Rehabilitation - Complex Case Management - Care Needs Assessment

Transcription

1 SERVICE STRATEGY FOR THE OLDER PERSON'S TEAM 2011 Rehabilitation - Complex Case Management - Care Needs Assessment

2 Service Strategy The Foreword The has developed from the amalgamation of a number of community based services into a single interdisciplinary team, aimed at supporting the wide range of health care needs of older people living in the community. Team membership includes health care professionals from the community based disciplines of Occupational Therapy, Physiotherapy and Public Health Nursing. Community interdisciplinary teams supporting the health needs of older people living at home have been in existence for a number of years, primarily through the work of the District Care Units (DCU) set up in the early 1990 s. Their aim was to enable older people to continue living in their own home by providing home based rehabilitation through an interdisciplinary team that consisted of Community Nursing, Community Occupational Therapy and Community Physiotherapy. Referral sources were identified as coming from the community (step-up) and from the acute hospital sector (step-down). Over the last 12 years community services in Dublin South City district have evolved from a DCU to a Community based home Rehabilitation Team (CRT). The purpose of this team was to enable frail older adults to remain living at home by responding promptly to their need for home-focused rehabilitation. The development and roll out of Primary Care Team structures within the last number of years has had a major impact on the role and function of the pre-existing DCU. The primary care strategy, Primary Care: A New Direction (DoHC 2001) acknowledged the central role of primary care in the future development of Irish heath services. Primary care is deemed the most appropriate setting to meet 90-95% of health and personal service needs of the population. The strategy aims to amalgamate and streamline support services by the setting up of primary healthcare teams across the country. This will be particularly helpful for vulnerable population groups such as the frail elderly. The focus on primary care has led some community care areas to disband their DCU s in favour of a more generic primary care multidisciplinary model to support the health care needs of older people. In Dublin South City the Community Rehabilitation Team began a process of re evaluation of its service and this has led to the development of the Older Person s Team. This team has drawn on its wealth of experience working as an interdisciplinary team and its expertise in supporting the health needs of frail older people in the community. The team have developed a number of core documents and policies that essentially define its role and function, as a specialised interdisciplinary team that acts as an important link between the various primary care team structures in Dublin South City. This networking team will endeavour to create continuity and integrated access to range of support services for older people including, community rehabilitation, complex case management, needs assessment coordination for long-term care applicants and assessment for home care packages. There is an awareness of the growing need for health care services and health sector policy to support growing functional dependency in care groups such as older people (WHO 2004). This increased demand for supportive services has arisen out of increased life expectancy and the preference of the majority of older people to live at home. 1

3 Service Strategy Service Strategy Endorsing the principles and objectives of services for older people as outlined by the Years Ahead Policy For Older People (DoH 1988) and ERHA (2001), the principal aim of The is to enable older people to live at home with dignity and independence for as long as possible. The hope to provide meaningful integration of care and community supports with improved equity and access to care pathways for older people living in the Dublin South City District Community Care Area. Neil Dunne Advanced Nurse Practitioner Dublin South City Table of Contents Older Persons Team Framework Document Page 1 Policy The Community Rehabilitation Team Policy 3 Home Care Package Policy Authors: Sinéad Crowe: Michelle Spencer: Marie Regan: Neil Dunne: Maev Lennon: Kim O Malley: Contributors: Imelda Dooley: Paula Barron: Alma Joyce: Julie Lynch: Nessa Lynch: Senior Occupational Therapist. Discharge Liaison OT St James Hospital. Senior Physiotherapist. Senior Occupational Therapist. Advanced Nurse Practitioner and Team Leader. Home Care Package Manager. Occupational Therapy Assistant. Manager for Older Person s. Physiotherapy Manager. Occupational Therapy Manager. Director of Nursing. HSE Performance and Development. 4 The Nursing Home Support Scheme and CSAR Coordination Policy 5 Complex Case Management Policy Individual Roles and Responsibilities Priority Policy DNA Policy Ground Rules Policy Professional Appearance/ Dress Code Policy Communications Policy Disclosure of Risk and Informed Consent Policy Client Confidentiality Policy References Appendix List

4 Service Strategy Service Strategy Contents Policy Page 1.0 Vision Mission Rationale for the Development of a Specialised in Dublin South City Purpose Aims Objectives An Integrated Approach to Care Pathways Multidisciplinary Involvement in Assessment, Planning and Evaluation of Care A Standardised Referral Pathway Standardised Assessment A Streamlined Process for Nursing Home Support Scheme (CSAR) Applications Supports to Primary Care Team (PCT) in the Management of Complex Cases Transition of Care of Complex Older Adult Cases from Acute Hospitals into the Community... 7 Fig 1.0 Structure Team membership Admission Criteria to the Referral Process... 9 Fig 2.0 Service Delivery Enablers... 9 Fig 3.0 Referral to the Older Persons Team Communication/Reporting Strategy to Referral Sources Discharge Assuring Quality Clinical Governance Clinical Audit Clinical Effectiveness Learning, Training and Development Client Involvement The Dublin South City 1.0 Vision The (OPT) will endeavour to empower older people to attain their highest optimal level of health in order that they may achieve their best quality of life, function and social integration in the most appropriate setting. 2.0 Mission We are a specialist community based in Dublin South City that provides direct and integrated health care support to older people, in order that they may remain living at home in the community with maximum independence. 3.0 Rationale for the Development of a Specialised in Dublin South City (DSC) With aging comes a natural physiological decline that reduces the ability of a person to recover from illness. Illnesses accumulate with age, increasing in both severity and number. Within the past two decades, a growing recognition of the complexity of health needs of frail older persons coupled with increasing evidence of the effectiveness of comprehensive assessment programmes have played a vital role in service provision. Evidence from recent meta-analyses of clinical trials of the effectiveness of specialised older person s programs suggests that frail older persons may experience a variety of health benefits from these specialised services (Aminzadeh et al., 2002; Rubenstein et al., 1989, 1991; Stuck et al., 1993). These benefits include: Improved diagnostic accuracy. Reduced medication use. Enhanced functional status. Improved placement decisions. Decreased use of acute and long term institutional services. Reduced cost of care and prolonged survival. It is important to find solutions to support independence and functional activity in the life of the older person. They are considered a central target group for programs aimed at preventing or delaying functional decline and disability. Community based older person s rehabilitation has been shown to increase or restore the client s functional ability (Evans & Brewis 2008). Addressing the needs of older adults in the community is a complex process and requires a specialized team approach to be effective. 4.0 Purpose The purpose of the (OPT) is to provide meaningful integration of care and community supports, with improved equity and access to care pathways for older people living in Dublin South City. The pathways of care identified are: Community Rehabilitation Team (CRT). Home Care Package (HCP) assessment and support. 4 5

5 Service Strategy Service Strategy Community long-term care applications through the Common Summary Assessment Report (CSAR) process. Support to Primary Care Teams in the management of Complex Cases (CC). 5.0 Aims The aim of the OPT is to develop dynamic collaborative partnerships with older people and family / carers living in the community, in order to support and guide them in the management of care throughout the health / illness continuum. We also aim to keep the older person living independently and functionally at home. This is achieved by: 1. A comprehensive multidisciplinary team assessment. 2. Community based moderate intensity interdisciplinary rehabilitation (DoHC and HSE Neurological Rehabilitation Strategy 2009). 3. Identifying the priority problems based on the clinical importance and patient readiness for action. 4. Goal setting and development of realistic care plans considering client resources and anticipated obstacles. 5. Creation of a continuum of self-management and support services needed to carry out the care plan after discharge. 6. Sustained follow-up to identify potential complications, make necessary modifications, and reinforce client efforts. 6.0 Objectives The objectives of the team are to offer older people and family / carers: An integrated approach to care pathways. Multidisciplinary involvement in assessment, planning and evaluation of care. A standardised referral process. Standardised assessments. A streamlined coordinated process for Nursing Home Support Scheme through CSAR applications. Support to Primary Care Team (PCT) in the Management of Complex Cases. Transition of care of complex older people from acute hospitals back into the community. 6.1 An Integrated Approach to Care Pathways The scarcity and fragmented nature of health and social support services in the community is a particular problem for family caregivers of frail older people within the Republic of Ireland (Ruddle 1997, Clairfield et al 2001,Garavan et al. 2001). The OPT in Dublin South City will use its collaborative referral links and processes to develop solution focused integrated pathways. The OPT works closely with the following services: Respite Care (Respite Planning). Day care. Geriatric assessment and rehabilitation. Community Intervention Team. Protection of older persons. Case conferences. Other specialist services. 6.2 Multidisciplinary Involvement in Assessment, Planning and Evaluation of Care Care planning of referred clients is achieved through the regular multidisciplinary clinical team meetings (See Ground Rule Policy ). 6.3 A Standardised Referral Pathway The OPT have developed a single standardised referral form (Appendix I) for use with Community Rehabilitation Team (CRT), long-term care (Common Summary Assessment Report (CSAR)) or Complex Case (CC) management pathways. 6.4 Standardised Assessment The team offers assessment to include the following: Falls and falls intervention. Cognitive impairment. Comprehensive Medical/Nursing assessment and review of medications. Community Occupational Therapy. Community Physiotherapy. Needs assessment for the Home Care Grant 6.5 A Streamlined Process for Nursing Home Support Scheme (CSAR) Applications The team will coordinate the completion of the CSAR and forward the application on to the local placement panel committee, for decision on the nursing home support scheme. Apart from a coordination role the team will also: Identify clients who may require long-term care and initiate the CSAR application process. Support older person and their family/carer through the needs assessment process for long-term care. 6.6 Supports to Primary Care Team (PCT) in the Management of Complex Cases The acts as a support to PCT caring for community based clients with complex care needs. This includes holistic assessments, support with family/carer meetings, MDT clinical meetings, formulating realistic goals and outcomes and onward referrals as required. 6.7 Transition of Care of Complex Older Adult Cases from Acute Hospitals back into the Community The team facilitates the transitional discharge of complex older client cases from the acute hospital back into the community. Interface with the hospitals is through the Home Care Package Manager, Hospital Discharge Liaison Community Occupational Therapist and the Community Advanced Nurse Practitioner on the team. 6 7

6 Service Strategy Service Strategy Figure 1.0 Structure Older Person s Team Community Rehab Team Community LTC Assessment (CSAR) Home Care Package Complex Community Dwelling Cases Community Based Referrals Hospital Discharge Referrals CSAR Coordination MDT Assessment Facilitate Discharge/ Case Management of Frail Older Adult MDT Rehab Assessment MDT Rehab Assessment Health Assessment/Screening Needs and Functional Assessment Supportive Case Management Role Community Rehab Admission (12-18 Weeks) Community Rehab Admission (12-18 Weeks) Local Placement Panel Home Care Package Case Management Discharge to Local Community Support/PCT Home Care Package The client must be aged 65 years and older presenting with complex needs and who is in need of, or review of a home care package. Complex Case Support The client must be aged 65 years and older presenting with complex needs and requires a team approach to intervention. The client must be aged 65 years and older and requires a period of respite care. 9.0 Referral Process The OPT will accept referrals using the standardised referral form (Appendix I) from Primary Care Team s and Acute Hospital Services which include the following disciplines: General Practitioners. Home Care Package Manager. Nursing Service. Physiotherapy. Occupational Therapy. Medical Social Worker. Community Intervention Team. Community units for older persons (respite/long-term care placement). Fig 2.0 Service Delivery Enablers 7.0 Team Membership The is a specialist team for older person s that consists of: Community and Individual Capacity for own Health and Wellbeing Older Person Refer Refer Advanced Nurse Practitioner. Home Care Package Manager. Senior Occupational Therapist. Discharge Liaison Occupational Therapist. Occupational Therapy Assistant. Senior Physiotherapist. Administrative support. Local Older Persons Manager (Strategic Team Role). Whole of Population Health Services Primary Community & Continuing Care Service (Screening Assessment, Early Intervention, Maintenance) Refer Refer Refer Community Older Person s Services Geriatric Assessment, Respite, Long Term Care, Day Care, Protection of Older Person s 8.0 Admission Criteria to the Community Rehabilitation The client must be aged 65 years and older presenting with rehabilitation needs requiring a team approach. The client must have identifiable, achievable rehabilitation goals that will improve or maintain function, mobility and self care within a safe environment. Community Long-Term Care Application (Common Summary Assessment Report (CSAR) The client must be aged 65 years and older who is no longer able to remain living at home with their current supports and now requires long term care. Specialised Health Services for Older People (Specialist Assessment, Treatment, Rehabilitation, Maintenance) Overall Goals: Optimise Health and Wellbeing of the Older Person Quality Care with Dignity and Respect 8 9

7 Service Strategy Service Strategy Fig 2.0 Service Delivery Enablers Community Rehabilitation Team Face-to-face Assessment by the OPT Referral to the (OPT) using a Standardised Referral Form Screening Process Team Leader determines: Whether client requires input from OPT or should referral be transferred to the PCT. The priority; Whether the client is complex or requires a period of rehabilitation or assessment / monitoring for Home Care Package Service or Long Term Care Placement Team Meeting Discussion Team meeting occurs following the initial assessment: The Team collaborate and develop a service plan and MDT goals (OT, PT & Nursing Goals). The timeframe for the client s rehabilitation period is determined and not exceeding 18 weeks. OT/PT/Nursing home visits with client to provide a period of rehabilitation and review above agreed goals with client. Environmental assessment OT/PT/Nursing feedback to OPT Team leader and client s progress on a fortnightly basis. Following completion of all OPT Rehabilitation and review of client s progress and agreed goals, Repeat outcome measures. Discharge client record client s progress on database. Team will complete MDT discharge letter. H.C.P. Client OPT will provide the HCP coordinator with a report of client s functional status /care needs and supports required to enable client remain living at home. Complex / Home Care Package (HCP) / Long Term Care (LTC) Client Face-to-face Assessment by the OPT using appropriate Screening Tools e.g.: OT use KATZ ADL assessment and SAILE screening tools; PT use the TUG, BERG Nursing use Barthel Index, Waterlow, NSI Team Meeting Discussion Each client s assessment will be discussed at a Meeting level. Development of functionally orientated support plan and MDT client goals are set. Following completion of all OPT interventions - Repeat Outcome Measures. Record Client s pre and post outcome measure scores. Team will complete MDT standardised discharge letter L.T.C. Client Complex Client Management OT/PT/Nursing Intervention. Environment assessment. Carer education/support. Regular Team meetings to allow discussion of client s progress and review of client goals. The OPT will coordinate and complete the Common Summary Assessment Report (CSAR) to facilitate the client s LTC Placement Communication / Reporting Strategy to Referral Sources Community referral sources will be invited to attend the initial clinical team meeting following MDT assessment of the referred client. Significant updates on the progress of a client admitted to the team s clinical case load will be communicated via written summary or telephone communication. All clients discharged from the clinical team list will have a summary discharge sent to the initial referral source (Appendix II) Discharge Clients are discharged from the OPT back to existing community services, Primary Care Team s or appropriate alternate care settings. Clients can be re-referred as their circumstances dictate Assuring Quality The OPT embraces the vision or framework adopted by the Commission on Patient Safety and Quality Assurance (2008), knowledgeable patients receiving safe and effective care from skilled health professionals in appropriate environments with assessed outcomes. The values underpinning this framework include openness, patient centeredness, learning and efficiency, good governance, leadership, evidence based practice, accountability and patient/family involvement. (DoHC, 2008, 08: 3) Clinical Governance Clinical governance defines the culture, the values, the processes and the procedures that must be in place in order to achieve sustained quality of care in healthcare organisations, (DoHC, 2008, 08:62). A matrix management structure is being adopted, e.g. the advanced nurse practitioner post provides clinical leadership to the team. Line management and professional supervision is provided by the relevant heads of services. The Manager for Older Person s together with the team and heads of services has strategic input into the team s development. The team has adopted a continuous quality improvement approach to service provision. The plan, do, study and act cycle is utilised to facilitate quality improvement initiatives Clinical Audit The team will complete a clinical audit of its service on a yearly basis. Results of the clinical audit will guide Continuous Quality Initiatives. The team will endorse the HSE Your Service Your Say Policy (2010) to enable clients, carers, health professionals and others to give their feedback regarding their experience of the overall OPT service Clinical Effectiveness To ensure that clients achieve the best outcomes from the OPT service; it is essential that all team members have access to the most up to date information. All interventions must be guided by evidence based practice relating to the particular conditions or speciality area

8 Service Strategy Service Strategy 16.0 Learning, Training and Development The quality of the OPT service is dependent on the knowledge and competence of people delivering these services. All client s accessing services from the OPT should be treated by health professionals who have the skills, knowledge and experience in delivering these services including specific competencies where required. The clinical competencies of all team members must be commensurate with the level of specialisation that is required. All team members should be involved in a system of life long learning and professional development Client Involvement The (OPT) and Older & Bolder Listen to older People. In rolling out strategies, do not make assumptions about what we need (Older and Bolder, Dublin Report, 2009, P 9). Older & Bolder is a National Alliance of seven Non-Governmental Organisations that aims to champion the rights of older people and to combat ageism. The members are: Active Retirement Ireland, Age & Opportunity, the Alzheimer Society of Ireland, the Carers Association, the Irish Hospice Foundation, the Irish Senior Citizens Parliament and Senior Help Line. The OPT endorses the group s submission to the National Positive Ageing Strategy to the Minister for Older People. This submission was formulated through an extensive and inclusive consultation process with older people throughout the country which asserts the right as citizens to equal participation in economic, social, cultural and political life and to equality of treatment by service providers across the board. Contents The Community Rehabilitation Team Policy Page 1.0 Introduction Aims of the Community Rehabilitation Team Objectives of the Community Rehabilitation Teamy Admission Criteria The Community Rehabilitation Team consists of Capacity of Service The Community Rehabilitation Team Goals Discharge Notification Referral to the Community Rehabilitation Team A strong message emerged from the consultation process that; Access to quality, accessible, integrated health care services, based on need, is viewed by participants as a fundamental and basic right. (Older and Bolder, 2009) The and Focus Group The OPT facilitated a focus group in May 2010 with older people living in the community and enabled a forum of discussion to occur. Discussions were directed on older person s experiences of the HSE, services for older person s available to them in the community and their key areas of concern for health services to the future: The main themes and findings that arose from the focus group with older people were: Older people identified that they would like a more coordinated and integrated community health service with one point of access to health services in the community. No key contact person older people find it hard to distinguish between health care professionals and their roles in the community and they would like to have a key worker to support them when difficulties arise. Older people who participated in the focus group stressed their concerns about funding issues around home help services as they identify this being an invaluable service in facilitating them to remain living at home. Older people strongly supported the existence of day centre facilities in the community they provide a social support, provide meals and encourage a variety of activities without which the older person would be at home isolated and as one participant said on my own, looking out the window. Older people report that when they receive a service it is mostly a good service and they are overall happy with the service but they must wait a while for the service

9 Service Strategy Service Strategy The Community Rehabilitation Team Dublin South City 1.0 Introduction The Community Rehabilitation Team (CRT), formerly known as the District Care Unit (DCU) is now a component of the (OPT) in Dublin South City. The team offers older persons a co-ordinated and interdisciplinary rehabilitation programme that is responsive to their needs and the needs of their family. Rehabilitation is a very broad concept and difficult to define. It is a problem solving process in which a person who experiences an impairment or loss of function acquires the knowledge, skills and supports for their optimal physical, psychological social and economic functioning. For older people, rehabilitation can be interpreted as: A process of returning to a former level of functional ability. Maintaining a person s level of functional ability when underlying medical condition remains static. Adapting to the needs and functional changes in older person s who have progressively deteriorating conditions. The general aim of rehabilitation is to reduce the impact of disease and maximise the person s level of participation in all aspects their lives (Squires & Hastings 2002). 2.0 Aims of the Community Rehabilitation Team To enable older people live fulfilling lives in their own homes. To enable older adults to access appropriate health and social services within the community. To improve the interface between acute and community care by facilitating the on going rehabilitation needs of frail older adults post discharge back into the community. The development of partnerships/links with health and social support services to enable clients with self-care limitations to live at home as independently as possible. 3.0 Objectives of the Community Rehabilitation Team To provide an individualised assessment involving members of the core CRT. The team will plan in collaboration with the client / carer a rehabilitation programme, to enable older people to return to a suitable level of independent living. To provide moderate intensity, interdisciplinary rehabilitation, to a mixed population. The duration of the service will vary according to individual need but has the potential to be extended to approximately 18 weeks. Implementation of an agreed rehabilitation treatment programme. Prevent unnecessary hospital stays. The provision of ongoing assessment, intervention and evaluation to meet mutually agreed aims. At the review, if further ongoing care is needed the CRT is responsible for referring the client on to appropriate services for assessment and provision of ongoing care. Provide equipment where appropriate for safe and independent living in the home environment. Provide support to carers. 4.0 Admission Criteria The client must be aged 65 years and older. The referred client must be medically stable. The referred client must have identifiable, achievable rehabilitation goals that will improve or maintain function, mobility and self care within a safe environment. These goals will be established by the team and client following an initial assessment and recorded on the OPT goal sheet (Appendix III). The client must have adequate cognitive function to allow participation in learning programmes, or have a carer who is able to prompt and support rehabilitation. The referred client must be able to actively, or to the best of their ability, participate and agree to their rehabilitation programme. The client must require therapeutic input from two or more team members. The client should not require acute medical or surgical intervention during their time admitted to the community rehabilitation team. If a client is admitted to hospital there will be a need for a new referral. The client should live in Dublin South City. Will comply with the DNA Policy for the OPT. Clients will be prioritised as per OPT prioritisation guidelines. 5.0 The Community Rehabilitation Team consists of Team coordinator (Advanced Nurse Practitioner Community Older Adults). Community Occupational Therapist/Occupational Therapy Assistant (0.5 WTE). Community Physiotherapist (0.5 WTE). Administration support (0.5 WTE). 6.0 Capacity of Service Older Person s services are complex and multifaceted and thus the service capacity will vary. According to the level of frailty and co morbidities approximate capacity for admissions will be 10. Referrals received will be discussed at team meetings and prioritised for assessment using the OPT priority guidelines. Should referrals exceed 10 a prioritised waiting list will be started. 7.0 The Community Rehabilitation Team Goals The OPT will set and record client related goals at the team meetings (Appendix III). Short-Term Goals: Provide a seamless discharge from acute facilities for older adults requiring on going rehabilitation. Full assessment and supportive intervention to promote independence in all activities of daily living. Assessment for mobility aids to support mobility, gait re-education, balance retraining and stair practice. Perform a comprehensive physical exam and functional assessment including mental status, cognitive and perceptual skills, social support and nutrition. Assessment and intervention supporting internal and external environmental changes. Assessment of safety risks. Pain Management education

10 Service Strategy Service Strategy Falls risk assessment and appropriate intervention. Supply and safe use of home adaptation / assistive equipment. Assessment of early levels of client motivation / tolerance. Education and health promotion activities to promote independence, safety and well being. Long-Term Goals: Maintain a person as active, independent and safely as possible in their own home. Plan for home / environmental adaptation. Re-involvement in leisure pursuits. Establishment of community support systems. To educate clients on the balance between activity and energy conservation. Onward referral as required. Prevention of admission to acute facilities. The WHO International Classification of Functioning, Disability and Health (ICF) will be used as a framework when choosing outcome measures Discharge Notification Clients discharged from the Community Rehabilitation Team will have a written discharge summary sent to their referral source and local Public Health Nurse (Appendix II).. Contents Home Care Package Policy Page 1.0 Introduction Definition of Home Care Package Referral to the Home Care Package Service Hospital Referrals Community Referrals Home Care Package Review Home Care Package Operational Processes & Procedures Assessment Referral to the Community Rehabilitation Team Referrals will originate from both the Hospital and Community setting: Hospital Referrals All hospital referrals are referred to the Community Rehabilitation Team by any member of the hospital multi disciplinary team (MDT). Referrals require a discharge summary of intervention by all members of the MDT (Appendix I). Community Referrals Referrals can be made by any member of the Primary Care Team (PCT) or Community Care Services using the teams referral form (Appendix I). Clients under the care of an established PCT will be initially assessed by the PCT with onward referral to the Community Rehabilitation Team if considered suitable for community rehabilitation 16 17

11 Service Strategy Service Strategy Home Care Package Service 1.0 Introduction A key component of the Government Policy is that the use of community and home based care should be maximised and should support the important role of family and informal carer, in order to maintain older people living at home for as long as possible. The Home Care Package Scheme () was introduced by Government and implemented across the Health Service Executive (HSE) in 2006 to support this policy. The scheme will be as flexible as possible within the confines of the legislative and policy objectives context in which HCP are provided. Within this context also HCP should be responsive to the assessed needs of the individual and informal carers and will improve equity of service throughout the local health offices. However the extent of the support available through the HCP scheme is subject to the limit of the resources allocated each year to the HSE for this particular scheme. Therefore, at times, individual applicants who have been approved for a HCP may be placed on a waiting list for the scheme following a risk assessment of their needs. The vast amount of beneficiaries of the scheme will be older people i.e. aged 65 years or over. However, there will be flexibility in relation to applications from persons approaching 65 years. In addition some people aged less than 65 years, for example a person who has developed early onset dementia (and where their assessed needs can be best met by Services for Older People), may also be considered as exceptional cases for the HCP scheme. Applications from persons aged less than 65 years will need to be approved by the General Manager. The core element of the package is additional hours provided by a trained carer. The client may need the support of a carer for basic needs such as getting up, washing and dressing and also with help getting back to bed in the evening. Domestic needs are met where possible by the Home Help Service. The H.S.E. funds the cost of this increase in care through care agencies that have been approved. Applications are made by health professionals in consultation with family. Department of Health & Children policy in relation to HCP states that, in the context of current legislation, Access to home care packages should be based on need and means testing should not be applied to home care packages (National Task Group HCP & HH, 2010). Accordingly, There is no requirement that an applicant should have a medical card in order to apply to be considered for a home care package, though the vast majority of beneficiaries are likely to be medical card holders. There is no financial means test applicable to the scheme. No charges will be levied on applicants in respect of services provided through the scheme. Contributions shall not be requested or accepted from recipients with respect to the provision of HCP services. Applicants care needs will be assessed to determine their requirement for a HCP. HCP will be allocated based on assessed care need within the limit of the resources available for the scheme. When resources are fully allocated at Local Health Office level and waiting lists are in operation a prioritisation mechanism for allocating resources (services & supports) to approved applicants will be implemented (National Task Group HCP & HH, 2010) 2.0 Definition of Home Care Package A Home Care Package (HCP) consists of community services and supports which may be provided to assist an older person, depending on their individual assessed care needs, to return home from hospital or residential care or to remain at home. A HCP refers to the enhanced level of community services and supports above the normal levels available from mainstream community services. HCPs do not replace existing services. The actual HCP provided to any individual may include paramedical, nursing, respite and / or home help and / or other services depending on the assessed care needs of the individual applicant. Enhanced level of community services is any additional level of services, over and above mainstream level of service, which is provided to support the assessed needs of the applicant. (National Task Group HCP & HH, 2010) 3.0 Referral to the Home Care Package Service There are two routes of referral for the Home Care Package Service. 1. Hospital. 2. Community and Primary Care Teams. Please see Appendix XIX regarding the HCP application form. 3.1 Hospital Referrals are assessed by Social Workers, together with Nurses Occupational Therapists and Physiotherapists using the Common Summary Assessment Report (CSAR). Following assessment the completed CSAR is forwarded to the Case Manager. Following discussion with staff and mindful of budget availability the Case Manager presents a schedule of care. Where there are complex needs a case conference may be requested to discuss care needs and clarify hours of care. 3.2 Community Referrals are assessed by the Public Health Nurse and members of the Primary Care Team. A request for additional hours of care is documented on the CSAR assessment form. Following discussion with staff and mindful of budget availability the Case Manager presents a schedule of care. In the H.S.E. Dublin South City area all clients in receipt of HCP can be referred to the (OPT). The team can where necessary provide additional Occupational Therapy and Physiotherapy services. They share information on the client s progress and address unmet needs. If it is clear to the OPT that eventually the HCP may no longer support a client whose needs have increased the OPT will facilitate and support families who wish to avail of long term placement with the completion of Common Summary Assessment Report (CSAR) (Appendix IV). 3.3 Home Care Package Review All home care packages are reviewed at least twice a year and more often as determined by health care professionals. Home care packages can be either increased or decreased following a comprehensive assessment

12 Service Strategy Service Strategy 4.0 Home Care Package Operational Processes & Procedures he operation of the scheme is set out as below. Application / Referral (Stage 1) Contents The Nursing Home Support Scheme and Common Summary Assessment Report Coordination Policy Care Needs Assessment (Stage 2) Prepare Draft Schedule of Services / Care Plan (Stage 3) Allocation of Mainstream Services as Appropriate (Stage 3 a) Recommend & Seek Approval of HCP if Appropriate (Stage 3 b) Page 1.0 Introduction Application Process The Role Fig 1.0 The Pathway for Long Term Care Capacity of Service The in Common Summary Assessment Report Completion 6.0 Referral for CSAR Determination of a HCP (Stage 4) Allocate Approved Supports & Finalise Schedule of Services & Care Plan Or Issue Refusal Or Add to Waiting List & Notify Applicant (Stage 5) Monitor & Review (National Task Group HCP & HH, 2010) 5.0 Assessment In Dublin South City area the Case Manager uses the CSAR (see Appendix IV) to assess new applicants and review client s progress. The CSAR is part of a process of developing a national common assessment approach for access to long term residential care for people over 65 years of age in the public, voluntary or private sectors

13 Service Strategy Service Strategy The Nursing Home Support Scheme and Common Summary Assessment Report Fig 1.0 The Pathway for Long Term Care NEED FOR LONG TERM CARE 1.0 Introduction The Nursing Homes Support Scheme is a new scheme of financial support for people who need long term nursing home care. It replaces the Subvention Scheme which has been in existence since Application Process There are 3 steps to the application process 1. An application for a Care Needs Assessment to identify whether the applicant needs long term nursing home care and will be carried out by health care professionals. The results of the Care Needs Assessment will be submitted in the form of a Common Summary Assessment Report (CSAR) (Appendix IV). 2. An application for state support. 3. An optional step to be completed if an applicant wishes to apply for the nursing home loan. This is termed ancillary state support in the legislation. 3.0 The Role The Older Person Team (OPT) acts to support Primary Care Team s and older people in the community with the completion of the CSAR documentation. This includes holistic assessments and support with family / carer. The team will coordinate the completion of the CSAR and forward the application on to the local placement panel, for decision on the nursing home support scheme. Apart from a coordination role the team will also: Identify clients who may require long-term care and initiate the CSAR application process. Support older person and their family/carer through the needs assessment process for long-term care. FINANCIAL ASSESSMENT NURSING HOME SUPPORT SCHEME (Completed application form) CSAR COMPLETED LOCAL PLACEMENT FORUM DECISION OLDER PERSONS TEAM, TEAM LEADER GERONTOLOGY ASSESSMENT 4.0 Capacity of Service According to the level of frailty and co morbidities approximate capacity for admissions will be 10. Referrals received will be discussed at team meetings and prioritised for assessment using the Priority Policy. Should referrals exceed 10 a prioritised waiting list will be started. 5.0 The in CSAR consists of Team Coordinator (Advanced Nurse Practitioner Community Older Adults). Occupational Therapist Physiotherapist Home Care Package Manager Administration support (0.5 WTE). 6.0 Referral for CSAR Referrals will be prioritised for assessment / co-ordination as per the priority guidelines. Referrals will originate from the Community setting: Community Referrals Referrals can be made by any member of the Primary Care Team or Community Care Services using the teams referral form (Appendix I)

14 Service Strategy Service Strategy Contents Complex Case Management Policy Page 1.0 Introduction Aims of Complex Case Management Objectives of Complex Case Management Admission Criteria The in Complex Case Management Capacity of Service The Complex Case Management Team Goals Discharge Notification Referral for Complex Case Management Complex Case Management Policy 1.0 Introduction The (OPT) is involved in supporting older people in the community with complex needs. Within the literature there is a lack of consensus on the meaning of the term complex needs, it is used by various disciplines, sometimes specifically, and most often interchangeably e.g. high support needs, complex health needs and multiple and complex needs. In view of this The OPT differentiates complex case management as a process by which adults with complex needs receive a service response that differs both in content and in intensity to that received by others with less complex needs. Complex needs are defined by the OPT as people with multiple medical conditions that interact, difficult psychosocial needs, high hospital admissions risk, who require health and related services of a type beyond that required generally. The OPT aims to enable older people to continue living in their own home. This includes holistic assessments, support with family / carer meetings, interdisciplinary team clinical meetings, formulating realistic goals, outcomes and care plans and onward referrals as required. The team facilitates the transitional discharge of complex older client cases from the acute hospital back into the community. Where a client is unable to stay at home coordination / assessment of Common Summary Assessment Report (CSAR) is provided (see Appendix IV). 2.0 Aims of Complex Case Management The aim of the OPT team is to develop dynamic collaborative partnerships with older people and family / carers living in the community in order to support and guide them in the management of care throughout the health / illness continuum. We also aim to keep the older person living independently and functionally at home. This is achieved by: Identifying the priority problems based on the clinical importance and client readiness for action. Creation of a continuum of self-management and support services needed to carry out the care plan after discharge. Sustained follow-up to identify potential complications, make necessary modifications, and reinforce client / carers efforts. To enable older adults to access appropriate health and social services within the community. Prevent unnecessary hospital stays. To support Primary Care Teams in the management of complex client cases. To improve the interface between acute and community care by facilitating the needs of frail older adults post discharge back into the community. 3.0 Objectives of Complex Case Management A comprehensive interdisciplinary team assessment: To provide an individualised assessment involving members of the OPT. The team will provide treatment and education based on these assessments. Goal setting and development of realistic care plans considering client resources and anticipated obstacles (Appendix III)

15 Service Strategy Service Strategy Provide equipment where appropriate for safe and independent living in the home environment. Provide support to carers. The provision of ongoing assessment, intervention and evaluation to meet mutually agreed aims. At the review, if further ongoing care is needed the OPT is responsible for referring the client on to appropriate services. The development of partnerships / links with health and social support services to enable clients with self-care limitations to live at home as independently as possible. Coordination and provision of respite as required. 4.0 Admission Criteria The client must be aged 65 years and older presenting with complex needs and requires a team approach to intervention. The client who requires a period of respite care. The referred client must be medically stable. The client must require input from two or more team members. The client should not require acute medical or surgical intervention during their time admitted to the community rehabilitation team. If a client is admitted to hospital there will be a need for a new referral. The client should live in Dublin South City. Will comply with the DNA Policy for the OPT. Clients will be prioritised as per OPT prioritisation guidelines. 5.0 The in Complex Case Management Consists of Team Leader (Advanced Nurse Practitioner Community Older Adults). Occupational Therapist Occupational Therapy Assistant (0.5 WTE). Physiotherapist (0.5 WTE). Home Care Package manager Administration support (0.5 WTE). 6.0 Capacity of Service Older Person s services are complex and multifaceted and thus the service capacity will vary according to the level of frailty and co morbidities approximate capacity for admissions will be 10. Referrals received will be discussed at team meetings and prioritised for assessment using the OPT priority guidelines. Should referrals exceed 10 a prioritised waiting list will be started. 7.0 The Complex Case Management Teams Goals The OPT will set and record client related goals at the team meetings (Appendix III). Short-Term Goals: Provide a seamless discharge from acute facilities for older adults with complex needs. Full assessment and supportive intervention to promote independence in all activities of daily living. Assessment of safety risks. Assessment for mobility aids to support mobility, gait re-education, balance retraining and stair practice. Perform a comprehensive physical exam and functional assessment including mental status, cognitive and perceptual skills, social support and nutrition. Assessment and intervention supporting internal and external environmental changes. Pain management education. Manual handling / risk assessment. Falls risk assessment and appropriate intervention. Supply and safe use of home adaptation/assistive equipment. Medication management. Continence management. Pressure care management. Education and health promotion activities to promote independence, safety and well being. Liaise with clients GP. Long-Term Goals: Maintain a person to continue to be as active, independent and safely as possible in their own home. Support and education to family/carers. Plan for home/environmental adaptation. Establishment of community support systems. Coordinate client respite as required. Onward referral as required to specialist services e.g. geriatric assessment and Common Summary Assessment Report (CSAR). Prevention of admission to acute facilities. 8.0 Discharge Notification Clients discharged from the OPT will have a written discharge summary sent to their referral source and local Public Health Nurse (Appendix II). 9.0 Referral for Complex Case Management Referrals will originate from both the Hospital and Community setting: Hospital Referrals All hospital referrals are referred to the OPT by any member of the hospital multidisciplinary team. Referrals require a discharge summary of intervention by all members of the multidisciplinary team (Appendix I). Community Referrals Referrals can be made by any member of the Primary Care Team or Community Care Services using the teams referral form (Appendix I). Clients under the care of an established Primary Care Team (PCT) will be initially assessed by the PCT with onward referral to the OPT if considered suitable

16 Service Strategy Service Strategy Contents Individual Roles and Responsibilities Page 1.0 Advanced Nurse Practitioner Occupational Therapist Occupational Therapy Assistant Physiotherapist Home Care Package Manager Individual Roles and Responsibilities 1.0 Advanced Nurse Practitioner (Community Older Adults) The Advanced Nurse Practitioner (ANP) is a provider of direct health care services to older adults and their families living in Dublin South City. This post acts as a linking post between the primary care sites and general community nursing services that accepts referrals from the various members of the primary and community health care teams. The ANP provides clinical leadership to the team in the role of the (OPT), Team Leader. This is a coordinating role responsible for: The structure and content of the interdisciplinary team clinical meetings. As team leader the ANP is the point of contact for all referrals to the OPT. Represents the team at all community service meetings. Maintains the joint interdisciplinary team care plans of clients admitted to the OPT. Retains the statistics on all clients referred to the team and coordinates the end of year clinical report to the various heads of discipline on the activities/through put of the OPT. Co-ordinates the sending of discharge letters. As a clinical member of the OPT the ANP provides a comprehensive health assessment of patients referred to the team. Community Rehabilitation Team Holistic assessment, health promotion and screening initiatives of frail older adults referred to the OPT. Performs a comprehensive physical exam considering physiologic changes of aging. Performs a comprehensive functional assessment, including mental status, social and community supports/resources and nutrition. Home Care Package Assessment of health status. Onward referral to geriatric screening services. Clinical support of the home care package case manager in the assessment / reassessment of need of clients referred or in receipt of a home care package. Complex Case Management Assesses health / illness by conducting a complete health history in light of physiologic and psychosocial changes of aging. A comprehensive health assessment of clients and their families who are considering a long-term care placement but are currently living at home. An identified nurse who will form a unique and dynamic collaborative partnership with older people and family caregivers of frail older adults, to support and guide them in the management of care throughout the health/illness continuum living in the community. Assess special risks of vulnerable older adults living in poor social circumstances for common patterns of illness and communicable disease

17 Service Strategy Service Strategy Common Summary Assessment Report (CSAR) Coordination of community CSAR referrals for clients applying for the Nursing Home Support Scheme. Assesses roles, tasks and stressors of informal system / family caregivers for older adults, particularly those identified with increased frailty. 2.0 Occupational Therapist Occupational Therapy (OT) is a profession that maximizes function, maintains independence, and promotes health and well being through occupation. The primary goal of OT is to enable the older person to participate in activities of daily living. Occupational Therapists achieve this outcome by enabling the older person to carry out activities of daily living that will enhance their ability to live independently and safely in their own home environment. This may necessitate modifying the home environment, increasing supports in the home and providing a falls prevention programme. Clients are actively involved in the therapeutic process, and outcomes of OT are diverse, client-driven and measured in terms of participation or satisfaction derived from that participation (Fisher et al., 2007). The elderly population is growing, and person s who are over 65 years and older often experience illness, cognitive impairment or disability that prevents them from participating in their daily activities. Due to the unique focus that Occupational Therapists have on occupation and daily life activities the ongoing OT intervention is wholly relevant to the frail, elderly population who are very often having difficulties with occupation. Occupation is everything people do in their daily routine, including carrying out their personal activities of daily living, enjoying life and contributing to the communities in which they live. Occupational performance areas include personal activities of daily living (PADL s comprise of the following activities eating, dressing, bathing, grooming, toileting, and transferring) instrumental activities of daily living (IADL s comprise of the following activities of preparing meals; communicating by telephone, writing, or computer; managing finances and medication routines; cleaning; doing laundry, food shopping, and other errands; travelling as a pedestrian or by public transportation; and driving) education, work, play, leisure, and social participation (Wressle et al., 2006). In the area of rehabilitation for the older person, OT focuses on self-care activities and improvement of fine motor coordination of muscles and joints, particularly in the upper extremities. OT focuses on activities of daily living because they are the cornerstone of independent living. The evaluation of the older person assesses the client s ability to complete everyday functional activities, balance, coordination, perceptual skills, and cognition, with a large emphasis on evaluation of the home environment and falls risks (Gitlin et al., 2006). How is Occupational Therapy provided? Occupational Therapists take a holistic approach to the needs of their older clients which usually involve three stages of care. The abilities of the client are assessed in the context of home, leisure, general lifestyle and routine and family supports. Following an assessment, the Occupational Therapist then collaborates with the client, family members in setting OT goals and also the in setting an Interdisciplinary Team Care Plan (See Appendix III) for each individual client. Depending on the nature and length of this intervention, the primary goal is always to maximise the client's skills to continue to live safely and independently in their own home environment. Occupational Therapy Goals for Clients referred to the to Include Community Rehabilitation Team, Home Care Package & Complex Case Management Provide a seamless discharge from the hospital to home through liaising with the Interdisciplinary Team. Assessment of skills in self care, domestic activities of daily living and social skills. Training in personal care activities, correct and safe method of transfers throughout the home and domestic management skills to increase independence. Assessment and modification of the home to improve safety, falls prevention and independent living. Therapeutic activities and upper limb rehabilitation to client / carer to promote posture and prevent contractures. Cognitive rehabilitation, memory assessment and techniques to cope with deficits in this area. Perceptual assessment and intervention as appropriate. Planning and teaching ways to adapt to, and compensate for, normal age related functional decline. Prescription and education to the client / carer in the use of adapted equipment or design of specialized equipment to assist with functional activity. Education in Falls Prevention, Energy Conservation and Joint Protection. Anxiety Management, Coping with Depression and Stress Management. Addressing many of the behavioural problems associated with Alzheimer s disease and dementia and in assisting caregivers with these issues (Gitlin & Corcoran, 2005). This population requires specialized activity programming that focuses on supporting remaining capabilities while maintaining health and safety. Teaching work simplification techniques and routine to maintain independent living Advice to carer s / family on moving and handling and transferring techniques. Health promotion to include healthy lifestyle and healthy diet. Advice on accessing public transport and community amenities. 3.0 Occupational Therapist Assistant The Occupational Therapist Assistant compliments the Occupational Therapist by assisting them in carrying out, and to complete, the client's treatment plan. The Assistant works under the direct supervision and guidelines as deemed appropriate by the Occupational Therapist. The Occupational Therapist Assistant facilitates the client in areas such as: Activities of Daily Living, Falls Prevention/Safety Risks, Re-enforcing Correct Transfer Methods, Joint Protection and Energy Conservation. If any new issues arise, it is the responsibility of the Occupational Therapist Assistant to bring this to the attention of the Occupational Therapist, to enable the Therapist to review or modify the client's treatment plan. The Occupational Therapist Assistant's role is very broad and it includes educating the client and/or carer in the proper and safe use of adaptive equipment. The Occupational Therapist Assistant makes several visits to the client, ensuring that they are progressing well and re-enforcing the client's safety and goals. The Occupational Therapist Assistant assists other members of the multidisciplinary team in the long term promotion of the client's continuing health. The Association of Occupational Therapists in Ireland outlines the role of the Occupational Therapist Assistant to be as follows (AOTI, 1985, 2008) 30 31

18 Service Strategy Service Strategy Instructing, assisting and interacting with clients in the performance of activities at the discretion of the Occupational Therapist. Participation with the Occupational Therapist in client programme planning. Preparation of materials and activity area for treatment. Report to the Occupational Therapist on client performance during activity. 4.0 Physiotherapy Physiotherapy is a health care profession concerned with human function, movement and maximising potential. It uses physical approaches to promote, maintain and restore physical, psychological and social well being, taking into account variations in health status. It is science-based, committed to extending, applying, evaluating and reviewing the evidence that underpins and informs its practice and delivery. The exercise of clinical judgement and informed interpretation is at its core (CSP 2002). Physiotherapy takes note of psychological, cultural and social factors influencing the older person. It tries to bring the client into an active role to help make the best of independence and function. Community Rehabilitation Team The Physiotherapist (PT) goals may include: Gait re education including indoor and outdoor mobility, gait pattern training and walking aids. Exercise including exercise tolerance and endurance training, progression of exercise plans, improvement of range of motion, strengthening of upper limbs, lower limbs and core. Home environment assessment including stairs, mobility aid appropriateness and falls risks. Energy conservation both indoors and outside. Falls prevention to include balance work, exercises, on/off floor practice/ education, environment check (trip hazards), footwear advice and education for patients and carers. Postural advice. Electrotherapy adjuncts including heat and ice therapy. Respiratory assessment and treatment including breathlessness education and ambulatory oxygen advice. Health education. Liaison with other service providers. Home Care Package The PT will Complete an assessment of need. Referral for treatment as required. Health education. Education of carers and clients. Common Summary Assessment Report The PT will Assist in the completion of an assessment of need. Refer for treatment as required. Complex Case Management The PT goals may include: To maximise function and quality of life. Assessment for appropriate aids and appliances. Tone and positioning advice and education to clients and carers. Education re chronic pain and other conditions to include TENS, heat, ice, posture and home environment. Transfer and bed mobility advice and education. Carer education re manual handling, equipment and safety. Respiratory including breathlessness education and ambulatory oxygen advice. Health education. The PT will liaise with other service providers to avoid duplication of services. 5.0 Home Care Package Manager The Home Care Package (HCP) Manager, while accountable to the senior manager in the Local Health Office Area, is responsible for the day to day allocation of the HCP resources to: Ensure the efficient and effective use of the available resources assigned to the scheme. Maximise the impact of these resources in the achievement of the objectives of the scheme including facilitation of timely discharges from acute hospitals. Facilitate contact with, and between, community services and acute hospital services in relation to HCP s, in majority of cases as direct liaison contact. Where possible reduce inappropriate admissions through the provision of a HCP. Reduce pressure on A&E Departments where appropriate through the provision of a HCP. Support older people to live in their own community by providing a HCP in appropriate cases. Employ appropriate performance management / monitoring to ensure that resources allocated are fully expended but not exceeded. The Home Care Package Manager role within the OPT will: Accept applications for home care package support from clients who fulfil the scheme s criteria. Refer to the OPT for assessment and intervention and progression to long term care as appropriate. Attend OPT team meetings when appropriate Assess the needs of patients together with other health professionals Decide what extra hours of care are needed based upon present community supports. Liaise with Care Agencies and coordinate care. Manage home care grants within budget Deal with complaints and queries. Liaise with PHN, Community Nurses. Occupational Therapists, Physiotherapists and the Advanced Nurse Practitioner

19 Service Strategy Service Strategy Contents Priority Policy Page 1.0 Screening of Clients Priority Clients Waiting List Priority Policy 1.0 Screening of Clients Screening for all clients is carried out at the fortnightly clinical meetings. It is based on the information presented on the referral form and additional written or verbal information provided by the referral source. 2.0 Priority Clients Clients with significant safety risk factors e.g. cognitive impairment, social isolation, high falls risk, environmental risks and skin vulnerability. Clients whose carers are under a high level of stress. Nature of medical condition e.g., recent joint surgery and fluctuating medical stability. Clients with high dependency needs and poor self advocacy. 3.0 Waiting List Different team members may have different clinical priorities based on their individual roles and responsibilities. Time scale for assessment would reflect this difference. However a team member will make contact to assess the client within fourteen days of initial Older Person s Team (OPT) screening. If the team has reached capacity (see individual CRT, CSAR and Complex Case Management policies) clients will be place on a waiting list dependant on need, the client / carer will be notified of the waiting list via telephone. If a waiting list is required clients will be further prioritised by using The Groningen Frailty Indicator (Slaets 2006) (Appendix V)

20 Service Strategy Service Strategy Contents DNA Policy Page 1.0 Introduction Procedure Ongoing needs DNA Policy 1.0 Introduction In the event that a client is not present on a prearranged visit a DNA policy has been put in place. The aim of the policy is for clients to be treated in a timely manner with maximum opportunity to engage with the service. 2.0 Procedure If unable to gain access on two prearranged visits a telephone call will be made to reschedule another appointment. The client / carer will be informed that if they fail to attend the next appointment they will be discharged from the (OPT). If telephone contact can not be made a letter will be sent to the client / carer requesting them to contact the service. If no contact has been made within three weeks the client will be discharged from the service. If a client is discharged from the service for this reason the referrer / PHN will be informed. 3.0 Ongoing Needs If a client needs further treatment from the OPT a new referral will be required

21 Service Strategy Service Strategy Contents Ground Rules Policy Page 1.0 Introduction Our Attitude and Culture Communication and Decision Making Quality Respect Fairness and Equity Leadership Accountability and Responsibility Team Meetings Ground Rules Policy 1.0 Introduction The (OPT), Dublin South City are committed to providing an integrated service approach to older persons with varied health and social needs living in the community. This can only be achieved if all team members are committed to the process, share same values and principles, deliver open and honest communication and deliver an equitable and high quality service. This ground rules policy sets out the team s core values and principles which are intended to assist team members to evaluate their professional relationships within the team and to articulate the team s expectations for proper behaviour and educate colleagues and staff. The ground rules policy as set out by the OPT govern the functional ways and means within which team members will engage with one another. In a world where there are many ways of communicating with each other, committing to, and following good ground rules is a positive step toward healthy integration. They also give the team leader and others in the group, implied consent to intervene when they are broken. The following sections of the document highlight and present the OPT agreed values and principles. The OPT ground rule policy is a living document and will be reviewed and altered as according to OPT needs and developments. 2.0 Our Attitude and Culture We will treat each team member with respect. We will always respect the client in his / her own home. We will observe a responsible dress code (see OPT Professional Appearance / Dress Code Policy). We will value constructive feedback. We will avoid being defensive and give feedback in a constructive manner. We will strive to recognize and observe individual and team accomplishments. As team members, we will work together to solve problems and catch-up on behind schedule work. We intend to develop good working relationships within the team. This will enhance trust, open and honest communication. We will respect professional decisions and will not cross professional boundaries. 3.0 Communication and Decision-Making We will listen, be non-judgmental and keep an open mind on issues. We will avoid defensive behaviour (denying problems, changing topics, cutting off a speaker). We will de-personalize discussion of issues. We use consensus for important decisions and issues. True consensus is when alternatives have been debated thoroughly by the group and everyone is prepared to accept that in the circumstances one particular solution is the best way forward. It is useful to ask if everyone is prepared to act publicly as if it were their preferred solution

22 Service Strategy Service Strategy 4.0 Quality We will continue to work to deliver evidence based best practice. We will continually audit and evaluate our performance / services and act upon the findings. We will encourage and facilitate continuous training and development for all our team members. We will support innovation and encourage creativity. If a team member believes they are being asked to do a task outside the scope of their own professional remit or the team s remit, he / she will bring this to the attention of the team leader for resolution. When we pose an issue or a problem, we will also try to present a solution. We will manage our caseload in a professional manner through development of a prioritisation system (see Priority Policy, OPT). We will aspire to the highest level of achievement in all aspects of our work. 5.0 Respect We will value clients and each other. Recognising the fundamental worth of people through trust, courtesy, mutual communication and collaboration. We will respect our clients, their families and each other as individuals in our communications. We will be caring, loyal, truthful, respectful, kind, considerate and empathetic. We will actively listen to the views and opinions of all stakeholders and consider them in our actions. We will show dignity, courtesy and professionalism to clients and team members at all times 6.0 Fairness and Equity The team will provide health and personal social services based on need and strive for the provision of an equitable health service for the older person. We will deliver high quality, reliable, person-centred services, delivered as close to the point-of-care as possible. We will provide equality of access and delivery of the full range of services for everyone. The team s aspirations for fairness and equity are to ensure those most disadvantaged and marginalised in our community have their health and personal care needs met. 7.0 Leadership We all have a role to play in leadership by communicating the vision, taking responsibility, building trust and confidence among colleagues and service users. Lead by example - We are all human beings with different strengths; we will learn from the strength of others who have enriched our lives. We will respect and acknowledge the role of our staff and instil pride in delivering our services. 8.0 Accountability and Responsibility We will be honest, consistent and accountable in decisions, words and actions. We will provide health and personal social services within our allocated budget. We will ensure integrity in our processes and practices. We will encourage and allow individual responsibility and empower our team members to manage their services. We will recognise performance and challenge underperformance and non performance. When something goes wrong, we will acknowledge, we will apologise and find out what happened. We will put mechanisms in place to ensure it will not happen again. We will stringently follow the HSE complaints procedure should a complaint be brought to the attention of the team. 9.0 Team Meetings We will hold a regular weekly meeting on Wednesday at 2:15pm in the Meeting room, St. Mary s Community Centre, Rathmines. Each meeting will have a chairperson who is responsible for keeping the meeting focused. This role is appropriate for the team leader, but the team may rotate the responsibility amongst its members. The chairperson's chief responsibilities are to: Formulate the agenda. Keep the discussion focused on the topic. Intervene if the discussion fragments into multiple conversations. Tactfully prevent anyone from dominating or being overlooked. Making sure no one interrupts a speaker. Brings discussions to a close. Restates what others have said for clarity. Notify the group when the time allotted for an agenda item has expired or is about to expire. The team then decides whether to continue discussion at the expense of other agenda items or postpone further discussion until another meeting. We will have an agenda for each meeting. At the end of the meeting, we will draft an agenda for the next meeting. The team leader will furnish and distribute an agenda by by lunch Tuesday. Team members are responsible for contacting the team leader or leaving a voice message or with any agenda items they want to include by 4pm Tuesday. Agenda items can be added at the meeting with the concurrence of the team. The agenda items need to be timed and prioritised. We will take minutes for each meeting Each meeting will have a scribe who records key subjects and main points raised, decisions / actions made (including who has agreed to do what and by when) and items that the group has agreed to raise again later in this meeting or at a future meeting. Team members will refer to the minutes to reconstruct discussion, remind themselves of decisions made or actions that need to be taken, or to see what happened at a meeting they missed. The responsibility for taking and distributing meeting minutes will rotated among core team members. Meeting minutes will be distributed within 7 days of the meeting. Please see appendix VI for template for recording minutes

23 Service Strategy Service Strategy Additional meetings can be scheduled to discuss critical issues or tabled items upon discussion and agreement with the team leader. Once a meeting begins, everyone is expected to give it full attention. No one should be called from the meeting unless it is important. All mobile phones should be turned off during a team meeting. All team members are expected to attend team meetings unless they are on annual leave, on organised courses or sick. If on annual leave the team member will provide written feedback for the meeting. See appendix VII which outlines the team s team meeting feedback form. The team leader can cancel or reschedule a team meeting if sufficient team members are unavailable or there is insufficient subject matter to meet about. Meetings will start promptly. All members are expected to be on-time. If, for extenuating circumstances a member is late, he/she must catch-up on their own. An action item list with responsibilities will be maintained, reviewed in meetings, and distributed with the meeting minutes. No responsibilities will be assigned unless the person accepts it. We will leave any disagreements at the meeting. Contents Professional Appearance / Dress Code Policy Page 1.0 Introduction Propose & Scope Principles Organisation Dress Code Infection Control HSE Identity and Security Cards Implementing & Monitoring

24 Service Strategy Service Strategy Professional Appearance / Dress Code Policy 1.0 Introduction The (OPT) complies with and endorses all HSE policies. The OPT, Professional Appearance and Dress Code Policy has been adopted from the National Health Service (NHS) Borders, Dress Code / Uniform Policy. Modifications have been made to the abovementioned policy formulating it to be specific to the community based OPT Service. An important aspect of providing health care is the confidence of the service users in our ability to deliver exemplar services in a professional manner. It is recognised that the appearance and standards of dress adopted by staff are an influencing factor on this confidence. There is a collective and individual responsibility to represent the HSE Dublin Mid Leinster,, OPT Service in a positive way to the community we serve and to instil confidence in the service we provide. The Dress Code Policy aims to outline standards through which the OPT members may uphold the professional image of the service within the community. Uniform and dress also forms an integral part of risk controls for health and safety purposes; moving & handling, infection control, controls for violence and aggression. This policy forms the good practice guidelines to ensure legal compliance with the Safety, Health and Welfare at Work Act 2005 and all associated Regulations / Acts. 2.0 Purpose and Scope The Dress Code Policy incorporates the recognition that: Within the OPT while all staff members in all disciplines do not wear a uniform the presentation of staff to project a professional image and to be safe applies to everyone. Dress codes must not hinder moving and handling requirements and may act as a barrier against the rigors of handling objects and patients. The Policy is supplemented by Dress Codes applicable within each discipline, these dress codes form part of the risk controls necessary to reduce identified risks to an acceptable level. Team members working in each area must comply with the applicable dress codes. This policy and all associated dress codes will be applied on an equitable basis. Personal appearance is important. 3.0 Principles These principles apply to all team members. Further to this policy team should refer to their own local dress code for guidance on their presentation. Team members not issued with uniform must ensure their clothing is suitable for the type of environment and activities they are expected to undertake during the course of their work. They must ensure that their attire does not present difficulties in relation to health and safety: moving & handling, personal protective clothing, security. It is important that team members maintain a high level of personal hygiene presenting a clean, neat and tidy appearance at work. Hair tied back when appropriate, hands and nails clean, nail varnish worn only when undertaking administrative duties. Jewellery, if worn, should be consistent with health and safety, infection control and professional standards for the local area. Jewellery type should reflect the potential risks associated with working in that area; no hoop earrings, long neck chains etc in areas where aggressive behaviours could be displayed. It is important, so as not to offend or put oneself at personal risk, body piercings should be appropriate to your local area and duties. Tattoos should be covered where practicable. Items of clothing should not be worn which would be reasonably considered to be revealing, offensive or provocative to service users, carers, colleagues or members of the public. Name badges should be worn in line with local dress codes and security arrangements. Footwear should be sensible and comply with local conditions for safety. 4.0 Organisation The HSE as an employer has responsibilities to: It is the team s responsibility to ensure adherence with this Policy and the local dress codes. The Leader has a responsibility to: Ensure Policy / dress codes are communicated at local induction and are readily accessible to all members of the OPT. Ensure all team members comply with policy and local dress codes. Delegate responsibility appropriately to aide compliance to policy and dress code. Team members have responsibility to: Wear appropriate clothing when a uniform is not provided, bearing in mind the type of work undertaken and any health and safety requirements. Follow the uniform policy and dress codes. Ensure their appearance is appropriate for the area of work. Act in a manner so as not to endanger themselves or others during the course of their work. 5.0 Dress Codes All local dress codes will be considered as policy for that area and will be implemented as such. 6.0 Infection Control The principles of infection control are core to the delivery of a professional and competent healthcare service. Hair should be clean and tidy, and team members delivering direct patient care should wear their hair off the collar. Nails should be short and well manicured. Nail varnish should not be worn unless as an agreed exception with the Infection Control Team

25 Service Strategy Service Strategy Jewellery only a band ring, small stud or sleeper earring can be worn. Wristwatches must not be worn when undertaking clinical procedures. Correct hand hygiene technique cannot be carried out when wearing a wristwatch. Footwear - correct footwear must be worn, as designated, for the particular area. Cardigans may be worn except when undertaking clinical care or having direct physical contact with patient. 7.0 HSE Identity and Security Cards All Employees who are issued with identity cards are required to attach the identity cards to their clothes/uniform in such a fashion that they will be visible to fellow Employees and members of the public. Employees must also take care of their identity cards, as often these cards also provide access to premises. Lost or stolen cards should be reported to the administrator/ person with responsibility for your building immediately. 8.0 Implementing & Monitoring The policy and dress code will be implemented through the line management system. Monitoring of compliance will be at local level. This policy is part of the terms and conditions of your employment and, therefore, forms part of your contract of employment with the HSE. Persistent non-compliance with the policy may be dealt with under the agreed HSE Disciplinary Policy. Please see hsenet.hse.ie/working_in_the_hse/hr_documents/policies_procedures/disciplinary_pro cedure_for_employees_of_the_hse,_2007.pdf Contents Communications Policy Page 1.0 Introduction Why a Communications Policy The Role of Communication The Challenge of Effective Communication The Vision for Communication The Aims of the Communication Strategy Who are our Stakeholders Responsibility and Accountability Methods of Communication Measures of Success Action Plan Implementation and Monitoring Evaluation and Review

26 Service Strategy Service Strategy Communications Policy 1.0 Introduction The (OPT) complies with and endorses all HSE policies. The OPT Communications Policy has been adopted from Milford Care Centre, Communications Strategy, Modifications have been made to the abovementioned policy formulating it to be specific to the community based OPT Service. The OPT, Dublin South City, was set up in 2009 to provide a specialised, high quality service and integrated care pathway for older people living in the area. The team provides services to older people through its Community Rehabilitation Team for Older People, Home Care Package Service, Complex Older Person s Cases and Nursing Home Support. As a health care provider, the OPT is required to be responsive to the needs of the population that it serves, and to be accountable for the resources that it has had entrusted to it. Communication is central to ensuring responsiveness and accountability in all its facets. The OPT is committed to improving communication at every level, to being open, honest and sensitive in all our communications. However, good communication does not just happen; it needs to be planned, supported and encouraged. The aim of the communication policy is to do just that; to put in place a plan that will guide the process required to deliver on this commitment (Milford Care Centre ). Nevertheless, there are challenges to be met. These include the logistical and planning issues of time and financial constraints, training, support and accessibility; the question of information management and dissemination, consultation and participation, and the test of responding to the diversity of needs of a multi-cultural society. In considering these, the communication policy sets out clear objectives: Communication should be Open and honest. Available and consistent. Participative. Clear. Accountability and responsibility easily identified. Any obstacles to communication pathways removed at every level. 2.0 Why a Communication Policy? Communication is often defined as an exchange of information. True communication requires a two way process. Information can be presented and exchanged orally, through writing, face-to-face, electronically or in small / large groups. Communication can be verbal and non-verbal (Milford Care Centre ). It is important to note the view expressed in the Health Reform Programme (2004:6) that communication is as much about listening and encouraging dialogue and feedback, as it is about telling. The OPT works with a variety of people and networks including: Clients Community Healthcare Staff (GP s, Nurses, Home Help s, HCA s) Hospital Staff Family members Carers Members of the public In recent times the Older Person s Service has evolved considerably. Such development has significant implications for the service, for client s and all those who have contact with the OPT, both directly and indirectly. 3.0 The Role of Communication Communication is about the exchange of information, ideas or beliefs. It implies several communication pathways or routes. It necessitates listening, engaging in dialogue, giving and receiving feedback and sharing information. Within the OPT communication involves different elements: treatment provision, service development and delivery, and strategy / policy making. It may take place on an individual or group basis. Good communication is essential for staff to undertake their roles effectively, to understand the aims and objectives of the organisation, and to engage with and contribute to the management of the organisation. It is vitally important for all clients, their families and carers, to know and understand their conditions, treatments and care plans. Equally, it is essential that they feel sufficiently informed and supported so as to be able to participate in discussions and decisions pertinent to their own situation. The National Advisory Committee Report noted that failure by health service staff to communicate effectively has been identified in many studies as a major impediment to the quality of care (DOHC 2001a:11). External stakeholders have differing information needs which must be addressed in appropriate ways to ensure that these needs are met. All parties, in different ways, should be able to understand the purpose and function of the various elements making up the OPT, so as to contribute to future planning and to comment in their interactions with the service. Feedback is an important tool for informing and influencing service provision, delivery and development. Effective communication builds trust and respect and ensures transparency in the decision making process. 4.0 The Challenge of Effective Communication Developing an effective communication strategy poses considerable challenges. These include: Staff, clients and public may feel that consultation/communication does not happen, or if it does that it is not really meaningful. Specifically, there may be a belief that: Views may be sought, but that nothing will happen or change as a consequence. The process is more informative than consultative. Views will not be taken seriously. Clients may be concerned that treatment or services will be affected. Ireland is now a culturally and linguistically diverse society

27 Service Strategy Service Strategy Time constraints thorough communication takes considerable time from the schedule of people already under pressure. Financial constraints e.g. time, travel costs. Training and support people may be unsure how to undertake consultation. Individuals may be reluctant to participate or may have the perception that a lack of detailed knowledge might limit input. Unrealistic expectations may be created resulting in disappointment and annoyance. A communication policy has to address these issues in such a way as to ensure maximum involvement and participation. 5.0 The Vision for Communication The vision for communication in the OPT is defined as the following: To be open, honest and sensitive in all our communications. Good communication cannot be taken for granted, it does not just happen ; it needs to be planned and supported. This communication policy creates a guiding plan to direct the processes that need to be put in place to enable us to deliver on the commitment to the principles of good communication that we are committed to delivering. These principles are outlined as follows: Openness. Honesty. Sensitivity. Availability. Consistency. Accountability. Participation. Clarity. Transparency. 6.0 Aims of the Communication Policy It is the aim of this policy, through the actions outlined, to enable the OPT to engage in: Communication that is Open and Honest Communication should be open and honest. Where it is not possible to give certain information, whether at all, or at a particular time, this should be stated. A prerequisite to open and honest communication is the development of a culture of trust. Members of the OPT, clients and families have the right to expect that their communication will be dealt with in a trusting, non-threatening manner that will allow their voice to be heard in a non-judgemental way. Communication that is Available and Consistent The OPT role, function and remit should be clearly and effectively communicated to all internal and external Stakeholders. The service shall have clearly designed systems / processes for disseminating information internally and externally. Information shall be provided in a manner that is consistent and can be understood by its recipients. Communication that is Accountable The role and remit of the team leader in promoting communication shall be clear. Decision making and organizational structures will support effective communication by ensuring clear accountability for outcomes. The OPT shall introduce and monitor feedback mechanisms. Where appropriate, action shall be taken on the feedback received. Communication that is Participatory All members of the OPT shall be provided with the information they need to enable them to do their jobs to the highest possible standard. All staff have a responsibility to inform themselves regarding issues / matters that are relevant to their role. Clients and their families / carers should have sufficient information to enable them make informed choices regarding their assessment, treatment and care plans. Staff and clients are encouraged to utilise the feedback mechanisms available. Ireland is becoming an increasingly culturally and linguistically diverse society. This necessitates the introduction of measures to ensure that the needs of those coming from different backgrounds are met, be they service users or providers. The OPT will, where necessary, provide interpreters to assist people to access and use our services. We will be aware of the needs of those with disabilities and will work with other agencies to develop effective responses to those needs. The OPT shall promote the concept of a learning organisation that encourages the dissemination of knowledge, the sharing of information and the undertaking of research. Communication that is Clear and Transparent Communication pathways must be clear and known to all staff and clients, families / carers, as appropriate. Feedback mechanisms shall be designed in such a manner as to facilitate feedback from the various service elements, e.g. staff, clients, families / carers, other service providers, suppliers. All communications should use language that is commonly used by the intended recipient(s) and written material should use layout and design that will help the reader understand the meaning easily. 7.0 Who are our Stakeholders? Whilst stakeholders may be readily identifiable to the organisation, their level of interaction with the OPT may vary, both in terms of the type of communication required and their relative priority at particular times. Our Stakeholders are both internal and external. Our audiences are not static ongoing review is required to ensure that their needs are met. Internal Stakeholders Clients and Families Clients, their families and carers are the focus of all the OPT services in Dublin South City. They have a range of information needs that may change through the period of their contact with the OPT. Members of the OPT seek to engage openly on a day to day basis with clients and their families about their wishes, concerns, hopes and fears. Health Service Executive (HSE) Health services in Ireland are experiencing considerable change following the establishment of the Health Service Executive (HSE) in The HSE is working toward the fulfilment of the Transformation Programme (HSE 2006) and the move toward the full implementation of the Primary Care Strategy (DOHC 2001b) Members of the OPT Within the staffing there are several sub-groups, relating to a service element, particular discipline, project or level of responsibility. These subgroups have different requirements that any communication systems must be robust enough to address

28 Service Strategy Service Strategy External Stakeholders General Public The OPT s relationship with the community it serves is vital. For services to be available and accessible they must be known and understood. Accurate information is essential to explain, clarify, inform and reassure members of the public about the nature and extent of the services available. Acute Hospitals The OPT works closely with the acute hospitals in the region, particularly St. James s, AMNCH, St. Vincent s, Mount Carmel, Clontarf, CRÚ Harold s Cross and Blackrock where 52% of the referrals to the Community Rehabilitation Team for Older Person s in 2009 were from clinicians working in the above hospitals. General Practitioners The care of older clients living in the community is entrusted to the General Practitioner (GP). The OPT supports the GP in providing that care. There is regular contact between members of the OPT and GPs regarding client care issues. Suppliers and Contractors There is interaction with a wide range of suppliers and contractors in the maintenance of operations and in the provision of services and equipment to the older person referred to the OPT. Unions The OPT recognises IMPACT, SIPTU and INO for staff negotiation purposes. Professional Organisations Members of the OPT are registered with professional bodies that regulate and oversee practice, qualifications and continuing professional development Local and National Groups Members of the OPT are actively involved with a variety of local and national groups representing the interest of Older Persons and Older Person s Service providers. Third Level Education Providers The OPT provides placements for undergraduate and postgraduate student education. 8.0 Responsibility and Accountability Effective communication must be multi-directional; internal to external and vice versa; up, down and horizontally. It should be accurate, timely and clear and presented in a format that meets the needs of recipients. Internally All members of the OPT have a responsibility to make themselves aware of information relevant to their work. They should use all avenues available to them to access this information. They should seek clarification, information, guidance and support from their Line Managers, where necessary. Externally All members of the OPT have a responsibility for communicating with clients and families / carers regarding their care and associated social needs. All members of the OPT shall be aware of their responsibilities regarding client confidentiality, privacy and dignity and their obligations under legislation (e.g. Data Protection and Freedom of Information legislation 1998). All members of the OPT shall ensure they use language that can be understood by the recipient. In addition, they will be aware of any appropriate information leaflets that are available which may assist them when communicating their message. Members of the OPT shall ensure that external clinical partners, e.g. GPs and Public Health Nurses, are kept informed regarding those of their clients with whom the OPT interacts. 9.0 Methods of Communication Good communication involves a continuous process of consultation and information sharing. However, there are also times when a more focused approach is required to let people know about a specific event, to review a service or incident, to consult on future activities and developments, or to take action to achieve change. Communication should not, however, only occur at the early planning stages of an undertaking, but must also feature throughout implementation and evaluation. Active partnership requires communication across all phases, undertaken in such a way as to empower and enable participation. There are many ways in which we can communicate, these can be: formal or informal verbal or written direct or indirect Views may be obtained via: one-to-one interviews, committees representative bodies the political system statutory/regulatory structures focus groups questionnaires/surveys advocates comment cards Internally, information may be given to staff via: line management structure notice boards intranet meetings staff briefings letters/memos Information may be given to clients, and their family / carers as appropriate, during the course of care, informal discussion or a formal family meeting. Communication with clients, families and other health care providers may be through a combination of telephone calls, letters and faxes. Within the OPT a variety of systems are used to share information. Category General internal information General external information Statistical Information Specialist Information Recipients All members of the OPT All Management All members of the OPT HSE Internal and External Clinicians Process Line management structure, team meetings, memos, s, letters, one-to-one meetings, intranet. OPT Information Leaflet, OPT Service Strategy Budgets, Audit Reports, Annual Activity Reports Education Programmes, In-services, conferences

29 Service Strategy Service Strategy 10.0 Measures of Success 10.1 Action Plan The success of any strategy is linked to the development and roll out of action plans. The action plan in Appendix XX identifies the actions, deliverables, target dates and responsibilities required to achieve the aims of the strategy Implementation and Monitoring The development of a communication policy, although key, is only the first step and is not synonymous with its implementation. Implementation covers the introduction of the policy, its dissemination throughout the system and the methods associated with both. Implementation of the policy will require additional resources in certain areas and successful outcomes in such areas will be dependent on these being made available. Monitoring is about checking that things are done in accordance with plans and timetables and has a current focus. Therefore, it may be regarded as part of implementation itself Evaluation and Review Evaluation is essentially a look back exercise to establish if the intended purpose has been achieved and whether it has performed in accordance with expectations. Evaluations help to identify what is working well and should be continued or expanded, or conversely, what is not successful and needs to be amended. Contents Disclosure of Risk and Informed Consent Policy Page 1.0 Introduction The Concept of Capacity Aim of the Consent Policy/Purpose/Definition Purpose Definition Elements of Valid Consent Procedure Medical/Nursing/Allied Health Responsibilities Where Capacity is brought into question In turn monitoring and evaluation reports will inform a review of the policy. This policy will be reviewed in 2011 and a measure of performance against the key performance indicators will be made. Protocols will be presented for the following communication areas used within the OPT: Telephone Communications (See Appendix VIII) Communications (See Appendix IX) Letter Communications (See Appendix X) Memos Communications (See Appendix XI) Meeting Minutes (See Appendix VI) Meeting Feedback Form (See Appendix VII Fax Communications (See Appendix XII) 54 55

30 Service Strategy Service Strategy Disclosure of Risk and Informed Consent Policy 1.0 Introduction The (OPT) complies with and endorses all HSE policies. The OPT, disclosure of risk and informed consent policy has been adopted from St Marys Hospital Consent Policy, Phoenix Park, Dublin. Modifications have been made to the abovementioned policy formulating it to be specific to the community based OPT service. There is a fundamental premise within the OPT, that the consent of the client is required for all treatment, whether of a routine or extraordinary nature. This respect for people s rights to determine what happens to their own bodies is a fundamental part of good practice. It is also a legal requirement. Consent stems from the concept of individual autonomy, which is based on the fundamental rights of the individual to self-determination. Issues of capacity and human rights are interlinked. If treatment is given without consent there are implications under the Constitution, human rights law, the law of torts and criminal law see Appendix XIII. 2.0 The Concept of Capacity Discussions about capacity arise in the issue of consent and also substitute decision-making for adults who lack capacity. There is a legal presumption of capacity of all adults to consent. The onus is on the person asserting a lack of capacity to provide adequate evidence to prove this. There is no one generally applicable definition of capacity. Judgements about capacity to consent are clinical decisions but ultimately, judgements that a person is legally incompetent is a decision for the courts, with far reaching civil liberty implications and must be conducted with due process. The assessment of capacity is hindered by the lack of a universally agreed definition, that clinical determination is not exact, that standards of capacity represent value choices and that a person s capacity can be intermittent, decision specific, complete or limited. This policy emphasises the link between consent, decisionmaking capacity and human rights and autonomy. It therefore accepts that any attempt to compromise this autonomy should be fully justified. It is recognised that there are areas where there is a conflict between the rights of the client and the duty of professionals and well being of others. The challenge is to balance these often-conflicting elements (HSE Patient Private Property Policy). 3.0 Aim of the Consent Policy The following offers guidelines for dealing with the issue of consent, which will underpin the development of any policies for the OPT, Dublin South City. 3.1 Purpose It is acknowledged that guidance around the topic of consent has to cover: Consent / refusal to treatment, examination or procedure in the medical sphere (e.g. wound dressing, administering injections). Consent / refusal to interventions from the multi-disciplinary team working in the OPT (e.g. home visit, referral for services, assessments). It is also necessary to include consent/refusal to decision making about personal care and welfare, financial management or any major decisions that may impact on lifestyle and social life choices. Issue of assessment of decision-making capacity to consent / refuse the above. Consent as outlined in this guidance will not address less clinical areas such as decisions about social interactions, values and choices. These should be viewed from the perspective of human rights, dignity, choice and respect for the individual. 3.2 Definition The administration of treatment to a person without their consent is unlawful. When an assessment is made that an adult lacks decision making capacity this does not remove the requirement for a legally effective consent. 4.0 Elements of Valid Consent: see Appendix XIV Consent must be voluntary. Given by someone with capacity to make a decision about the intervention proposed. Based on sufficient information. Based on understanding the decision Being able to communicate the decision. 5.0 Procedure These procedures are formulated with concerns that the clients capacity to make decisions can be overestimated, which could result in client s making choices that are inconsistent with their best interests or underestimated, which results in a denial of autonomous choice 6.0 Medical, Nursing and Allied Health Professional Responsibilities: A healthcare practitioner must assess a client s decision making capacity to decide whether or not to consent to the proposed treatment, before acting on a client s consent or accepting a client s refusal. NB. The area of assessment of capacity is fraught with uncertainty. The assessment of capacity requires clinical judgement guided by professional guidelines and legal requirements. Speak to / consult with client first about their views of the situation. The main factors to be taken into account are the client s understanding of the purpose and nature of the intervention, its benefits, risks and alternatives and consequences of not receiving the treatment. It is also important that the client can retain the information long enough to balance and weigh it up in order to arrive at a decision. If related to a nursing procedure, inform the medical representative and the carer about their decision. If you are sure the client can clearly demonstrate capacity to decide, their decision is to be accepted as valid. The decision on capacity is not related to the decision-making choices of the individual. The decisions made should guide assessment of understanding but should not be conclusive of capacity. Be aware that impairment may not be apparent on superficial questioning. It may be necessary to speak with the client on more than one occasion to ensure consistency in their response and decision. Underestimation of a client s capacity is more likely in long-term care facilities or in individuals with specific diagnoses such as Alzheimer s disease

31 Service Strategy Service Strategy 6.1 Where capacity to consent is brought into question adopt the following: The client s Consultant / General Practitioner must be informed that these procedures are being followed. Check whether a recent formal assessment (e.g. MMSE), has been completed in the last three months. If there is a perception that there is a marked or sudden deterioration, a formal assessment from the Occupational Therapist is to be requested and the Medical Personnel are informed. At this point it may be helpful to discuss the situation with relatives, those who know the client to gain some insight into their perception of his / her mental capacity. If the outcome of the assessment does not demonstrate that capacity to consent exists and no formal substitute decision making arrangement exists, all reports and assessments should be furnished to the client s General Practitioner / Consultant for further assessment to occur. There is no legal basis on which a relative can give consent on behalf of an adult, aged 18 or above, having reached the age of majority, irrespective of the adult s decisionmaking capacity. Recording: Assessments regarding mental capacity should be carefully recorded, dated and signed in the clients file. Equally, concerns or evidence regarding undue influence, misrepresentation, coercion or duress should be recorded as they may invalidate consent at a later time. Contents Client Confidentiality Policy Page 1.0 Introduction Persons Affected Policy Definitions Responsibilities Procedures Legislation Informing the Client about the Confidentiality Policy Amendments and Corrections Disclosure Communication of Client Information Client Related Mail Storage and Security Retention of Client Information Disposal of Client Information Enforcement Of Confidentiality Policy

32 Service Strategy Service Strategy Client Confidentiality Policy 1.0 Introduction The (OPT) complies with and endorses all HSE policies. The OPT, Client Confidentiality Policy has been adopted from The Adelaide and Meath Hospital, Dublin; Policies and Procedures on Confidentiality of Patient Information. Modifications have been made to the above mentioned policy formulating it to be specific to the community based Service. The HSE Dublin Mid Leinster,, OPT is committed to the concept of confidentiality as a core personal right of every citizen and to safeguarding the confidentially of all client information. The purpose of this policy is to define the organisation confidentiality policy for client information. 2.0 Persons Affected All employees and all third parties of the OPT in Dublin South City who have or can gain access to client information. 3.0 Policy The OPT in Dublin South City recognises the client s right to privacy. Confidentiality is at the core of the relationship between clients and carers and as a result we expect all information to be handled sensitively and confidentially. Therefore it is the policy of the OPT in Dublin South City that: Client information will be restricted to members of the OPT in Dublin South City on a need-to-know basis, as determined by their role or service responsibilities. Healthcare delivery associates will receive relevant, appropriate and agreed information on their clients. The OPT in Dublin South City expects healthcare delivery associates to handle this shared client information confidentially and securely in adherence to the Data Protection Acts 1998 and If client information is disclosed to a third party, the OPT in Dublin South City will hold the said party to the same set of confidentiality and privacy principles that the organisation adheres to. As a public body the OPT in Dublin South City will adhere to the Data Protection Acts 1998 and 2003, as governed by legislation. Any member of the OPT in Dublin South City will be subject to disciplinary action if he/she breaches the organisation s confidentiality policy. 4.0 Definitions Confidential Information Is any information collected, processed or utilised, where it is reasonable for an individual who provides the information to assume that it will be held in confidence, and it has been anonymised, pseudonymised or encrypted. Data Protection Acts 1988 and 2003 The data protection principles give a clear framework for the clarification and processing of personal data whether in computerised or manual form particularly in regard to use, sharing, disclosure, confidentiality and security of personal data instead of clarification and processes required ensuring confidentially and protecting the individual. These principles will ensure that an organisation will have data collection processes which are open, transparent and accountable. They aim to balance the timely flow of information, while still protecting the individual s privacy and maintaining confidentiality. The data protection principles are defined in law for organisations who collect and process personal identifiable data in respect to a living individual. Disclosure The release, transfer, provision of access to, or divulging of client identifiable information to persons or entities external to the organisation. Educational Institutes This refers to educational institutes who have students attending or visiting the OPT in Dublin South City e.g. Trinity College Dublin. Healthcare Delivery Associates This refers to the OPT associated healthcare providers, who are not direct members of the team. They must be directly involved in the delivery of healthcare to a specific client and include e.g. General Practitioner, Public Health Nurse, Medical Supply Company Representatives, Nursing Homes, and Specialists. They must be identified caregivers for a specified client before sharing of client information. This sharing of relevant, specific and agreed client information is required to deliver continuity of care as well as a safe and quality service. Identifiable Information: Is information, which enables data to be identified as belonging to a specific Individual and includes: Demographic - Client's name, address, full postcode, date of birth. Images - pictures, photographs including digital images, videos, audiotapes or other images of clients. This includes images used for training or publication. Unique ID s (identification s) - Identification numbers and local client identifiable codes. Anything else that may be used or linked to identify a client directly or indirectly. This includes: rare diseases, drug treatments or statistical analyses, within a small population, and which may allow individuals to be identified. Incidental Disclosure A secondary use or disclosure that cannot be reasonably prevented, and occurs as a by-product of an otherwise permitted use or disclosure. Legal Representative A parent, guardian or other person who has the authority to act on behalf of a minor client in making decisions related to health care. For adult clients it means the legal guardian of an incompetent client, who is the health care agent, designated to act for an incapacitated client s health care. Client If not otherwise stated, when referring to the client in relation to consent, access and/ or disclosure it generally includes the client and/or their parent/guardian and/or their legal representative see third party responsibilities

33 Service Strategy Service Strategy Students This refers to all students attending the OPT in Dublin South City, who are not employed by the HSE or the OPT, and who have access to client information. Third Parties This refers to any party other than a HSE employee / OPT member or healthcare delivery associate who has access to client information or require access to client information. 5.0 Responsibilities Employees Responsibilities: It is the responsibility of all members of the OPT who have access to client information to familiarise themselves with this policy and apply it to practice., Team Leader Responsibilities: It is the responsibility of the team leader to: Ensure this policy is available to all members of the team and third parties, as appropriate. That they have the processes and guidelines in place to enable adherence to this policy. That all non-employees who are affected by this policy have signed the appropriate confidentiality agreement. They must retain these agreements. That all breaches are reported to the Human Resources (HR) department. That is reviewed and updated, as appropriate. Human Resources responsibilities: It is the responsibility of the HR department to: Ensure that all employees have been issued with a contract of employment, which will include a confidentiality section: Disseminate the staff handbook which will contain the following short synopsis of the Confidentiality policy. In the course of your employment you may have access to, or hear information concerning, the medical or personal affairs of clients and / or Employees, or other Health Service business. Such records and information are strictly confidential and, unless acting on the instructions of an authorised officer, on no account must information concerning Employees, clients or other Health Service business be divulged or discussed except in the performance of normal duty. In addition, records must never be left in such a manner that unauthorised persons can obtain access to them and records must be kept in safe custody when no longer required. Any breaches of the policy will be dealt with in accordance with the HSE Disciplinary Policy. The policy can be found at: hsenet.hse.ie/working_in_the_hse/hr_documents/policies_procedures/discipli nary_procedure_for_employees_of_the_hse,_2007.pdf Third Party Responsibilities: It is the responsibility of third parties, who have access to the OPT client information, to: Be aware of and adhere to the OPT privacy and confidentiality principles. 6.0 Procedures In order to ensure uniformity of practice and establish clear and agreed understanding of the organisation confidentiality commitment, this section will clarify and establish: The organisations commitments to confidentiality and the Data Protection Acts 1998 and The balance for organisational confidentiality, which protects privacy, and ensures confidentiality without disruption to the quality of care delivery. Who will have access to client information and records? What, by whom, to whom and how client information may be disclosed. Disciplinary processes for breach of confidentiality. How the policy will be disseminated. Where all staff members will have access to the policy and related material. All members of the (OPT) are required to adhere to the following procedures, as appropriate to their role and practice. 6.1 Legislation Registration The HSE is registered with the Data Protection Commission, as it is an organisation that is involved in the production, processing, maintenance, and disposal of personal and sensitive identifiable information on individuals. Data Protection Acts 1988 and 2003 The OPT in Dublin South City will adhere to the Data Protection Acts 1988 and 2003 as governed by: The Data Protection Act The European Communities (Data Protection) Regulations of The European Union (EU) Directive 95/46/EC (1995) as they are adopted in full by the Irish government. Any future legislation produced by the Irish Government on Data Protection. As a result this policy will be reviewed, as required, if any relevant legislation should arise prior to the policy review date. 6.2 Informing the Client about the Confidentiality Policy. Reference will be made to client confidentiality in the OPT Client Information Booklet. Clients will be able to request more information on the OPT confidentiality policy as to: What is being collected, processed, and stored about them. The purposes for which it has and is being collected and stored. What form it is being stored in. The source of the information. How the data will be utilised. Who is or will it be disclosed to. That they can have access to the data. How they can have access to the data. That they have a right to amend or correct data. Clients may request this from the OPT Leader. This will be provided without constraint, and without excessive delay

34 Service Strategy Service Strategy In the course of client treatment, the OPT in Dublin South City will transfer data to other health care providers as appropriate to the particular procedure. Clients will be able to request more information on the confidentiality policy as to disclosure- see section disclosure and exceptions: Exceptions as designated in the Data Protection Acts 1988 and Access to certain specified health and social work data which is likely to cause serious harm to the data subject or which would be contrary to the public interest. Data pertaining to crime prevention. Data pertaining to security of prisons. Data, which is considered necessary to protect international relations. Data estimating required for liability on the foot of claims. Data, which is governed by legal professional privilege. Where the may disagree with the client s request. This will be provided without constraint, and without excessive delay. Where exceptions apply the client will be informed in writing. 6.3 Amendments and Corrections Clients will have the right to have incorrect data held about them corrected or erased. The OPT will reply to such a request within 40 days and there will be no fee. 6.4 Disclosure Disclosure of client information will be made only in compliance with the Data Protection Acts 1988 and 2003, and the HSE s Confidentiality and Freedom of Information policies. Client related confidential information must only be disclosed to the client, their parent/guardian and/or their legal representative. When consent is involved and obtained the client has a right at any time to revoke this authorisation. Exceptions Client information should only be used or disclosed for the purpose which it has been collected or for another directly related purpose. It can be used or disclosed for some other purpose in accordance with section 8 of the Data Protection Acts 1988 and 2003 only when: The client has explicitly consented. It is required urgently to prevent or treat injury or damage, which is especially relevant in certain healthcare situations. It is required certain health and social data section 8 of the Data Protection Act It is a requirement for the reporting of child welfare concerns Children First chapter 4. For crime prevention: for detection or investigation on a case by case basis. For protecting international relations. It required by law or subject to disclosure due to a court order. It is required for legal proceedings. Healthcare Delivery Associates Members of the OPT in Dublin South City will disclose client information, which directly relates to a specific client to whom they are providing care, to healthcare delivery associates. Due care will be taken to ensure that: It is relevant and appropriate. The appropriate party receives the information. That a record of the information and/or communication is kept as part of the client s healthcare record, e.g.: Copy of GP s discharge summary letter. Pharmacy prescriptions. Specialist referral letter or referral notes. Electronic transactions can be tracked if necessary. Observers Any individual who attends the at their workplace; to observe a procedure, tour a department or conduct a site visit, or volunteer, which will afford them access to client information, must adhere to the OPT confidentiality policy. They must sign a confidentiality agreement via the department or facilitators in question. The client consent must be obtained prior to such individuals being present, if procedures or direct client care involved. The individual departments must retain the agreements. Business Associates/Vendors Any business associate/vendor, who has access to client information, will adhere to the OPT confidentiality policy. They must sign a confidentiality agreement prior to access to identifiable client information, via the OPT department, which must specify that the associate / vendor will follow instructions of the OPT and will ensure that they will provide sufficient guarantees in respect of security. The individual departments must retain the agreements. Students Students who attend the OPT workplace must adhere to the OPT confidentiality policy. They must sign a confidentiality agreement prior to access to identifiable client information, via their educational department or educational institute. The educational department or educational institute must retain these agreements. Third Party Disclosure The OPT will inform clients if their client identifiable information is disclosed to any third party, including: Who has or will receive the data. Any rectification of the data. Erasure or blockage of the data. Why it has occurred. Third parties who have access to client information, as part of their working processes will adhere to the OPT Confidentiality policy. Research and Audit Client information utilised for audit or research: Will be non-identifiable. Will have all efforts made to obtain consent, as appropriate. Will only be done so after the research proposal has passed the universities ethics committee criteria and process. Client information utilised for research or audit, which is identifiable, will require consent. A record of this consent will be kept within the client s records. 6.5 Communication of Client Information Verbal Communication Members of the OPT will be careful and discrete when discussing or presenting client or care delivery information. They will ensure: That it is appropriate and relevant. That others will not overhear them

35 Service Strategy Service Strategy That they protect the identity and privacy of the client. That gossip or derogatory remarks will not be used. That when presenting or teaching all-biographical and identifiable data will be removed especially from photographs, images, videos, screen shoots, and results etc. Census Boards White boards or census boards may, if necessary for client care, be in public view. They must only contain client s name and caregiver information only. If a client objects, their information must not be included on the white/census board. Indication of consent is to be entered in the client s medical notes. Informal Communications Members of the OPT will be careful and discrete when: Printing out reports, screens and client information that relate or contain client s information or client care delivery information. Writing informal notes, which relate or contain clients, information or clients care delivery information. They will ensure that all such information is disposed of appropriately in the designated confidential document bins or disposed of using a shredder, as supplied by the OPT. Telephone Communication (Appendix VII) Generally members of the OPT should not provide clinical information via the phone. Exceptions will only be made at the healthcare professional s discretion, using their best judgement. Due care must be taken when discussing client information via the telephone by: Ensuring that the relevant appropriate party receives the information. Further identification must be sought, such as a client date of birth, to ensure the identity of the caller. That it is appropriate that this individual receive the information. That the information is appropriate. That they are not over heard. That a record is kept of the information disclosed, within the client record, to whom, why and dates disclosed. That when discussing the information prior to disclosure that the hold buttons on the phone is utilised. That when the call is completed that the telephone, especially a cordless phone, is disconnected. Communication (Appendix IX). Members of the OPT will take due care when utilising communications to discuss or transfer client or care delivery information. It is advised that confidential client information is not sent via except when the original manual delivery methods will not meet the immediate care requirements of the client. Reasonable effort will be taken to ensure: That identifiable information is not typed in the subject field. That the transmission is sent to the appropriate destination. That the recipient is clearly identified at the address. That the recipient is aware that they are being sent, when they are being sent, where they are being sent? That the address is verified prior to transmissions of information. That the recipient verifies receipt of the information immediately after transmission. That the is printed and stored in the client s record. out of context in relation to client record or information will not be sent. Care will be taken to avoid reference to third parties. That the OPT disclosure and Data Protection Acts 1988 and 2003 are adhered to. If an communication is sent in error then the recipient will be contacted and requested to delete/destroy the communication and: A record of this will be lodged in the client records. An incident form will be completed and returned to risk management. All OPT (OPT) s sent external to the HSE network must carry a standard footer informing the recipient that: The is confidential, privileged and is intended for use for the designated recipient only. That the designated recipient will treat the information confidentially and in adherence to the Data Protection Act. Any review, dissemination, distribution, or copying is prohibited. If received in error, to destroy the message and inform the OPT. Facsimile Communication (Appendix XII). All members of the OPT will not transfer client or care delivery information via facsimile if at all possible. They will be faxed only: o When the original manual or electronic delivery methods do not meet the immediate care requirements of the client. That the OPT disclosure and Data Protection Acts 1988 and 2003 are adhered to. Reasonable effort will be taken to ensure: Facsimile transmission is sent to the appropriate destination. That the recipient is clearly identified at the facsimile address. That the recipient is aware that they are being sent, when the are being sent, where they are being sent to and that they are available to receive the information. Facsimile numbers are checked and rechecked prior to transmissions of information. That the recipient verifies receipt of the information immediately after transmission. Client information transmitted via facsimile will be done via machines situated in secure, designated, limited areas. Only authorised appropriate personnel will transmit client information via facsimile. Only authorised personal will have access to these machines and that these personnel will have received appropriate training on the transmission of confidential facsimiles. Facsimile records, along with verification of receipts, will be held in the client records. If facsimiles are sent in error then redial will be utilised and the recipient asked to destroy the fax. A record of this will be lodged in the client records. An incident form will be completed and returned to risk management. All OPT facsimiles sent must carry a standard footer informing the recipient that: The facsimile is confidential, privileged and is intended for use for the designated recipient only. That the designated recipient will treat the information confidentially and in adherence to the data protect act. Any review, dissemination, distribution, or copying is prohibited. If received in error to destroy the message and inform the OPT 66 67

36 Service Strategy Service Strategy Voic All members of the OPT will take due care when utilising voic / answering machine communications to discuss or transfer client or care delivery information. Diagnostic, treatment or client related must not be left on voice mail/ answering machine, without the client s prior authorisation. Appointment/scheduling information may be left on voic /answering machine. This information may contain specific health information, with the client s prior authorisation. Dictation All members of the OPT will take due care when utilising dictation devices as tools for communicating or sharing client information. Due care must be taken to ensure that: The information is relevant and appropriate. The relevant parties receive the information. That the information is erased after it is transcribed or entered to a database. That the device is not left in an inappropriate location and left open to incidental disclosure. 6.6 Client Related Mail All members of the OPT will take due care when opening and dealing with client related correspondence. In the OPT it is the responsibility of the Team leader to open all mail marked for the attention of the team. In his/her absence other team members will be designated to open the mail. Any correspondence marked private, personal and/or confidential will be forwarded, unopened, to the addressee unless the addressee is absent from the office for two days or more. In this instance a designated manager at a senior level will open the correspondence. In the OPT all clients related mail requires that: Client related mail will be opened immediately on receipt. Client related mail will be date stamped. The employee who opens the mail ensures that the mail is dealt with. The employee who opens the mail ensures, if necessary, that the correspondence is dealt with in his/her colleague's absence. Client related mail will be distributed immediately to the relevant staff members. Client related correspondence for other departments will be re-directed immediately. 6.7 Storage and Security Manual Client Information Storage and Security Client information will be stored securely. All members of the OPT will ensure that: Doors are shut, as appropriate. Cabinets are locked. Identifiable information is stored in a closed area and is therefore not visible to unauthorised users. Client information is not left unattended. Client information is not made inaccessible to unauthorised users. That client information is labelled appropriately. That client information/records are returned to the appropriate area, as soon, as is possible. Electronic Client Information Storage and Security All members of the OPT employees will familiarise themselves with the HSE ICT policies on: Computer Security and Data Protection. Personal and Client Data. Security and Password Use policy. This can be found on the HSE Intranet site: All members of the OPT will ensure that they can log on and out of the HSE network and all applications that they have access to, using their unique ID (username and password). They will: Not leave applications unattended when client information is on view. Not share or reveal passwords. Prevent casual viewing of client information by others, when viewing a screen 6.8 Retention of Client Information All members of the OPT will familiarise themselves with and adhere to the HSE Healthcare record retention policy. All retained client information will be: Held in a secure location. Access will be in accordance to this policy and based on a legitimate need to view them. 6.9 Disposal of Client Information Manual Client Information Manual client information includes all paper records, informal notes, faxes, reports and printed s. All members of the OPT will dispose of client information appropriately in the appropriate locked documentation bin. Electronic Client Information All members of the OPT will familiarise and adhere to the HSE policy on disposal of electronic client information, as relevant to their practice. This includes the disposal of floppy discs and s. Relevant employees will familiarise themselves and adhere to the HSE policy on disposal of backups and remote tapes Enforcement of Confidentially Policy Disciplinary Action Members of the OPT will be subject to disciplinary action if he/she: Access confidential information other than on a need-to-know basis. Fails to maintain the OPT computerized and manual records confidentially. Fails to maintain confidential client information. Fails to share client information appropriately to healthcare delivery associates. Fails to prevent disclosure of client confidential information to unauthorized third parties. Observers, Business Associates/Vendors, Students and Third Party Breaches Members of the OPT who are supervisors of individuals who are not employed by the HSE must inform the relevant external parties about the breach, e.g. educational institutes such as University of Dublin (Trinity College). This must be done verbally and then followed with a letter

37 Service Strategy Service Strategy Members of the OPT who are supervisors of individuals who are not employed by the HSE must inform the relevant external parties about the breach, e.g. educational institutes such as University of Dublin (Trinity College). This must be done verbally and then followed with a letter. The OPT must take the appropriate action they deem necessary to ensure adherence to this policy e.g. remove access to client information by the individual who has committed the breach. In the event of further breaches associated with an external third party the OPT may consider: Termination of agreement with the said third party. Legal action. Clients Clients and/or their representatives will be able to file a complaint, at any time, if they believe that a client s confidentiality has been breached. This will be filed initially with the OPT Leader and then in turn reported to the HR department. Breaches of Confidentiality Reporting Members of the OPT will report any intended deliberate: Breaches, Suspected breaches, of confidentiality to their OPT Leader or if that is not possible to the HR department. Dissemination of Confidentiality Policy All employees will be familiar with the OPT Confidentiality policy and how it applies to practice. Staff Handbook All members of the OPT will receive a copy of the confidentiality policy during induction period. Departments A copy of the confidentiality policy will be disseminated to department heads on completion of the final agreed policy. A memo will be disseminated to department heads informing them of changes, when they occur due to policy review and/or updating. The OPT Leader will disseminate this policy to third parties, as appropriate, to conduct business. This includes educational institutes who have students who attend the OPT Service. References The Adelaide and Meath Hospital, Dublin; Policies and Procedures on Confidentiality of Patient Information Aminzadeh F., Byszewski A., Dalziel W. & Amos S. (2002) Patient Adherence to the recommendations of an interdisciplinary geriatric day hospital program. Clinical Gerontologist. 26, 1-2. AOTI submission to the DoCH/HSE Rehabilitation Strategy, (2008) Association of Occupational Therapists in Ireland, Dublin (AOTI) (1985) Occupational Therapy Assistant Post, Guidelines and Protocols, Dublin Clarfield M.A., Bergman H. & Kane R. (2001) Fragmentation of care for frail older people: an international problem. Experience from three countries: Israel, Canada, and the United States. Journal of the American Geriatrics Society 49, CSP: Curriculum Framework for qualifying programmes in physiotherapy Data Protection Commissioner. (1988a). Guide to the Data Protection Act Dublin: Cahill Printers Limited. Data Protection Commissioner. (1988b). Keeping personal information on Computer: Your responsibilities. Guidelines for Data Controllers. Dublin: Stationery Office. Department of Health and Children (1988) The Years Ahead: A Policy for the Elderly. The Stationary Office, Dublin Department of Health and Children (2001a) Report of the National Advisory Committee on Palliative Care, Dublin: Stationery Office. Department of Health and Children (2001b) Primary Care. A New Direction, Dublin: Stationery Office. Department of Health and Children (2008) Commission on Patient Safety and Quality Assurance. Building a Culture of Patient Safety. Dublin: Stationery Office. Department of Health and Children and HSE Neurological Rehabilitation Strategy Eastern Regional Health Authority (2001) Review of the Ten Year Action Plan for Services for Older People ERHA, Dublin. The European Convention on Human Rights Act (2003) The Council of Europe Convention for the Protection of Human Rights and Fundamental Freedoms ( ECHR ) [online], available

38 Service Strategy Service Strategy European Community. (1995) European Union s Data Protection Directive 95/46/EU. Brussels: European Union. European Community. (2001) Data Protection Regulations Official Journal of the European Communities. Evans L. & Brewis C. (2008) The efficacy of community based rehabilitation programmes for adults with TBI. International Journal of Therapy and Rehabilitation 15 (10). Fisher AG., Atler K. & Potts A. (2007) Effectiveness of occupational therapy with frail community living older adults. Scandinavian Journal of Occupational Therapy.Vol 14, Garvan R., Winder R. & McGee H. (2001) Health and Social Services for Older People (HeSSOP). Dublin. National Council on Ageing and Older People. Gitlin, LN. & Corcoran, M. (2005). Occupational therapy and dementia care: The home environment skill-building program for individuals and families. American Occupational Therapy Association. Gitlin, LN. Hauck, WW. Winter, L. Dennis, MP. & Schulz, R. (2006) Effect of an In-Home Occupational and Physical Therapy Intervention on Reducing Mortality in Functionally Vulnerable Older People: Preliminary Findings. Journal of the American Geriatrics Society, JAGS, Vol. 54: Government of Ireland. (2003). Data Protection Act. Dublin: Stationary Office. Data Protection (Amendment) Act 2003 (.pdf KB) Government of Ireland. (1988). Data Protection Act. Dublin: Stationery office. Health Reform Programme, Communications Strategy (2004) Communicating for Change [online], available Health Service Executive, (2010) Your Service Your Say Policy, [online], available Health Service Executive, (2009), Nursing Homes Support Scheme, [online] available Health Service Executive, (2006), Transformation Programme , Naas: Health Service Executive. Health Service Executive, Business Classification Scheme and Retention Schedule [online], available HSE Business Classification Scheme and Retention Schedule [726kb] Health Service Executive, Children First National Guidelines for the Protection and Welfare of Children [online], available e_and_protection/children_first_/ Health Service Executive, Code of Practice Policy [online], available hsenet.hse.ie/hse_central/consumer_affairs/ysysdocuments/records_management/n HO_Code_of_Practice_1.pdf Health Service Executive, Confidentiality Statement from the Employee Handbook [online], available hsenet.hse.ie/working_in_the_hse/hr_documents/employee_resource_pack/employe e_handbook.pdf Health Service Executive, Disciplinary Policy, [online], available hsenet.hse.ie/working_in_the_hse/hr_documents/policies_procedures/disciplinary_pr ocedure_for_employees_of_the_hse,_2007.pdf Health Service Executive, Electronic Communications Policy [online], available hsenet.hse.ie/hse_central/commercial_and_support_services/ict/policies_and_proce dures/policies/hse_electronic_communications_policy.pdf Health Service Executive, Encryption Policy [online], available hsenet.hse.ie/intranet/hse_central/commercial_and_support_services/ict/policies_and _Procedures/Policies/HSE_Encryption_Policy.pdf Health Service Executive, Freedom of Information Act 2000 and disclosure of information to the public [online], available hsenet.hse.ie/hse_central/consumer_affairs/ysysdocuments/freedom_of_information/ A_Practical.pdf Health Service Executive, Information Security Policy [online], available hsenet.hse.ie/intranet/hse_central/commercial_and_support_services/ict/policies_and _Procedures/Policies/HSE_Information_Security_Policy.pdf Health Service Executive, Information Technology Acceptable Use Policy [online], available hsenet.hse.ie/hse_central/commercial_and_support_services/ict/policies_and_proce dures/policies/hse_information_technology_acceptable_use_policy.pdf Health Service Executive, Password Standards Policy [online], available hsenet.hse.ie/intranet/hse_central/commercial_and_support_services/ict/policies_and _Procedures/Policies/HSE_Password_Standards_Policy.pdf Health Service Executive, Patient Private Property Policy [online], available hsenet.hse.ie/hse_central/integratedservices/performanceandfinancialmanagement/pa tient_private_property_central_unit/ppp%20guidelines/ppp_guidelines.pdf Health Service Executive, Records Management Policy [online], available hsenet.hse.ie/hospital_staff_hub/mullingar/policies,_procedures_guidelines_midland_ar ea/general_regional/hsema001_policy_-_records_management_policy.pdf Health Service Executive, Patient Private Property [online], available hsenet.hse.ie/hse_central/integratedservices/performanceandfinancialmanagement/pa tient_private_property_central_unit/ppp%20guidelines/ppp_guidelines.pdf 72 73

39 Service Strategy Service Strategy International Covenant on Civil and Political Rights (1966), [online], available International Covenant on Economic, Social and Cultural Rights, (1966) [online], available Law and the Elderly (2003), [online], available Lunacy Regulation (Ireland) Act 1871, [online] available Milford Care Centre, Communications Strategy , [online], available National Health Service Borders, Dress Code/Uniform Policy: Uniform/Dress Code Working Group, Occupational Health & Safety Services July 2004 National Task Group Home Care Package & Home Help, 2010, National Guidelines & Procedures for Standardised Implementation of the Home Care Packages Scheme. Health Service Executive Non-Fatal Offences against the Person Act (1997), No. 26, Acts of the Oireachtas, Produced by the Office of the Attorney General, Dublin Stuck, A.E., Siu, A.L., Wieland, G.D., Adams, J.& Reubenstein, L.Z (1993) Comprehansive geriatric assessment: A meta-analysis of controlled trails. The Lancet, 342, St Mary s Hospital Consent Policy, Phoenix Park, Dublin 20 Squires, A.J. and Hastings, M.B. (2002) Rehabilitation of the Older Person: a Handbook for the Interdisciplinary Team, 3rd Edition, London: Nelson Thorne s Ltd. United Nations Principles for Older Persons (1991), [online] available The Universal Declaration of Human Rights (1948) [online], available Vulnerable Adults and the Law: Capacity (2005), [online], available World Health Organisation (2004) Home Based Long Term Care, retrieved 20 January 2006, available at: Wressle, E. Filipsson, V. Andersson, L. Jacobsson B. Martinsson, K. & Engel K. (2006) Evaluation of occupational therapy interventions for elderly patients in Swedish acute care: A pilot study. Scandinavian Journal of Occupational Therapy, Vol 13, Older & Bolder Septmeber (2009) A Bounty not a Burden! Submission on the National Positive Ageing Strategy. Dublin, Older and Bolder. Powers of Attorney Act (1996), [online], available Principles Concerning the Legal Protection of Incapable Adults (1999), Council of Europe, Committee of Ministers, Recommendation No R (99) 4 Rubenstein, L.Z., Siu, A.L. & Wieland, D. (1989) Comprehensive geriatric assessment: towards understanding its efficacy. Aging, 1 (2), Rubenstein, L.Z.,Stuck, A.E., Siu, A.L. & Wieland, D (1991). Impacts of geriatric evaluation and management programs on defined outcomes: Overview of evidence. Journal of American Geriatrics Society, Supplement 39, 8S-16S. Ruddle H., Donoghue F. & Mulvihill R (1997) The Years Ahead Report: A Review of the Implementation of its Recommendations. Dublin.NCAOP. Safety, Health and Welfare at Work Act 2005, Acts of the Oireachtas, Produced by the Office of the Attorney General, Dublin Slaets J.P.J (2006) Vulnerability in the elderly: fraility. The Medical Clinics of North America 90,

40 Service Strategy Contents Appendix List Framework Document REFERRAL FORM St. Mary's Community Centre Richmond Hill Rathmines Dublin 6 Tel: (01) Fax: (01) Page Appendix I Referral Form Appendix II Discharge Letter Appendix III Goal Setting Sheet Appendix IV CSAR Documentation Appendix V The Groningen Frailty Indicator Appendix VI Meeting Minutes Template Appendix VII Meeting Feedback form Appendix VIII Telephone Communications Appendix IX Communications Appendix X Letter Communications Appendix XI Memo s Communications Appendix XII Fax Communications Appendix XIII Implications of Treatment Without Consent Appendix XIV Elements of Valid Consent Appendix XV Ward of Court and Enduring Power of Attorney Appendix XVI Policy of Acknowledgement Form Appendix XVII Policy Audit Form Appendix XVIII Permission For Photographs Appendix XIX Home Care Package Application Form Appendix XX Action Plan Templates CLIENT DETAILS Name: Address: Tel. No.: Lives: Alone With family/carer Other (specify) Consultant: Hospital: Date of Admission: Date of Discharge: Referred by: Title: Contact Details: MEDICAL DETAILS Reason for Referral: Primary Diagnosis: Past Medical History: Home Care Package: Yes No Date of Birth: Male Female GMS/LTI No: Main Carer: Relationship: Carer Contact Details: GP: GP Contact Details: REASON FOR REFERRAL Community Rehabilitation Team Complex Client Case Management Home Care Package CSAR Coordination Date of Referral: Medications: Test results (including X-Rays): Other Relevant Information: 76 77

41 RELEVANT REPORTS CONSULTANT St. Mary's Community Centre Richmond Hill Rathmines Dublin 6 Tel: (01) Fax: (01) SIGNATURE: DATE: Discharge Letter NURSING Dear, Re: Name: Date: DOB: SIGNATURE: DATE: OCCUPATIONAL THERAPY SIGNATURE: DATE: PHYSIOTHERAPY SIGNATURE: DATE: SOCIAL WORK SIGNATURE: DATE: Address: The above client was referred to the Older Persons Team on During the time on this team the client received the following treatment/interventions; Nursing report: Occupational Therapy: Physiotherapy: Outcome: This client is now ready for discharge from the Older Persons Team. Neill Dunne Older Persons Team 78 79

42 For office use only St. Mary's Community Centre Richmond Hill Rathmines Dublin 6 Tel: (01) Fax: (01) Goal Setting Sheet Client Name: DOB: Date Goal Action Discipline Time Achieved Signature (date) COMMON SUMMARY ASSESSMENT REPORT Please complete all sections clearly in block capitals. Read guidance notes before completing I confirm that the assessment process and purpose has been explained to me. I consent that information may be shared as appropriate by relevant health and social care professionals in the processing of this application. Signature _ Applicant/Specified Person Date (Delete as appropriate) 1. SOURCE OF REFERRAL (PLEASE TICK): Community Hospital Acute Hospital GP Mental Health Community Nursing Home Name of Referring Location: Date of Referral: 2. PERSONAL DETAILS: First Name: Surname(s): Preferred Name: Current Address: Home/Past Address (If relevant): Tel No(s): Date of Birth (DD/MM/YYYY) Medical Card No: Hospital Number: PPS No. : 3. PERSONAL CIRCUMSTANCES: Marital Status: Single Married Widowed Separated Divorced Other Living Circumstance: Alone With Spouse With partner With family With carer With Other Describe Housing situation (See guidance document): Who is the Principal Carer: What level of support do they provide? (Please include contact details): Assessment of Carerʼs needs completed? Yes No (Please attach if available) Identify any family members, neighbours, friends who provide support: Contact Person/Specified Person/Care Rep: Relationship to applicant? (Contact details address/phone/mobile): GP: PHN &/or CMHN: Contact Details: Contact Details Health Centre: 4. ALL APPLICANTS have the right to self-determination and capacity to do so is assumed unless otherwise proven. His/her preference to stay at home or to be admitted to residential long-term care must be sought and recorded. Has the personʼs above preference been discussed with him/her? Yes No If YES - brief outline of outcome If No - Provide a reason and identify with whom it has been discussed & outline outcome 80 Completed by: NAME: Role: Date: Signature: (PRINT) 81

43 For office use only CSAR Applicant s Name DOB 5. RECORD OF CURRENT COMMUNITY/HOME SUPPORT SERVICES (See Guidance Document before completing): SERVICE Home Day Aids and (Tick) Help/Support Care Respite Meals Supply Laundry Appliances Hours/Times p/w or relevant time or if refused services SERVICE PHN/CMHN Family support/ Therapy or Services (Tick) Private Carer other discipline Day Hospital Refused Hours/Times p/w or relevant time or if refused services Completed by: NAME: Role: Date: Signature: (PRINT) 6(a). CURRENT DIAGNOSIS AND MEDICAL SUMMARY: (Please include only relevant conditions) For office use only CSAR Applicant s Name DOB 8: ASSESSMENTS DATE DATE 8 (A): BARTHEL INDEX Please insert Date(s) Undertaken WEIGHTING SCORE SCORE SCORE Bowel (Preceding week) Continent Occasional Accident Incontinent (Or needs an enema) Bladder (Preceding hours) Continent Occasional Accident Incontinent (Or Catheterised & Unable to Manage) Grooming Independent Needs Help Toilet Use Independent Needs Some Help Dependent Feeding Independent Needs Some Help Unable Transfer (From bed to chair & back) Independent Minimal Help Needed Major Help (1-2 persons) Needed Unable (No sitting balance) Mobility Independent Walks with help of 1 person Wheelchair Iindependent Immobile Dressing Independent (Buttons, zips and laces) Needs Help (But can do half unaided) Dependent Stairs Independent (Up & down must carry walking aid) Needs Help (Verbal or physical/carrying of aid) Unable Bathing Independent (Getting in & out unaided & wash self) Dependent Findings Independent (20) Low Dependency (16-19) Medium Dependency (11-15 ) High Dependency (6-10) Maximum Dependency ( 0-5) TOTAL Completed by: NAME: Role: Date: Signature: (PRINT) 8 (B): COMMUNICATION Tick Date Signature No problems Retains most information and can indicate needs verbally Difficulty speaking but retains information and indicates needs non-verbally Can speak but cannot indicate needs or retain information Completed by: NAME: Role: Date: Signature: (PRINT) 6(b). DETAILS OF THE PERSON S MENTAL HEALTH STATUS: (Please attach any supporting documentation, if available) No effective means of communication 8 (C): COGNITIVE SCREENING REPORT - BY DATE ORDER IF MORE THAN ONE AVAILABLE Cognitive Assessment Date Result Signature Date Result Signature (Specify Screening Tool) Completed by: NAME: Role: Date: Signature: (PRINT) 7. CURRENT MEDICATIONS (See Guidance Notes - Not for Purpose of Dispensing) Name of Drug Dosage Frequency Name of Drug Dosage Frequency Pressure Sore Risk Falls Risk Nutritional Risk Wandering Risk 8 (D): OTHER ASSESSMENTS (Specify Tool Used) Result Date Signature Other - Specify 8 (E): OTHER SIGNIFICANT MEDICAL/SOCIAL/ RISK FACTORS THAT SHOULD BE CONSIDERED AS PART OF THE CARE NEEDS ASSESSMENT: Completed by: NAME: Role: Date: Signature: (PRINT) 82 Completed by: NAME: Role: Date: Signature: (PRINT) 83

44 For office use only CSAR Applicant s Name DOB 9: ADDITIONAL COMMENTS e.g. Employment, Recreational or Social Needs (Attach supporting documentation): Completed by: NAME: Role: Date: Signature: (PRINT) 10(a). HEALTH PROFESSIONAL REPORTS. (Please attach if relevant. Tick to indicate a report is appended) Nursing Dietician Occupational Therapy Speech and Language Other Physiotherapy Psychology Podiatry Social Work 10(b). SPECIALIST ASSESSMENT (Best practice recommends that all older people should have a Consultant Geriatrician/Old Age Psychiatry assessment prior to a decision being made about their future care needs.) Geriatric Medicine Completed Date: Signature: Old Age Psychiatry Completed Date: Signature: Rehabilitation Consultant Completed Date: Signature: Neurologist Completed Date: Signature: Other(Specify) Completed Date: Signature: Specialist Comment: (Or append report) Completed by: NAME: Specialty: Date: Signature: (PRINT) 11. RECOMMENDATION BY MDT. For Completion by MDT. See Guidance Notes It is the recommendation of this MDT that this personʼs overall care needs are currently best met within a Long Term Residential Care Setting (Please Tick): Yes No Confirmation of MDTʼs Recommendation Name: Role: Date: Signature: Confirmation of LPFʼs Determination Name: Role: Date: Signature: IF LONG TERM CARE IS NOT DETERMINED TO BE APPROPRIATE-THE FOLLOWING SERVICE(S) ARE RECOMMENDED BY LPF Service Recommended Comment(s) Confirmation of LPFʼs Determination Name: Role: Date: Signature: Home Day Meals Aids/ Help/Support Care Respite Supply Laundry Appliances PHN/CMHN Therapy or other Day Other Other discipline Hospital (Specify) (Specify) 84 Confirmation of MDTʼs Recommendation Name: Role: Date: Signature: Name & Signature of Professional Co-ordinating completion of this CSAR Form NAME: Role: Date: Signature: (PRINT) 12. LPF DETERMINATION OF CARE NEEDS FOR COMPLETION BY LPF ONLY It is the determination of this LPF that this personʼs overall care needs are currently best met by: (Please Tick) Additional Information Long Term Residential Care Setting Sheltered Housing Other (Specify) At Home with Community Supports Likelihood of change in personal circumstances Low Risk Medium Risk High Risk Confirmation of LPFʼs Determination Name: Role: Date: Signature: Service Strategy The Groningen Frailty Indicator. Mobility Is the client able to carry out these tasks without any help? (The use of help resources, such as walking stick, walking frame, wheelchair, is considered independent) 1. Shopping 2. Walking around outside (around the house or to the neighbours) 3. Dressing and undressing 4. Going to the toilet Physical Fitness 5. What mark does the client give him/herself for physical fitness? (scale 0 to 10) Vision 6. Does the client experience problems in life as a result of poor vision? Hearing 7. Does the client experience problems in daily life because of difficulty hearing? Nourishment 8. During the last six months has the client lost a lot of weight unwillingly? (3kg in 1 month or 6 kg in 2 months) Morbidity 9. Does the client take four or more different types of medicine? Cognition (perception) 10. Does the client have any complaints about his/her memory or is the client known to have a dementia syndrome? Psychosocial 11. Does the client sometimes experience an emptiness around him/herself? 12. Does the client sometimes miss people around him/herself? 13. Does the client sometimes feel abandoned? 14. Has the client recently felt down-hearted or sad? 15. Has the client recently felt nervous or anxious? Scoring: Questions 1-4: independent = 0; dependent = 1 Question 5: 0-6 = 1; 7-10 = 0 Questions 6-9: no =0; yes =1 Question 10: no and sometimes = 0; yes =1 Questions 11-15: no = 0; sometimes and yes =1 0-5 = Low Risk = Medium Risk = High Risk Scoring Scale 0-15 pts (Slaets 2006) 85

45 Service Strategy Service Strategy Minutes Form for Team Meeting Feedback Form for Team Meetings Date/Time Venue Attendees Duration Staff member: Meeting Date: Client Name: Report: Apologies Agenda Item(s) Plan: 1 Matters Arising Client Name: Report: Matters Arising: Action: Plan: 2 3 Action: Action: Client Name: Report: 4 Action: Plan: 5 Next Meeting: Minutes: Chairperson/Time Keeper: 86 87

46 Service Strategy Service Strategy Client Name: Report: Telephone Communications Plan: Client Name: Report: Plan: Client Name: Report: Plan: Client Name: Report: Plan Telephone Communications How we handle the phone reflects on each one of us and the HSE and the Older Person s Team (OPT) as a whole. Guidelines need to be agreed to ensure an overall image of professionalism for the team. The telephone sits unobtrusively on your desk but it can dominate you unless you tame it! To use your telephone effectively, you need to manage its use. Outward calls should be scheduled to suit your timetable and that of your respondent. Inward calls should be filtered, if possible, so that you are not interrupted in the middle of other work. Once you are using the telephone you need to develop some procedures that ensure you get the most out of each call and that you do not waste time. Scheduling Outward Calls At the beginning of each day: Make a list of the calls you have to make Put them in order of priority (essential, desirable, those that can be rescheduled if necessary) Allocate times for each call, trying if possible, to bunch them and to bear in mind when each call is likely to be suitable for your respondent. Appropriate Greetings and Endings Appropriate greetings and endings to calls help build a good rapport and avoid misunderstandings and wasting time. The three elements of an appropriate greeting are: Identifying the OPT Giving your name This can be found on the HSE Intranet site: Asking how you can help the caller. When you close the call you should: Make sure that the caller has no more queries Thank the caller Let the caller put down the receiver first so they don't feel you have cut them off. Good Afternoon, Occupational Therapy, Joe Bloggs Speaking Good Morning,, Joe Bloggs Speaking Gathering Information A telephone call is a purposeful activity. Your caller will have some objective in mind and you will need to elicit this objective as quickly and as clearly as possible. In a simple information-seeking call, all you need to do is ask for the caller's name, address, telephone and fax numbers. However, in more complex situations, you need to develop your questioning techniques so that you obtain the necessary facts. You need to: Ascertain the nature of the query Verify that the query applies to the OPT, Dublin South City

47 Service Strategy Service Strategy Listening Skills Another skill in receiving telephone calls is the ability to listen properly. Passive listening is simply allowing the caller to talk and not taking any action to ensure we have the right message. By actively listening we mean first indicating to the caller that we are listening by interrupting in an encouraging manner interruptions could be 'yes', 'I see', 'Okay', right, I know what you mean, or they could be prompts to encourage the caller to say more: 'is that true?', 'are you sure?', etc. And secondly we mean asking questions or using prompts to ensure that the caller gives precise information so that the message we receive is accurate. This can be done by the use of wh- questions: What? /who? /when? /where? And by techniques such as echoing and reformulating. Suggesting and Verifying a Course of Action Once you have an accurate picture of the situation, you are in a position to propose a course of action to your caller. You should: Outline the proposal and check that it is acceptable to the caller. Confirm that they understood what is to be done. Take Notes If you handle a lot of calls each day, then it is essential to log each one under date and time. For all calls you should make a note of who rang, for what reason and the action you agreed with times and details of address, telephone number etc. Dealing with Difficult Callers From time to time you may receive a difficult call, especially if the caller has a complaint/issue. First remember that this caller is a customer/client. What you should do is: Listen without interrupting. Gather the facts and make a note of them. Take their details so you can get back to them. Sympathise with them and offer to act as fast as you can. Apologise if you have made the mistake. Stay calm even thought the caller is angry and possibly abusive. Telephone etiquette Just because you can't see the caller, it doesn't mean you have the right to suspend the normal rules of politeness. Be helpful to the caller even if the subject of the call is not strictly speaking your field of responsibility. This means trying to find someone who can help now, or someone who can ring them back later. Don't put the caller on hold and then leave them suspended there indefinitely. Remember too that you give out subliminal signals by the tone of your voice, the clarity with which you speak, how fast you speak, the pitch of your voice. You should always devote your full attention to the call; mistakes and misunderstandings will arise if you are doing something else at the same time. Even if the call is a difficult or heated one, stay calm; try to be helpful and never slam the phone down. Things to Avoid When on the Phone It's easy to fall into the trap of believing that because your caller can't see you, they won't be affected by what you are doing and what's going on around you. Remember not to: Let it ring more than four times. Eat and drink while talking on the phone. Be too familiar. Talk to someone else in your office. Have too much background noise. Speak too quietly or too loudly. Speak too quickly. Placing the Caller on Hold Always ask the caller if they would like to hold. Avoid hold please. Let them know how long it will take and ask if they would prefer to be called back. Update the caller regularly and be specific about what you need to do. Transferring Calls The same courtesy applies to transferring a caller as does to placing a caller on hold. Ask them if they would like to be transferred. If the caller wants to be transferred give them the number and name to which they are to be transferred in case they get disconnected. Stay on line to make sure the call is transferred and if possible advise the person who will receive the transferred call of the situation. Taking Messages A complete message includes the following: Name of the Caller. Date and time of call. Complete contact telephone number. Any other information the caller gives. Repeat the message to the caller to confirm. Avoid using notes or post-its. Messages should be ed. If somebody is covering your phone, be sure to pick up your messages. Voic Voic should be used at all times when you are away from your desk. The voic message should be clear and suggest options to the caller. Agreement with colleagues should be made if their number is to be used. John Bloggs is away from his phone at the moment. Please leave your number and a brief message or alternatively call his colleague Mary Bloggs on , thank you Voic messages should be checked and followed-up as soon as possible

48 Service Strategy Service Strategy Communications Write a Meaningful Subject Line Recipients scan the subject line in order to decide whether to open, forward, file or trash a message. Remember - your message is not the only one in your recipient's mailbox. What is important to you may not be important to your reader. Rather than boldly announcing that the secret contents of your message are important, write an informative headline that actually communicates at least the core of what you feel is so important. Keep the Message Focused and Readable Often recipients only read partway through a long message, hit "reply" as soon as they have something to contribute and forget to keep reading. This is all part of human nature. If your contains multiple messages that are only loosely related, in order to avoid the risk that your reader will reply only to the first item that grabs his or her fancy, you could number your points to ensure they are all read (adding an introductory line that states how many parts there are to the message). If the points are substantial enough, split them up into separate messages so your recipient can delete, respond, file or forward each item individually. So to keep the message readable, use standard capitalisation and spelling, especially when your message asks your recipient to do work for you. Avoid using text-talk. Skip lines between paragraphs and avoid fancy typefaces. Don't depend upon bold font or large size to add emphasis. Don't type in all-caps. Online, all-caps mean shouting. Regardless of your intention, people will react as if you meant to be aggressive. Avoid Attachments Put your information in the body of your whenever possible. Attachments are increasingly dangerous carriers of viruses, take time to download, take up needless space on your recipient's computer and don't always translate correctly (especially for people who might read their on lap-tops). Instead of sending a whole word processor file, just copy and paste the relevant text into the (unless of course your recipient actually needs to view file in order to edit or archive it). Identify Yourself Clearly When contacting someone for the first time, always include your name, position title and any other important identification information in the first few sentences and all messages should include your name, contact details etc at the end. If you are following up on a face-to-face contact, you might appear too timid if you assume your recipient doesn't remember you; but you can drop casual hints to jog their memory: "I enjoyed talking with you about Management Development in the canteen the other day." Proof-Read Your before you Send it If you are asking someone else to do work for you, take the time to make your message look professional. While your spell check won't catch every mistake, at the very least it will catch a few typos. If you are sending a message to a large group of people, take an extra minute or two before you hit "send". Show a draft to a close associate and ask them to proof read it for you. Don't Assume Privacy Don't send anything over that you wouldn't want posted -- with your name attached -- in the canteen. is not secure. A curious person, hackers, a malicious criminal or even An Garda Siochana can easily intercept your . The HSE s administrator has the ability to read any and all messages (and you may be subject to disciplinary procedures should you write anything inappropriate). Distinguish between Formal and Informal Situations When you are writing to a friend or a close colleague, it is OK to use "smilies" or abbreviations and non-standard punctuation and spelling (like that found in text messaging). These linguistic shortcuts are generally signs of friendship. Don't use informal language when your reader expects a more formal approach. Always know the situation and write accordingly. Respond Promptly If you want to appear professional and courteous, make yourself available to your correspondents. Show Respect and Restraint If someone s you a request, it is perfectly acceptable to forward the request to a person who can help. For example: Joe Bloggs Team Leader of the Health Service Executive, St Mary s Day Centre Rathmines Dublin 6 Telephone Mobile

49 Service Strategy Service Strategy Letter Communications Internal Memo Communications Internal Memorandum To : c.c : From : Mr Joe Blogggs,, Dublin South City Date : Subject : 94 95

50 Service Strategy Service Strategy Fax Communications Implications of Treatment without Consent FAX MESSAGE The information contained in this fax is confidential and / or privileged. The fax is intended to be read only by the person or firm named below. If the reader of this fax is not the intended recipient or a representative of the intended recipient, you are hereby notified that any review, dissemination or copying of this fax is prohibited. If you have received this fax in error, please notify the sender and return it to the sender of the above address. Date: No. of pages (Including cover sheet): To: Organisation: From: (a) (b) (c) (d) (e) Constitutional rights: Constitutional rights are unaffected by lack of capacity. The unenumerated rights to bodily integrity and privacy are contained in Article Equality before the law and respect for human dignity are also constitutional rights. The European Convention on Human Rights: The Council of Europe Convention for the Protection of Human Rights and Fundamental Freedoms ( ECHR ), gives a comprehensive list of rights, in particular Article 8 - respect for private and family life, Article 12 - right to marry and found a family and Article 14 - rights to be enjoyed without discrimination. The European Convention on Human Rights Act 2003 makes the EHCR binding on Ireland, though not part of domestic law. The Council of Europe recommendation on Principles Concerning the Legal Protection of Incapable Adults (1999) is indicative of best practice in this area. United Nations Universal Declaration of Human Rights 1948; International Covenant on Civil and Political Rights (1966) and International Covenant on Economic, Social and Cultural Rights (1966); United Nations Principles for Older Persons (1991). The Law of Torts: Treatment without consent can give rise to a claim for trespass to the person and/or professional negligence. Telephone: (f) Criminal Law: Treatment without consent may constitute an assault under the Non-Fatal Offences against the Person Act, Fax: Urgent For Review Please comment Please reply Please recycle RE: MESSAGE: 96 97

51 Service Strategy Service Strategy Elements of Valid Consent The Ward of Court System Consent must be voluntary: Being voluntary means that consent/refusal should be given freely, without undue influence, coercion or under duress. The principles of undue influence would mean that a court would declare invalid, any decision made, where undue influence could be proven. The context must allow the patient to voluntarily make a decision to consent or to decline the proposed treatment. Given by someone with capacity: The presumption that the person has decision-making capacity must be held unless the contrary can be shown by careful assessment. However, clinical judgements alone are not sufficient as a declaration of legal incompetence. Currently, the decision is made by the High Court in relation to general legal capacity. However, many cases dealing with the issue of mental capacity do so in an issue specific context, not necessarily heard in a High Court e.g.: Capacity to make a valid will, Capacity to marry, Capacity to engage in litigation, Capacity to give consent to medical procedures. Must be based on sufficient information: This means the individual must have the capacity to understand the information and believe it. The information should be given in an accessible format in language/signs and symbols that are easy to understand, enhanced by human or mechanical aid if needed. Sufficient information should include the implications of the decision. The person must have the ability to retain the information for long enough to be able to weigh it up arrive at a decision based on this process. It should be noted that there is some uncertainty in the Irish Court s approach to consent. This uncertainty is around non-elective treatment. Failure to give sufficient information to obtain consent could be seen as negligence. Based on understanding the decision: This consists of the capability of the person to understand and believe the information, understand and appreciate the nature and consequence of the decision and the available choices and weighing relevant information in the balance. Being able to communicate the decision: Inability to communicate a decision can be caused by mental disorder or physical disability. Much of this can and should be overcome by the use of human or assistive technology. Communication does not have to be verbal or in writing but by bodily signs. The main requirement is that the decision can be communicated to a third party who is required to implement the decision. The Wards of Court system is the main legal mechanism available for substitute decisionmaking in Ireland. The operation of the Wards of Court system rests with the President of the High Court, administered by the Registrar of the Office of the Wards of Court. The relevant legislation is the Lunacy Regulation (Ireland) Act 1871 and Order 67, Rules of the Superior Courts The person seeking to have another made a Ward of Court is known as the petitioner. Anyone may present the petition. A solicitor is required. The petition requires the supporting affidavits of two registered medical practitioners. The notice of the ward ship application must be served in all cases on the respondent, who has seven days to object to the ward ship proceedings. At the time of making a ward ship order the Judge makes an order appointing a Committee of the Person and/or the Estate. When an adult is made a Ward of Court, the President of the High Court has authority to make decisions on consent to medical treatment. Note: In two recent Consultation Papers, Law and the Elderly (2003) and Vulnerable Adults and the Law: Capacity (2005), The Law Reform Commission proposes that the existing Wards of Court system be abolished and replaced by a new system of Guardianship. Enduring Power of Attorney A person with capacity may execute an enduring power of attorney ( EPA ). This gives another person the power to act on their behalf if the donor loses mental capacity at a future date (Powers of Attorney Act 1996). The appointed attorney may have power over the property, financial and business affairs and personal care decisions of the donor. The personal care decisions are: (a) Where the donor should live, (b) With whom the donor should live, (c) Whom the donor should see and not see, (d) What training or rehabilitation the donor should get, (e) The donor s diet and dress, (f) Inspection of the donor s personal papers, (g) Housing, social welfare and other benefits for the donor Section 4 (1) of the 1996 Act The definition of personal care does not include authority to make decisions on medical care or surgery; it does include decisions that may have health care implications

52 Service Strategy Service Strategy Policy Acknowledgement Form Policy Audit Form DATE DISCIPLINE PRINT NAME SIGNATURE The aim of this policy was relevant to the clinical environment /department Strongly Agree Agree Disagree Strongly Disagree Non Applicable The education regarding this policy was sufficient Strongly Agree Agree Disagree Strongly Disagree Non Applicable The communication method regarding this policy was adequate Strongly Agree Agree Disagree Strongly Disagree Non Applicable The health professional responsible for implementing this policy was clearly stated Strongly Agree Agree Disagree Strongly Disagree Non Applicable The information within this policy was clear and unambiguous Strongly Agree Agree Disagree Strongly Disagree Non Applicable The implementation of this policy was successful Strongly Agree Agree Disagree Strongly Disagree Non Applicable If you believe these questions have not fully explored staff opinion, briefly add any further comments below:

53 Service Strategy Form HCP 01 Permission for Photographs I do/do not consent to such photographs being published for the specific purpose described below. This consent does not extend to any further publication(s). This photograph is for the information of the Service and also for use of e.g. publishing an article in conjunction with the HSE Learning Education and Development Department. Home Care Package Scheme Application Form You can use this form to apply for a Home Care Package. A Home Care Package is a set of services provided by the HSE to help an older person to be cared for in their own home. Completed forms should be returned to your local HSE Home Care Packages Scheme offices. Staff in that office can also help you to complete your application. Before completing this form you can read more detailed information on the scheme in the Home Care Package Scheme Information Booklet, which also provides a list of all 32 local offices. Part 1 Your Details Please use BLOCK CAPITALS Name of Applicant Do you consent to these images being shared with other HSE Health Professionals as appropriate? Yes No Home Address Signature If living with relatives/in a hospital/nursing home state Current Address Date If in hospital/nursing home please also complete the following: 1. Name of Ward/Unit I, (Name). (Profession) have informed the client/guardian of the nature, purpose, location and duration of storage of the material provided. 2. Date of admission 3. Expected date of discharge 4. Medical Record Number Date of Birth D D M M Y Y Y Y Gender Male Female Signature Date Location of Equipment Primary Community and Continuing Care Directorate Photography equipment will be stored, supervised, maintained and managed in the area deemed most appropriate by the line manger with responsibility for the equipment. Daytime phone no. address Do you have a medical card? Yes No Support and Contacts GP Name Address Mobile or alternative phone no. Please supply the number Telephone Number Public Health Nurse Name Address Telephone Number (if known)

54 Home Care Package Scheme Application Form Family Member Contact Name Address Telephone Number Relationship to applicant Who will help you make arrangements for your Home Care Package? Name & Telephone Number Relationship to applicant Department of Social Protection supports Is Carers Allowance/Carers Benefit/Respite Care Grant currently being paid to someone to care for you? Yes No If yes please state - Type of payment(s) Name of person receiving the payment Address of person receiving payment Does this person live with you at your current address? Yes Contact telephone number of person receiving payment If no allowances are being paid, it may be that your carer should apply for one of these supports. More information is available from the Department of Social Protection. Social Welfare Services Office, Government Buildings, Ballinalee Road, Longford Tel: (043) Locall: Part 2 Application for Home Care Package I wish to apply for Home Care Package under the Home Care Package Scheme. I understand that this application is for additional care in the home and if my care needs can be met from regular community services, then I may not receive the Home Care Package at this time. As part of this application I understand that the HSE will make arrangements for a Care Needs Assessment to be undertaken. Any organisation with information relevant to my care needs may provide the HSE with this information. The content of the Care Needs Assessment report may be provided to, or shared with, relevant health professionals, if required. The signature below indicates consent to this access. The HSE will treat all information and personal data provided to them as confidential. The HSE will only disclose information or personal data to other people or bodies according to the law. I am aware that I must report to the HSE, within 10 working days, any changes in my circumstances which may affect my entitlement to a Home Care Package i.e. admission to hospital, availing of respite care or a period away from home to stay with family member, able to manage at home without supports. I confirm that I have read and understood this application form. I have read the statement above and I say that the information given by me on this form is correct to the best of my knowledge and belief. Signed: No Date D D M M Y Y Y Y Home Care Package Scheme Application Form Part 3 To be completed only where the person who may need a Home Care Package is unable to sign this application I, hereby wish to apply for/refer for a Home Care Package for who it appears may need a Home Care Package and is unable to make the application on his/her own behalf due to. I have informed him/her that this application is being made. Signed: Name in Block Letters Address Date D D M M Y Y Y Y Phone Number Relationship to Applicant: If this application/referral is being made by anyone other than the client or his/her representative please tick the appropriate box below 1. SOURCE OF REFERRAL (PLEASE TICK): Community Hospital Acute Hospital GP Mental Health Unit Community Nursing Home Name of Location Date of Referral D D M M Y Y Y Y To comply with data protection legislation the HSE wishes to advise that information supplied in this form will be recorded on a computer system. Completed forms should be returned to your local HSE Home Care Packages Scheme offices. Staff in that office can also help you to complete your application. If you have a comment, compliment or complaint about any aspect of the Home Care Package scheme, please contact the HSE. You can do so in the following ways: Ring - LoCall : Your call will be answered by a staff member from HSE Consumer Affairs. Talk to any member of HSE staff, service manager or complaints officer by contacting the local health office. Complete and submit the HSE s Your Service, Your Say comment card. Staff can help you put your complaint in writing, if you require assistance. yoursay@hse.ie with your feedback. Send a letter or fax to any HSE location. Staff can help you put your complaint in writing, if you require assistance

55 Service Strategy Local Health Office Dublin South East Dublin South City Dublin South West Dublin West Dun Laoghaire Kildare/West Wicklow Laois/Offaly Longford/ Westmeath Wicklow Local Health Office Cavan Monaghan Dublin North Central Dublin North Dublin North West Louth Meath HCP Manager(s) Name & Address HSE, Vergemount Hall, Clonskeagh, Dublin 6 Telephone HSE, St Mary s Day Centre, Richmond Hill, Rathmines, Dublin 6 Telephone HSE, Brookfield Health Centre, Rossfield Avenue, Tallaght, Dublin 24 Telephone HSE, Cherry Orchard Hospital, Ballyfermot, Dublin 10 Telephone Dun Laoghaire Local Health Office, Tivoli Road, Dun Laoghaire, Co. Dublin Telephone HSE, Poplar House, Naas, Co. Kildare Telephone Community Stores, MDA Business Park, Irishtown, Mountmellick, Co. Laois Telephone HSE, Health Centre, Longford Road, Mullingar, Co. Westmeath Telephone HSE, Block B, Civic Centre, Bray, Co. Wicklow Telephone HCP Manager(s) Contact Home Support Department, St. Felim s Complex, Cavan Telephone Home Support Department, PCCC Building, Rooskey, Monaghan Telephone Care Co-ordinator, Ballymun Health Care Facility, Ballymun Road, Dublin 9 Telephone Care Co-Ordinator, Coolock Health Centre, Cromcastle Road, Dublin 5 Telephone HSE, Rathdown Rd, Dublin 7 Telephone The Home Support office, Market Street, Dundalk Telephone or Home Support Department Floor 1, Beechmount Shopping Centre, Trim Rd., Navan, Co. Meath Telephone Local Health Office Carlow/ Kilkenny Cork South Lee Cork North Lee Cork North Cork Cork West Cork Kerry Tipperary South Waterford Wexford Local Health Office Clare Donegal Mayo Galway Limerick Nr. Tipperary/ East Limerick Roscommon Sligo/Leitrim HCP Manager(s) Name & Address Assistant Director of Public Health Nursing Community Services James Green, Kilkenny Telephone Acting Senior Executive Officer HSE, Floor 3, Abbeycourt House, George s Quay, Cork Telephone , A/ADPHN Floor 4, Abbey court House. Georges Quay Cork Telephone Assistant Director of Public Health Nursing, HSE - South, North Cork Rathealy Road, Fermoy, Co. Cork Telephone Director of Public Health Nursing, West Cork Local Health Office, HSE South, Coolnagarrane, Skibbereen, Co. Cork Telephone Health Centre,Camp,Co. Kerry Telephone , , South Tipperary LHO, St. Luke s Hospital, Western Road, Clonmel, Co. Tipperary Telephone HSE South, Waterford Community Services, Cork Road, Waterford Telephone HSE, George s St, Wexford Telephone HCP Scheme Address Co-ordinator, St. Joseph s Hospital, Ennis, Co. Clare Telephone HSE West, Navenny St., Ballybofey, Co. Donegal Telephone St. Mary s H.Q., Castlebar, Co. Mayo Telephone Home Care Support Co-Ordinator, SEO, Older Persons Services, Galway PCCC, 25 Newcastle Road, Galway Telephone Unit 4, St. Camillus Hospital, Shelbourne Rd., Limerick Telephone HCP Co-Ordinator, Hospital of Assumption, Thurles, Co. Tipperary Telephone HSE Offices, Lanesboro Rd., Roscommon Telephone , Services for Older People, HSE West, Markievicz House, Sligo Telephone Action Planning Recording Template Key Result Area/ Priority / Issue (Be Specific): Actions Person Responsible Time to be Completed Completed If No Why (Be Specific & sequential) by Yes / No Any further outcomes / dependencies:

56

57 Printed by HSE Print & Design Tel: (01) Fax: (01)