Tailoring complex health needs (feature)

Our continuing care assessment team takes pride of place on the front-page of the next edition of our @CLCH magazine. Here, you can read the full length 'long read' article that featured in the magazine.

Pic.: Nina Sharp [left], and Vasilica Jackson 

"Continuing care is a bespoke, discreet part of the NHS", says Nina Sharp, a nurse assessor in the continuing care assessment team based at St Charles Hospital, and also a registered nurse since 1983.
 

"Prior to joining the continuing care team back in 2005, I was a district nurse and my experience from that role feeds into my job here well as one of the core skills as a district nurse is assessment."

Nina is one of 15 healthcare professionals who make up CLCH's continuing care assessment team and who produce detailed assessments for people who require care arranged and funded by the NHS in either their own home, registered care home or other agreed setting. Continuing care is often provided to someone whose requirements and needs cannot be met by existing universal or specialist services alone, including in a hospital environment. Essentially the patient will receive tailored care and support to meet their assessed needs at no cost to them.

To be eligible for NHS continuing healthcare, you must be assessed by a team of healthcare professionals (a "multi-disciplinary team") as having a "primary health need", and Nina and the team's role range from: assessing the patient's health care needs; understanding their complexities; looking at how intense the needs are; and analysing the risks to the person's health if the right care isn't provided at the right time.

Nina explains: "I regularly draw on my experience from being a district nurse as I understand how care looks in the community and build-up a picture of what's feasible and what the issues might be for providing care outside of a hospital setting."

A person's full assessment is undertaken by the multi-disciplinary team, and it is Nina's role within this team to assess each patient who is referred to the service, understand what their level of needs are, and figure out whether they are eligible for support and if so, what this might potentially look like.

A critical factor of providing the assessment and building up the package of care is keeping the person, their family and support network fully involved at every stage.

"The more we work with the family - the better", says Vasilica Jackson, a renal specialist nurse in the team, and is part of a two person team who complete new referral assessments.

"You have to listen to the family's views as they will know the person, their needs and what might potentially work for them. We have to involve the family from the first instance. It has to be a transparent process for them throughout."

Vasilica has been working in the assessment team since 2012 and has not only seen referrals increase over recent years, but also the different requirements and recommendations for these referrals becoming more complex.

"The assessment is long-winded and thorough because it has to be. However, there are fast-track assessments available. We provide fast-track assessments because of rapid deterioration or imminent death as that person might not be able to wait for weeks or days even."

The team's assessment will consider the person's needs under and including the following areas: behaviour; cognition (understanding); mobility; continence; skin (wounds and ulcers); breathing; among other key areas. Each of the needs are then given a weighting marked 'priority', 'severe', 'high', 'moderate', 'low' or 'no needs, and if there is at least one priority need, or severe needs in at least two areas then the person should normally be eligible for NHS continuing care, and the wheels of putting their care into place are put into motion.

"We are always busy but our working relationships within the team are extremely tight and with the introduction of the fast-track assessments, of which we roughly receive through around twenty a week - we have to all be able to juggle our responsibilities very well", outlines Vasilica.

The fast-track assessments are available if someone's condition is rapidly deteriorating or if they are nearing the end of their life, and an appropriate care package can be put in place as soon as possible - normally within 48 hours.

If you are eligible for a normal review then the needs and support package is often reviewed within three months to see what is working, and whether needs have changed. After the three month review, the package is reviewed annually and can, on occasion, be removed if there are other means of managing the patient's healthcare.

"The basis of our team is communication, managing complexities, and ensuring the package of care we provide is right", says Vasilica. "The crucial thing in our roles as assessors is the experience. When meeting with someone and their family, you have to be able to read between the lines and you need to have experience, and the knowledge to communicate in different ways. Empathy is also a key part of my role."

Nina suggests that the changing demographic, the "time-bomb demographic" is making assessing needs and putting packages of cares together to fit these needs more difficult.

"Medicine is moving forward, and we know that people are living longer. Needs are becoming more complex, people are surviving longer and it is up to us as healthcare professionals to figure out how to help and support them in the evolving community", says Nina.

"Over the years care packages have changed and one of the main challenges now is managing people's expectations around what support they will receive. Ten years ago the healthcare landscape was different and we daily have difficult conversations with patients and their families around what can and cannot, in some instances, be provided. Sometimes we face anger, but more often than not we are helping to relieve anxieties."

"The best part of my job and working in continuing care are the little things", Vasilica summarises. "It's nice to act as someone's advocate and find out a solution for dealing with their complexities.. One of the best feelings is getting a patient who wishes to die at home back to their home. Obviously this is sad, but there is a sense of satisfaction that they will be somewhere familiar when they pass."

"I've been very lucky", says Nina. "I've always enjoyed my jobs, something of which you don't hear so often now. Even though it can be sad, I've seen the same family pop-up - a husband and wife years apart. It can make you feel a part of the community and that you are actually contributing something."