infirm Patients between NHS Trusts and the Welsh Ambulance Service. Discharge Arrangements for Children and Young People 11. The National Service Framework for Children, Young People and Maternity Services in Wales will be published in July Within the framework, a number of standards contain recommendations and requirements relevant to the discharge of children from hospital. A selfassessment tool within the Framework will assist local agencies in delivering effective discharge arrangements for children and young people. In addition, further guidance specific to the discharge of children from hospital will be included within Continuing NHS Health Care Guidance and Framework for Children to be developed and issued during However, staff working in adult settings should ensure they refer to the National Service Framework for Children, Young People and Maternity Services in Wales (to be issued in July 2005) and be alert to specific needs and requirements when: planning the discharge of young disabled people who may be at a transition between children s and adult services; 4

7 considering the special needs of women under the age of 18 using maternity services; and considering the specific needs of children and young people receiving NHS in-patient care within other adult wards. Background and Context 13. People being discharged from hospital are entitled to expect and receive a smooth transition from one stage of care to the next. A lack of coordinated and person centred planning for discharge can lead to poor outcomes for patients, possibly jeopardising health and safety or leading to inappropriate readmission to hospital. From a wider perspective poor discharge planning not only contributes to delays in the discharge process and extended and inappropriate lengths of stay in hospital, but can also lead to premature discharge and possible readmission. 14. Planning for hospital discharge is part of an ongoing process and must begin at - or sometimes, as in the case of elective admissions prior to - admission to hospital. The key to ensuring good patient outcomes relies on two factors - the ability of organisations to conduct timely, appropriate person centred assessments, and the responsiveness of services to meet identified needs. If either of these factors is not actively managed discharges can occur too soon, be delayed or be effected to an unsafe or unsuitable environment. 15. For adults, assessments undertaken to support hospital discharge need to be within the context of Unified Assessment (including the Care Programme Approach for psychiatric settings). The Unified Assessment approach to assessment will facilitate the sharing of information between health and social care professionals and should be co-ordinated by a care co-ordinator. The assessment should build a rounded picture of the patient and carer s needs culminating in a service delivery plan which will provide the framework of care and support for discharge. Further detail and implementation timescales on Unified Assessment is provided within WHC(2002)32/NAFWC 09/2002 Creating a Unified and Fair System for Assessing and Managing Care. Where relevant, it is important that information obtained from service providers is considered to inform the overall assessment and care planning process. 16. Many patients discharged from hospital will not require ongoing care from either NHS or social care agencies and the discharge arrangements can be considered simple in nature. However, some patients will require further support, either on a short-term basis to support rehabilitation and recovery, or on a longer-term basis to meet ongoing care needs. These more complex discharge arrangements are likely to be lower in number but will require effective planning and co-ordination utilising Unified Assessment as the tool to identify the nature and complexity of the care required to ensure a positive outcome. Some patients will 5

8 require minimal support and/or interventions on discharge, whilst others will require complex, multi-agency support either on a short or longerterm basis. The differing levels of need and risk the level, quantity, and frequency of care - should be identified and reflected within a Unified Assessment, and the care planning and management approach may include the need to consider a number of care options, which should be recorded within the service delivery plan. Examples of these care options may include (but are not confined to): the need to access Intermediate Care services (WHC(2002)128/NAFWC 43/2002: Intermediate Care Guidance provides further detail), single agency or shared packages of care in a patients own home/community setting, a residential or nursing care placement (including the need to ensure appropriate assessment for NHS Funded Registered Nursing Care - NHS Funded Nursing Care in Care Homes Guidance WHC(2004)024/NAFWC 25/2004 refers), and Continuing NHS Health Care within a range of settings (WHC(2004)54/NAFWC 41/2004: NHS Responsibilities for Meeting Continuing NHS Health Care Needs and Framework for Implementation refers). 17. For people who have low levels of need and are unlikely to require complex care, it may be appropriate to consider the use of support schemes developed and run by voluntary agencies. In addition, voluntary organisations may contribute support services as part of more complex multi-agency care provision. The need for these services should be considered by commissioners when ensuring a full range of services is provided to meet need. If voluntary organisations are to provide support on discharge they must be involved in the assessment and care planning process. 18. Separate Guidance issued as Welsh Health Circulars/National Assembly for Wales Circulars and referred to in Paragraph 10 provides further detail on Intermediate Care, NHS Funded Nursing Care in Care Homes and Continuing NHS Health Care. This Guidance will therefore not refer to those areas in detail, but will provide linkage as necessary. Collaborative Working 19. Effective multi-agency and multi-professional working is essential to ensure the successful management of discharge from hospital. Decisions on further care requirements following hospital discharge are based upon professional assessments of health, social care and other related needs, taking into account the patient s views and consideration of the views of relatives, advocates or others who know the patient well, within the context of Unified Assessment. It is essential therefore that the input 6

9 from professionals and others to these assessments is co-ordinated effectively and in a timely and responsive manner. Developing and working to agreed joint local protocols helps to ensure these outcomes. Similarly, it is important to deliver services in a co-ordinated way to ensure there are no gaps in services or duplication of efforts. 20. Effective partnership working will support the implementation of Unified Assessment and enable effective assessments to be undertaken to inform safe discharge and future care planning. 21. Effective communication at all levels and across all organisations, including relevant non-statutory agencies is necessary for the patient to experience a co-ordinated patient journey from pre-admission through to hospital discharge. The Discharge Process Key Principles 22. The following are to be considered as key principles of discharge planning and local multi-agency policies and supporting protocols must reflect them: Planning for hospital discharge must begin at, or in the case of elective admissions before, admission to hospital. It should be considered as a process not an event. Planning for hospital discharge requires the input and engagement of all appropriate members of the multi-disciplinary and multi-agency team. In addition to trust and local authority staff, it is important that these planning arrangements include the Welsh Ambulance Services NHS Trust and voluntary/non statutory partners. The individual s interests and wishes are central to the hospital discharge planning process and are taken into account when considering future care options. The assessment and discharge process must be person centred and involve regular consultation with the patient and his/her family/carer/advocate, and where appropriate paid care staff or providers of services. The hospital discharge process should be co-ordinated by a named person who has responsibility for co-ordinating all stages of the patient s journey. The further development of integrated care pathways will facilitate and support the management of discharge arrangements as an ongoing process. A whole systems approach to assessment, commissioning and delivering services will facilitate effective hospital discharge arrangements. Implicit within this is an ethos of multidisciplinary and multi-agency working, to include housing, support and other needs which relate directly to the individual s health and wellbeing. 7

10 The ability to discharge effectively is dependent upon the availability of a range of services to meet ongoing or longer-term care needs. Local Multi-agency Discharge Policies: Key Components 23. NHS trusts are expected to work with partners to ensure that local multiagency discharge policies include the key components identified within this Guidance. This list should not be viewed as definitive or exhaustive - local policies should reflect any other key elements considered necessary to effect safe, timely hospital discharge arrangements. 24. Hospital discharge policies must include the following key components: actions to ensure safe and timely discharge arrangements are initiated prior to or as soon as possible after admission. The process of planning discharge from hospital needs to operate concurrently with clinical care to ensure timely discharge is effected. This helps to ensure that patients clinically fit for discharge - determined by the clinician responsible for the in patient care, in consultation with all necessary colleagues in the multidisciplinary and multi-agency team are able to be transferred to the next stage of care in an appropriate and timely manner; multidisciplinary and multi-agency working is reflected both within the discharge policy and discharge arrangements; hospital discharge planning is seen as a continuous process that takes place seven days a week. Whilst not all members of the multi-agency team may be available on this basis, communication, co-ordination and planning can and should continue. This will be particularly significant in planning simple/non complex discharges which comprise the majority of hospital discharge arrangements; the discharge policy is implemented within the framework, context and principles of Unified Assessment and the care management approach. In the event of patient transfer, either to another ward within the same hospital or to another hospital/trust the assessment information collated to inform care planning must be shared with the receiving area to avoid duplication of assessment and potential extended lengths of stay; a named individual/care co-ordinator is responsible for co-ordinating progress through the system, including discharge planning arrangements; the provision of an estimated discharge date, reviewed and amended as necessary, to assist in the planning of discharge arrangements should be considered. Recent work undertaken by the Modernisation Agency has 8

11 demonstrated that predicting the length of stay is fundamental to timely discharge. The provision of a documented discharge date allows families and carers the opportunity to plan for discharge and can reduce the demand for hospital transport, including reducing demand for ambulance transport. Variations in predicted and actual discharge dates need to be monitored as part of the overall discharge planning audit arrangements in place; a process/review to ensure all arrangements are in place on the day of discharge. This should include ensuring all equipment, transport, medication and ongoing needs for services have been identified, planned for and met in a timely manner. The ability of the patient to manage their medication at home should be assessed and arrangements made as appropriate to ensure ongoing compliance; clarification of roles and responsibilities for each professional group, including responsibilities for co-ordinating all staff involved in the discharge process, both directly within the hospital and within community settings; patients and their carers/families are fully engaged at all stages in the hospital discharge process. Where appropriate, information obtained from paid care staff or providers of services should be taken into account as part of the overall assessment process; patients and their families and/or carers are provided with written and verbal information in a range of formats appropriate to them, taking into account any sensory or spoken language needs. The information should include details of arrangements and any relevant information regarding their future treatment and care; local audit arrangements operate to ensure the discharge policy and the supporting documentation are consistently and effectively implemented and applied. This should include user feedback, and be considered within the context of continuous improvement and the wider clinical governance responsibilities of both NHS trusts and Local Health Boards. Multi-agency training is provided to all staff involved in discharge planning. This should include both training as part of an induction programme and regular and pertinent updating to a multi-agency agreed, developed and implemented programme. Specific training within this context needs to be provided for closely related policy areas (for example Continuing NHS Health Care) to ensure staff are fully conversant with their role in assessment and care planning. specific protocols are in place and embedded within the discharge policy related to: - locally agreed standards for response times for all agencies; 9

12 - locally agreed information sharing protocols, including the need to ensure the provision of timely, legible discharge information to GPs and other community based staff providing follow on care. The need to provide summary information on diagnosis and treatment - both current and planned - is essential. Local audit arrangement should include this requirement in order to monitor compliance; - agreed referral procedures for assessment and intervention, including procedures to ensure referrals to all professional groups are appropriate, necessary and timely; - any required assessments for NHS funded nursing care eligibility (NHS Funded Nursing Care in Care Homes Guidance WHC(2004)024/NAFWC 25/2004 refers); - Continuing NHS Health Care assessments and procedures (WHC(2004)54/NAFWC 41/2004 refers); - carers assessment (Carers and Disabled Children Act 2000, Guidance to the 2000 Act, Practitioners Guide to Carers Assessment and The Carers (Equal Opportunities) Act 2004, to be implemented in April 2005 refers); - people who are homeless to ensure they are assessed in a timely manner to determine whether they have access to accommodation on discharge. Arrangements should also ensure that where people are returning to accommodation that is likely to have a negative impact on their mental or physical health and wellbeing, they are referred to specialist housing advice and home adaptation services. This will require early and effective liaison and communication with all relevant services and agencies; - explicit procedures for cases where patients do not have the mental capacity to represent themselves. Reference also needs to be made to patients subject to the Mental Health Act (1983) (Mental Health Act Code of Practice 1983 refers). The principles within the Act will need to be taken into account when arranging discharge both from mental health in-patient care and for patients with mental health needs within general hospitals/nhs facilities; - people with learning disabilities. The Learning Disability Strategy sets out the key principles to be considered and included within discharge arrangements. - the additional considerations to be taken into account when arranging discharge for vulnerable groups. This would need to consider Adult Protection procedures and provide guidance to front line staff on any additional factors to be considered. This would also be pertinent to those staff working in Accident and Emergency 10

13 Departments where vulnerable patients may be discharged directly home; - use of interpreters, translators, and advocacy services; - access to intermediate care and rehabilitation services; - access to any additional early discharge schemes operating, either to care homes or for enhanced short term packages of care in community settings; - care home placements including directions on choice and local protocols related to the management of choice. WHC(2004)066/NAFWC46/2004:Guidance on National Assistance Act 1948 (Choice of Accommodation) Directions 1993 provides further information; - the management of discharge from hospital against medical advice and refusal of discharge, and - the management of discharge directly from Accident and Emergency Departments. Accountability 25. Each professional group will be required to work within their professional framework and be accountable for their actions. The implications of this in ensuring hospital discharge is safe, effective, and to a suitable setting need to be considered by multi-professional and multi-agency teams. Explicit and shared agreements related to each individual s role and responsibilities as part of the multi-agency team will support effective organisational accountability arrangements. Performance Management 26. All agencies will need to ensure they have in place local audit systems to provide them with valuable management information on the effectiveness of their hospital discharge arrangements. Such systems should include user perspectives and feedback. In instances where discharge planning has proved to be ineffective, leading to an inability to discharge in a timely manner or possibly to hospital readmission, this information needs to be shared and analysed to inform review of the local policy and any additional training needs that arise. 27. Delays in timely discharge and transfer arrangements are reported to the Welsh Assembly Government through a monthly snapshot census. This data provides valuable management and commissioning information and 11

14 assists local health and social care communities to identify gaps in service provision and analyse reasons for delays in order to inform service planning and redesign. Local Health Boards, NHS trusts and local authority social services departments all have an important role to play in ensuring this information is used and acted upon. 28. The Regional Offices of the Welsh Assembly Government monitor delayed transfers of care performance as part of their wider performance management responsibilities related to the delivery of the Services and Financial Framework (SaFF) operating in Wales. The Role of Commissioning 29. Commissioners need to ensure that services provided meet identified needs and collect and utilise management information on discharge planning to ensure the timely availability of services. Effective and timely discharge requires the availability of appropriate and alternative care options to ensure identified needs are met. The need for service development or redesign to reflect the provision of effective assessment and discharge arrangements should be reflected in the Health, Social Care and Wellbeing Strategies, commissioning plans, and relevant contracts for service provision. 12

15 ANNEXES Annex A: Checklist of Key Requirements As referred to within the main text of this Guidance, much of the Guidance is not new, but updates and reinforces current arrangements related to discharge planning. Where Local Health Boards, NHS trusts and local authorities are confident that the requirements of this Guidance are already being met, it is not expected that major changes will be required to such policies by the production of this Guidance. The following checklist will assist local organisations to determine specific areas of current discharge policies and protocols that require further development. STATEMENT SELF ASSESSMENT Discharge Policies and any supporting protocols have been developed on a multi-agency and multi-professional basis, including consultation with voluntary/non statutory partners and the Welsh Ambulance Trust. Multi-agency and multi-professional working is reflected within the discharge policy and arrangements. Patients and their families/carers are fully engaged at all stages in the discharge process. Discharge planning commences on or as soon as possible after admission to hospital. In the case of elective admissions, planning commences prior to hospital admission. 13

16 The use of estimated discharge dates is implemented. Estimated discharge dates are reviewed as necessary, with a monitoring of predicted and actual discharge dates used as a local performance management tool. Discharge planning is a process that operates 7 days a week. The discharge policy and supporting protocols reflect the principles of Unified Assessment. A named individual/care co-ordinator is responsible for co-ordinating the discharge planning arrangements. Roles and responsibilities are clearly defined and shared. Audit arrangements monitor the application of the discharge policy and supporting protocols. Information in a range of appropriate formats is available specifically for patients and their families/carers. Multi agency training is provided within both induction programmes and regular updating. Training includes both hospital discharge arrangements and specific areas such as continuing health care. Locally agreed response times are included as a specific protocol within the discharge policy. 14

17 Locally agreed referral procedures are included as a specific protocol within the discharge policy. Locally agreed information sharing protocols are in place, to facilitate a unified approach to assessment. A process exists to ensure timely, legible discharge information is provided to GPs and other community based staff who will be providing follow on care. Local audit arrangement should include this requirement in order to monitor compliance. Specific protocols exist relating to care home placements, including local protocols on choice and assessments for NHS funded nursing care eligibility. Specific protocols related to continuing NHS health care assessment requirements and procedures are included within the discharge policy. Guidance on carers assessments is provided. Guidance is included on the management of safe discharge arrangements for homeless people. Procedures exist within the discharge policy to protect patients who do not have the mental capacity to represent themselves. 15

18 Reference is made to additional considerations for vulnerable groups, with clear linkage to Adult Protection procedures. The procedure to access interpreters, translators, and advocacy services is included. Processes to access and refer into intermediate care services. Protocols exist to support access, eligibility and referral into early discharge schemes operating, either to care homes or enhanced short-term community based support. Specific protocols relating to the management of refusal of discharge and discharge against medical advice, including the procedure to obtain legal advice where necessary. Specific guidance is provided on discharge directly from Accident and Emergency Units. 16

19 Annex B: Definitions The following terms are used within this Guidance: Assessment The process whereby the needs of and risks to/from an individual are identified and their impact on independence, daily functioning and quality of life is evaluated, so that appropriate action can be planned. Assessment involves both professionals and those with the needs thinking through different explanations for how the needs have arisen, and how different needs interact with each other. Assessments should cover the following three systems: the service user system, the informal care network system, and the formal care network system. Assessment starts from the first of these and moves outward. Further information is obtained within the Guidance WHC(2002)32/NAFWC 09/2002: Creating a Unified and Fair System for Assessing and Managing Care. Complex When the patient s needs are complicated, due to the interaction of multiple factors that require frequent assessment and/or review. Continuing NHS Health Care This describes a package of health care arranged and funded solely by the NHS. WHC(2004)54/NAFWC 41/2004:NHS Responsibilities for Meeting Continuing NHS Health Care Needs: Guidance and Framework for Implementation in Wales provides further information. Intermediate Care A range of usually time limited services, involving cross professional and agency working, provided on the basis of a comprehensive assessment, which have a planned outcome of maximising independence, targeting those who would otherwise face a prolonged hospital stay or inappropriate admission. (WHC(2002)128/NAFWC 43/2002: Intermediate Care Guidance provides further detail). NHS Funded Nursing Care The funding by the NHS of the care by a registered nurse in a care home providing nursing. (NHS Funded Nursing Care in Care Homes Guidance WHC(2004) 024/NAFWC 25/2004 refers). 17