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OVER 65 YEARS COMMUNITY CARE PLACEMENT TOOL
Name of Service User............................................................. D.O.B. .........................................
Address: .....................................................................................................................................................
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This is the first score | This is a review |
The purpose of this form is to assist the process of identifying the care setting most appropriate to meeting the needs of a service user. The form should be completed by a competent clinician, who may be the case manager or lead clinician. Scores should be based on valid multi-disciplinary assessments.
This process will require the involvement and judgement of appropriately qualified and experienced professionals such as doctors, occupational therapists, physiotherapists, psychiatrists. registered nurses, social workers, specialist nurses. Prior to completing the placement tool the assessment details sheet must be completed. Without this the tool will not be accepted as valid for placement purposes.
It is essential that before this scoring form is completed that consent is gained from the service user and their perspective and expectations are taken into consideration in any decisions that are made.
On completion of the scoring process, the form and any additional relevant information should be forwarded to the relevant establishment for a funding decision to be ratified .
Where it becomes apparent that the Service User's needs are extremely complex then a full case conference may be required before a decision can be proposed..
To complete the form, under each section, tick only one category where the section is relevant to the service user . If the section is not relevant then leave the section blank.
ASSESSMENT DETAILS
TYPE OF ASSESSMENT | COMPLETED BY: | DATE |
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ASSESSMENT SHEET COMPLETED BY: PRINT NAME AND DESIGNATION: SIGNATURE:
DATE:
Category | Type of Assistance | Tick appropriate box |
Nutrition and Hydration | Needs Assistance with shopping Diabetic or special diet Eating aids Physical feeding/help with drinking Verbal prompting Gastrostomy feeding PEG if independent and self caring |
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Nasogastric tube feeding Swallowing problems Parenteral feeding Gastrostomy feeding PEG requiring supervision |
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| Dysphagia with risk of aspiration requiring complex care plan |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Elimination | Needs verbal prompting or orientation Occasional urinary incontinence Occasional faecal incontinence Ostomies - ileostomy, colostomy etc. if self caring |
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Constant incontinence - urine faeces both Catheterised (must have specialist intervention from continence advisor) Ostomies - if need staff intervention Regular enemas Assisted evacuation of bowel |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Skin Integrity | Chronic wound requiring regular dressing from Registered Community Nurse* or hospital out-patient department e.g. leg ulcer Post - operative wound care requiring dressing from Registered Community Nurse* or hospital out-patient department |
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Pressure Sores - superficial red area - Stage 1 pressure sore managed under supervision of Registered Community Nurse* |
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Stage 2 pressure sore Stage 3 pressure sore Stage 4 pressure sore |
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Stage 4 pressure sore requiring the intervention of two or more RNs or non topical treatment e.g. mechanical pump |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Medication | Dispensing of oral medication Application of ointment/eye drops Application of creams/ointments etc. |
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| Administration of rectal preparations (suppositories) by a Registered Community Nurse Intramuscular injections by Registered Community Nurse* or GP |
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Intravenous/subcutaneous infusions Intravenous bolus drugs |
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Patient whose condition is unstable and unpredictable requiring frequent change in dosage and administration of medication. |
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Comments |
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Category | Type of Assistance | Tick appropriate box | |
Personal Care | Some assistance with dressing, washing and bathing Regular eye or mouth care |
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Requires moderate assistance with personal care needs |
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Completely dependent on staff for all personal care needs |
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Comments: |
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Category | Type of Assistance | Tick appropriate box | |
Pressure Relief | Minimal risk requiring - standing regularly change in position occasionally |
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Vulnerable requiring care supervised by a Registered Community Nurse* - change in position regularly - pressure relieving device/s |
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Elevated risk requiring - establishing and evaluation of repositioning schedule - requires alternating or other high tech mattress plus change in position |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Mobility and Transfer | Unable to complete household tasks Mobile with walking aid Mobile requiring supervision from one person |
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History of multiple falls Able to weight bear and requiring limited assistance from one/two people with walking and getting in and out of chair/bed Wheelchair independent |
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Very limited mobility requiring constant supervision of two or more people for walking and getting in and out of bed Totally immobile requiring sling hoist at all times Wheelchair dependent |
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Complex needs requiring RN intervention for every transfer and position change, e.g. pain, osteoporosis, contractures etc |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Epilepsy | Well controlled on medication |
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Seizures occur but good recovery |
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Rectal diazepam required to aid safe recovery |
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At risk of status epilepticus |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Memory & Orientation | Safety and well being can be maintained at home by means of family support, if necessary supplemented by a care package In a residential environment regular but not constant observation. is sufficient to maintain safety and well being. |
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| Requires 24 hour support to ensure safety and well being. Has memory and orientation problems but does not wander; may have some sleep problems but does not wander at night; is amenable to interventions. |
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| Memory loss and poor orientation result in wandering during the day to the extent that a monitored or restricted environment is necessary. May wander at night. Loss of orientation has noticeable and negative effect on interactions with others and responsiveness to interventions. |
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| Has advanced dementia with severe memory loss, confusion and lack of orientation. Close observation and monitoring by trained psychiatric staff in a restricted environment is essential to ensure safety. |
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Comments |
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Category | Type of Assistance | Tick appropriate box |
Chronic Mental Health Problems | Is suffering from a long standing mental health condition such as bi-polar disorder, chronic anxiety, depression or schizophrenia, which is monitored and dealt with by the GP; may receive home based support from a member of the community mental health team; may attend as an out patient to mental health services for specialist medical support. . |
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| ** Is suffering from a long standing mental health condition as described above but requires a supported and supervised environment to ensure well being and safety. There will be a need for staff to have received additional NVQ level training in caring for these clients with active support from the community mental health team. |
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| Has a chronic mental health problem which could necessitate intervention from a qualified psychiatric nurse at any time during a 24 hour period. |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Behaviour | Mild behaviour disturbance, restless, occasionally not amenable to receiving personal care but not to the extent that care is compromised. |
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| Exhibits behaviour which requires liaison and advice from community mental health staff. Presentation could include repetitive behaviour/conversation, may communicate only by means of non-verbal cues. However provided the client is appropriately supervised he/she does not put herself or others at risk. No overt aggression to other residents/clients. May be reluctant to receive personal care but not to the extent that care is compromised. |
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| Exhibits behaviour which requires skilled intervention and management in co-operation with community mental health services. Unsociable, uninhibited, repetitive behaviour/conversation, uncommunicative or other behaviour which is likely to disturb other residents' person or possessions, unsociable behaviour at mealtimes but does not put themselves or others at risk. Requires ongoing mental health assessment from community mental health services. |
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| Challenging behaviour to staff and other residents Unable to maintain personal safety without constant staff monitoring Detention under Article 7 of Jersey Mental Health Law (Treatment Order) |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Diabetes | Well controlled on diet/medication |
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May be prone to regular hypoglycaemic attacks and needs regular monitoring |
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Unstable requiring continuous monitoring of blood sugar with frequent changes in insulin Regularly requires interventions, e.g. glucose orally/IV |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Pain | Mild to moderate controlled by analgesia |
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| Severe pain requiring regular interventions and analgesia under the supervision of a Registered Community Nurse* |
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| Unable to communicate moderate to severe pain requiring regular interventions and analgesia Intolerable pain requiring syringe driver/injections all or most of the time |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Breathing | Mild problems self controlled by inhalers and nebulisers |
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| Requires supervision with inhalers and nebulisers On continuous oxygen therapy managed with minimal assistance |
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| Continuous oxygen therapy plus unstable respiratory condition requiring regular interventions |
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| Requires artificial ventilation |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Sleep | Interrupted sleep pattern but stays in bed/or has sufficient mobility to get out of bed safely/or will summon assistance. |
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| Interrupted sleep pattern with some confusion and/or difficulties in settling back to sleep; doesn't summon assistance; doesn't wander. |
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| Poor sleeper due to confusion and prone to wandering |
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| Disturbed sleep pattern due to confusion, prone to wandering and presenting with challenging behaviour Complete change of diurnal sleep pattern – changes night into day |
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Comments: |
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Category | Type of Assistance | Tick appropriate box |
Sensory Impairment | Partially sighted/deaf |
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| Totally blind/deaf |
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| Unconscious |
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Comments: |
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KEY
Home Care or Residential Care | High Dependency Residential Care | High Dependency EMI Residential Care |
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Standard Nursing Care | High Dependency Continuing Nursing Care | High Dependency EMI Nursing Care |
* This does not include a registered nurse working for a residential home. ** These clients to be placed in a residential home with mental health registration
SCORING - add up the ticks for each category
Home Care or Residential Care Total | High Dependency Residential Care Total | High Dependency EMI Residential Care Total | Standard Nursing Care Total | High Dependency EMI Nursing Total | High Dependency Continuing Nursing Care |
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• If there is a score of less than 6 in the Residential Care section, the possibility of supported home care should be considered.
• If there is a score of 1 or more in the nursing home section, the client will require care provided in a nursing home setting.
• If there is a score of more than 5 in the high dependency residential care section, then a multidisciplinary case conference should be carried out to establish the most appropriate care setting for the client.
• Any score in the high dependency mental health residential care section will indicate that the client requires care to be provided in a home registered for Elderly Mental Infirm (EMI) under the category of mental disorder.
• Any score in the high dependency continuing nursing care requires care to be provided in a hospital or nursing home with equivalent facilities and standards.
• Any score in the EMI nursing section requires the client to be placed in a Registered Mental Nursing Home or long stay hospital.
• Where a client scores in both high dependency continuing nursing care and high dependency EMI care, the most appropriate setting should be decided by a multidisciplinary case conference.
CONCLUSION:
This service user's needs require:
SUPPORTED HOME CARE
RESIDENTIAL CARE HIGH DEPENDENCY RESIDENTIAL CARE HIGH DEPENDENCY MENTAL HEALTH RESIDENTIAL CARE NURSING CARE HIGH DEPENDENCY EMI NURSING CARE HIGH DEPENDENCY CONTINUING NURSING CARE
Is the service user in agreement with the placement outcome?
YES NO UNABLE TO CONSENT
If no what is the service user's preference for placement? (Please specify)
Where there is a discrepancy between the placement outcome and the service user's wishes, refer to placement panel for complex care package.
Name of Scorer Signature of Scorer
....................................................................... . Date of Completion............................................ Future Date of Review..........................................
Names of staff attending MDT/ Case Conference where applicable Name Designation
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. . ..