CM A2 Establish an individual's functional capabilities in the context of long term conditions clinical management

Overview

This standard covers assessing an individual who has a long term condition and whose functional capabilities need to be assessed as part of an overall assessment process for case management. While the functional assessments identified in this unit are most typically called for in relation to the older person, they would be applicable to a child or young person and an adult of working age as well if the circumstances demanded it. This standard is relevant to those who provide proactive and co-ordinated Case Management. Here, Case Management means identifying and risk stratifying vulnerable, high-risk people with complex multiple long term conditions. Case Management should take place within the philosophy of enabling and promoting self care, self management and independence. Users of this standard will need to ensure that practice reflects up to date information and policies. Version No 1

Knowledge and Understanding

You will need to know and understand:

1. the reasons why your role, responsibilities and accountability should always be explained
2. procedures for securing the work environment prior to interaction with the individual
3. the importance of securing the environment
4. risk assessment methods and how to identify the different levels of risk possible for an individual
5. the impact of age and development on an individual’s capabilities e.g. sensory impairment, cognition, confusion, anxiety, decreased mobility
6. why it is important to establish informed consent to the assessment you are intending to make and how to proceed when consent cannot be, or is not provided by the individual directly
7. the methods that are used to obtain informed consent and how to confirm that sufficient information has been provided on which to base this judgment
8. the steps you should take when unable to arrive at a satisfactory judgment
9. the importance of clear communication in clinical situations
10. the importance of recording information clearly, accurately and legibly
11. why it is important to be aware of the pitfalls of stereotyping the individual and the effects of this on assessment
12. the methodologies and equipment used to assess capabilities in relation to:
1. mobility
2. function in relation to the activities of daily living
3. cognition
4. perception
13. what information you need to gather and use to form an accurate picture of the individual’s capabilities and needs
14. the difficulties that can arise in reaching a judgment on the capabilities and needs of the individual
15. the steps you would take to ensure that the privacy, dignity, wishes and beliefs of the individual are maintained
16. what actions can and must not be taken to minimise discomfort when assessing an individual presenting with different types of symptoms
17. why it is important to the thoroughness and accuracy of your assessment that the individual is encouraged to participate as fully as possible
18. why it is important to be aware of and monitor changes in the individual’s condition over the course of your assessment
19. clinical norms with regard to people presenting for assessment in a variety of scenarios (e.g. suffering from urinary tract infections, being medically unwell but not needing hospital admission)
20. the contra-indications for presenting conditions
21. why it is important to ensure that you obtain as much background information as possible
22. why it is important to ensure that all information is taken into account in making decisions
23. the processes you would go through to arrive at a justifiable assessment of an individual
24. the importance of communicating and agreeing assessment outcomes and planned care packages with the individual
25. the organisational policy and practice with regard to the keeping and sharing of records
26. the legislation which relates to working with a child, young person, vulnerable adult or older person, including confidentiality and information sharing, the provision of services, anti-discriminatory practice, informed consent, relevant mental health legislation and care programme approach
27. the ethics concerning consent and confidentiality, and the tensions which may exist between an individual’s rights and the organisation’s responsibility to individuals

Performance Criteria

You must be able to do the following:

1. confirm that the area you are working in is safe prior to conducting your assessment
2. clarify and confirm that the individual is of a suitable health status for the tests to be carried out
3. confirm that the environment is safe and suitable for the assessment to proceed
4. recognise when you are not the appropriate assessor and refer the individual to the appropriate practitioner
5. explain clearly to the individual:
1. your own role and its scope, responsibilities and accountability in relation to the assessment
2. what information will be obtained and stored in records
3. with whom the information might be shared
4. what is involved in the assessment
6. obtain the informed consent of the person for the actions undertaken and agree the information which may be passed to others
7. form an accurate and justifiable evaluation of the risks to the individual based on your assessment
8. find out as much as possible about the circumstances relating to the individual requiring assessment including:
1. the pre-morbid capabilities of the individual
2. any pre-existing conditions that may influence the assessment
3. the circumstances which led to him or her presenting for assessment
4. the individual’s home/care circumstances
9. conduct the assessment systematically and thoroughly
10. use appropriate methodologies and associated equipment to gather as full a picture as possible of the individual’s capabilities and any deficits
11. respect the individual’s privacy, dignity, wishes and beliefs
12. minimise any unnecessary discomfort and encourage the individual to participate as fully as possible in the process
13. monitor and record any changes in the individual’s health status since you have been in attendance and respond promptly to any signs of deterioration
14. communicate with the individual clearly and in a manner and pace that is appropriate to:
1. their level of understanding
2. their culture and background
3. their needs for reassurance and support
15. keep accurate, complete and legible records of the findings of your assessment.
16. make use of and interpret accurately all of the available information
17. use the information available at the time to develop a justifiable judgment with regard to:
1. the functional capabilities of the individual
2. the implications of any changes in the health status of the individual since you have been in attendance
3. the nature, severity and extent of any deficits in the individual’s functional capabilities
18. balance any additional or unusual aspects of the individual’s functional capabilities against the overall picture of the their needs, acknowledging any uncertainties and conflicts
19. recognise accurately potential signs of abuse and report them promptly to the appropriate person, in line with national and organisational policy
20. form an accurate and justifiable evaluation of the risks to the individual based on your assessment
21. make full and effective use of any protocols, guidelines and other sources of information and advice to inform your decision making
22. arrive at a judgment in an appropriate timeframe and refer the individual on to the appropriate pathway in line with your conclusions
23. seek additional support and advice from other practitioners as necessary to arrive at a satisfactory judgment as to the functional capabilities of the individual
24. exchange information promptly on the results and health and social care implications of your assessment with other practitioners involved in providing a care programme for the individual
25. discuss the outcome of your assessments with the individual, encouraging them to ask questions and confirm their understanding
26. maintain full, accurate and legible records of your assessment and make these available for future reference in line with organisational practices

Additional Information

This National Occupational Standard was developed by Skills for Health. This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004): Dimension: HWB6 Assessment and treatment planning