B
CHS233 Contribute to the assessment of needs and the planning, evaluation and review of individualised programmes of care for individuals
Overview
This standard covers working as a member of an inter-disciplinary team through contributing to the assessment of service users' needs, contributing to the planning of individualised programmes of care, and contributing to evaluation and review. The assessment methods and approaches and the nature of interventions will be those which are agreed on a case-by-case basis with other members of the inter-disciplinary team. The term ‘inter-disciplinary team' has been used to mean teams formed of practitioners drawn from different professions (or different disciplines within a profession) who are working together as a co-ordinated team to achieve agreed objectives with service users.
As you will be one of the main points of contact with individuals and will be undertaking specific individualised programmes of care, probably on a person-focused basis, there is a strong focus in this standard on promoting individual's rights. Due to the nature of the interventions, there will also be a number of issues related to confidentiality and consideration of who has access to certain information.
The focus of the work is likely to be related to the services offered by an integrated service such as a rehabilitation standard, community team or in day care, or the service offered by a functional team, such as assertive outreach, crisis intervention. It is likely that the practitioner will specialise in working with one particular service user group or in one setting.
Users of this standard will need to ensure that practice reflects up to date information and policies.
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Knowledge and Understanding
You will need to know and understand:
- the principles of inter-disciplinary working
- how inter-disciplinary working differs from other models of care provision
- the role of other workers who are contributing to the care programme and the particular benefits and strengths which each brings
- your role in the inter-disciplinary team and how it relates to the roles of the other team members
- the purpose of clarifying your own role and that of others when working with different individuals
- ways in which inter-agency and inter-disciplinary working can contribute to more effective delivery of care
- why effective communication is particularly important in an inter-disciplinary team
- the philosophy and approach of the inter-disciplinary team and its members
- your responsibility to keep records
- the purpose of involving individuals and significant others in the assessment process
- the purpose of keeping records of the assessment process
- the differing arrangements which may need to be put in place to make the assessment of needs effective
- the purpose of clarifying individuals' and significant others' understanding of the process and in clearing up any misunderstandings
- why it is important to recognise and support the rights of individuals and significant others and their role within the assessment process
- the type of background information which is necessary to undertake the assessment properly
- methods of supporting individuals and significant others in contributing to the assessment process
- methods of assessing individuals' health and wellbeing needs and the needs of the service user group with whom you work
- methods of interacting effectively with people
- methods of encouraging individuals and significant others to be actively involved in the process of assessment, and empowered to contribute
- how to present views and suggestions constructively and effectively
- why problems should be notified and what should happen if they are not
- the role of other agencies who are working in the planning process and the particular benefits and strengths which each brings
- the purpose of delivering staged goals within programmes of care and how these can be best developed to take account of different individuals' needs
- the purpose of planning specific aspects of care as part of an overall programme of care
- the range of services that are available to individuals and which members of the team lead on which services
- the potential difference between the individual's and significant others' views of the services they need and the views of people working in the team
- the disagreements which might arise between those involved in the planning and ways of negotiating with others so that a working agreement can be reached
- the functions and resources within the agency and the relationship of this to the needs of the individual and significant others
- how the services you are able to offer are affected by service contracts and resource limitations in the agency in which you are placed
- the range of needs that individuals may have and how these may conflict
- the different purposes which programmes of care may have for different individuals with health and wellbeing needs
- the particular requirements which different individuals may have and how these can be managed within the planning process
- the different type of activities and interventions which are commonly used with the individuals with health and wellbeing needs, the purpose of these and how they may differ from those used with other service user groups
- the range and purposes of interventions available and the relationship of these to individual needs, interests, preferences, age, gender
- the effects which cultural differences may have on the suitability of interventions for particular individuals
- the interventions which are to be made for the particular individuals concerned, their purposes and goals
- why final decisions should be recorded and disseminated to the appropriate people
- why evaluation is necessary and how it can be used to improve performance in the short and long term
- methods of involving individuals and significant others effectively in evaluation and the purpose of doing this
- methods of evaluating the process and outcomes of different interventions
- how to evaluate individual's progress towards agreed goals
- the purpose of modifying activities in the light of the evaluation with individuals, significant others and other members of the team
- methods of evaluation relevant to different interventions, how they work and how they need to be adapted according to the individual and their needs
- how to evaluate your own contribution constructively and make recommendations for improvement
- the different ways in which the way the team works with individuals and significant others might be improved
- how to communicate with individuals, significant others and other team members effectively
- how to explore differences of opinion and confusion constructively
- your role and responsibilities in recording the evaluation and review of programmes of care
- how you can determine when you are in need of further support and who to seek it from
Performance Criteria
You must be able to do the following:
- agree your role in assessing the individual's needs with other members of the care team
- offer clear and accurate information to individuals and significant others on the assessment and your role and the roles of other members of the care team within it
- obtain appropriate and necessary background information to allow the assessment to proceed effectively
- seek confirmation of the individual's and significant others' understanding of the assessment, any related interventions and the expectations they have of the team's services
- throughout the assessment, your interaction is appropriate to the individual and appropriate others and designed to emphasise their role as equal partners in the process
- carry out the assessment in the correct form and sequence and for the correct duration
- encourage individuals and significant others to contribute to the process, ask questions, seek advice and express any concerns
- seek support from an appropriate person as soon as is possible when any problems arise with the assessment
- pass relevant information to others in the care team who are involved in assessing the individual's needs in sufficient time for it to be of use
- ensure your records of the assessment are complete, legible, accurate and structured in a way which allows others to use them easily
- explain what will happen as a result of the assessment to individuals in an appropriate manner, level and pace
- accurately identify the purpose of the care programme and how this will meet the needs of the individual in discussion with relevant others
- clarify and confirm your role in the overall care programme with those concerned
- identify the particular requirements of the individual from their records and in discussion with other team members
- seek further advice, clarification and support from the other members of the team when you have any concerns about:
- the nature and purpose of the care programme
- the individual's needs
- your role in meeting these needs
- others' roles in meeting these needs
- explore the different activities and interventions which will form the care programme and how these will inter-relate, with other members of the team
- agree how the individual's needs may best be met, the different goals along the way and your role in this with other members of the team
- ensure that your contribution to the care programme is sufficient to enable effective interventions to take place whilst being an efficient use of resources
- ensure your records of the planning process and outcomes are accurate, legible and complete and consistent with your role and responsibility within the team
- identify the progress which individuals have made towards agreed goals and discuss this with individuals, significant others and any others involved
- assist individuals and significant others to evaluate the extent to which the sessions have met the agreed purposes and goals
- discuss and agree the reasons for activities not achieving their agreed aims with individuals and significant others
- clearly communicate your evaluation of the sessions and their effectiveness in meeting the individual's needs to the other members of the team
- discuss and agree ways in which the team could improve how it works with individuals and significant others with other team members
- explore any problems between different members of the team to allow a clearer understanding to be reached
- ensure your records of agreements reached are accurate, legible and complete
- modify your contribution to individualised programmes of care according to the agreements reached by the team
Additional Information
This National Occupational Standard was developed by Skills for Health. This standard replaced MH25.
This standard links with the following dimension within the NHS Knowledge and Skills Framework (October 2004):
Dimension: HWB2 Assessment and Care Planning to Meet Health and Wellbeing Needs