The needs assessment process is perhaps the single most important part of optimising care for the older person in integrated care. The challenge for managers is to ensure that the client-centred assessment takes place within a ‘whole system’ that delivers the right assessment at the right time. This process should not be seen simply as a matter of data collection but also as a starting point for making priorities and optimising the resources – and thus the care – from the client’s various care providers. The information arising from the needs assessment will be the basis for organising the chain of care and managing the system.
To the client, the needs assessment is the grounds by which he or she is seen as an individual and can interact with the service provider and the funding agency, and can thus discuss and influence the care. To the manager, the needs assessment is a more objective tool with which he or she can balance the resources to the summarised needs of clients. On a systemic level, the needs assessment provides information that enables authorities to scrutinise costs of care in comparison to other costs in society, and make priorities.
It can be tempting to make a rough estimate of what a client might need, but it pays off to try to obtain a more holistic view (including functional deficiencies that need to be supported by various services, and strengths that could be a base for further rehabilitation to support client autonomy). This view can enable data to be gathered through one process to be used for all levels of decision-making: from the care given via management of staff and resources to national monitoring, or even international research. A comprehensive assessment covers many domains, the most important ranging from health care, physical and social function, psychological and spiritual needs to environmental and economical needs, as well as the preferences of the client and informal carers.
It is beyond the scope of this resource book to go too deeply into the philosophical concepts of client ‘need’. However, managers must nevertheless consider that there is always someone defining the need. It may be the client and the family, the integrated team, the single assessor among the health and social service professionals or the purchaser. Alternatively, the need may be defined by government. One way or another, whoever defines them or however they are defined, this is the opportunity for the manager to influence the team members and division of labour, to balance the available resources to the assessed needs and client demands.
When managing the care needs in relation to services provided, the manager has to consider all of the following perspectives:
These perspectives are shown in Fig 2, below.
Key
Source: Adapted from unpublished material from Stockholm County Council
The prevailing attitude in many countries is that there is a need for a comprehensive process that is more structured and standardised, to establish the basis on which the service packages are planned. This type of process makes it more difficult to overlook client needs that are important, or not immediately evident, which could decrease their quality of life in the future.
A ‘needs assessment’ is a process of establishing the needs of a service user. It may trigger a package of services. The assessment may be carried out at various stages, so it can serve several goals, and it falls into three main types:
The first option, an eligibility assessment, is the least resource consuming of the three, and may be the initial step in a care episode. If the client’s needs do not seem to be too complex, a simple needs assessment (the second option) could be added to the eligibility process. For example, if an older person needs help with cooking or laundry, and no family or friends are available, the decision to provide meal services or washing services does not need a full needs assessment. The third option of a full evaluation is more costly but is needed in integrated care for people with complex needs, to organise, provide and manage their care from different agencies or professionals.
The overall objective of the needs assessment is to obtain a picture of the client’s needs that balances their requests for services with an objective analysis of their needs (in the light of limited public funding), and spending decisions. This process involves ethical decisions, drawing on concepts such as equity, integrity, and autonomy.
The needs assessment is intended to support clinicians in planning care for individuals, and to support service planners to ensure that service developments are matched to greatest need as far as possible, and to prioritise between different needs (see Achterberg et al 1999, Aminzadeh and Dalziel 2002, Challis and Hughes 2002, Hawes et al 1997). Depending on the reason for the needs assessment, as outlined in the previous section, more direct objectives can be identified.
The needs assessment for eligibility of services may be performed to:
Today, most EU countries have a legislation on this type of assessment, to assure a more just access to services within each member state.
A simple (short) needs assessment may be performed to suggest a care plan delivery for people with few needs, where only a few service packages will be considered. In some cases, this simple approach is adequate. For example, when only a few services are considered, such as shopping, cooking or transport services, a simple needs assessment will enable service providers to find out whether the client is satisfied with the quality, and to detect whether a rearrangement is necessary. It can also enable management to make sure their services are producing the desired results. This assessment can also enable screening into more heavy care.
Where clients have more comprehensive needs, professionals and informal carers are presented with more challenges. Here, the needs assessment provides a structure for collecting the information from all parties involved, where this ‘global’ information is used for all as a basis for visualising the needs for integration of services and shared responsibilities.
The more comprehensive needs assessment is carried out to:
The purpose of this type of needs assessment is to obtain a view of the client’s needs that is fuller than that of the eligibility assessment. The reason for this is that a broader assessment might highlight new needs that have not been dealt with earlier. At first glimpse, this may lead to higher resource consumption, but evidence shows that identifying and handling needs earlier on improves the quality of care and quality of life. It also enables service providers to prioritise their activities better.
For the manager of integrated care, a needs assessment at this level provides a reliable summary description of the area or agency workload to request and allocate resources more appropriately. They can use this information to help intertwine the services that are delivered by several participants in the care of the older person. This information also enables providers to meet their legal requirements to provide authorities with information about their work.
A needs assessment may be carried out as part of an evaluation of the services given. If this is a standardised and comprehensive procedure, this could solve various problems.
The existing services may not meet the client’s needs for a number of reasons. For example, if they are based on historical factors, they may be obsolete or out of line with the client’s current needs. Without re-evaluation of services, historical inequalities or errors may be perpetuated. Another possibility is that the services may be too demand-led. In this case, only those who ask for the services receive them, and only the most urgent needs are met. This prevents service users from obtaining early information about the client’s physical, cognitive or social decline that may enable them to put preventative measures in place. Another problem is that needs that are obvious at a first glance may not always be the ones to cover first.
Risks such as these are more easily prevented if service providers carry out a more structured needs assessment, based on more global knowledge of the service user’s needs and declining functions with increasing age. If a client is suffering from incontinence, a simple solution would be to prescribe the use of diapers rather than making a thorough investigation of the cause of the incontinence. This risk is evident if the staff believes incontinence is a natural part of being old – as with loss of memory, appetite or thirst, and these misconceptions can be a hotbed for ageism and stereotypic views of elderly people. But by requesting a more thorough picture of the client needs and analysing the educational needs of the staff, the providers can clarify which problems are simply due to ageing and which require treatment. In some cases this may also enable preventative treatment in certain conditions, if they are discovered sufficiently early.
Nevertheless, a needs assessment will not resolve all issues – indeed, it may even give rise to new questions, such as:
To deal with a discrepancy between client needs and preferences, it is important to involve the client and his or her relatives in the care planning process. This situation should also be dealt with in the team discussions, to ensure a true balance between different interests. With a fuller picture of the client needs, we can more easily make priorities and remodel different services, if we consider them based on clients’ unmet or over-met needs.
Furthermore, if the assessment is carried out comprehensively, this increases the likelihood of discovering risk areas and preventing risks such as psychiatric conditions (often disguised by the client or relatives), violence between spouses (often not reported), and environmental risks (carpets and electrical cables to stumble on, lack of heating or air conditioning).
The care provider uses the comprehensive needs assessment to obtain a better picture of the client, and can use this to provide a more professional care plan, alongside the other members of the care providing team. This is more easily done if the assessment is carried out by professionals who are involved in the actual care delivery. They can also work with the client to balance different needs over time and to help prevent physical and social decline. As a result, the service providers will have better self-esteem in their employment, and will have a better sense of their professional development.
A full assessment also provides the client with a better view of the types of preventative measures than the assessor, or care provider, can offer. Evidence shows that multi-disciplinary groups are preferable to single-discipline approaches in needs assessment (Fleming et al 1995), even if they are still uncommon (Morris et al 1997). However, the multi-dimensional approach has also been addressed as cumbersome and time-consuming (Applegate et al 1990).
On the management level, a standardised assessment also allows one to aggregate functional and needs data from the individual to the population served. Managers who do not use the suggested models and techniques referenced later, will have a much more difficult task to defend the resource allocation of their organisations. Neither can they adjust the competence and educational level of the team around the client.
Most European countries have some legal prerequisites on how and when to carry out the eligibility needs assessment, but few support the use of a comprehensive assessment process. Instead, this is the responsibility of the professional care givers working with the client. Governments do not wish to be too closely involved in more thorough assessment processes because of the often prevailing division of responsibility, where the government has the responsibility of surveillance while the local authorities have the role of implementing and executing assessment and care delivery. So the legal frameworks are designed only to help the funding agencies and care providers offer social and health care support, based on equity, allowing for the client’s integrity and supporting their autonomy. However, there is no common, European-wide model for establishing the access and financing of services to older people.
In some countries, such as the Netherlands, eligibility to long-term care or home-care services is assessed by actors independent from those involved in care provision and funding, based on standardised procedures and instruments. In most of the Nordic countries, eligibility assessment is carried out by funding and/or care providing agencies, either together or separately. A few governments, such as that of the United Kingdom, are already requesting a needs assessment that combines social and health care needs in the same process.
These models can work at a range of levels. They can provide everything from a simple screening of needs by a single assessor to a comprehensive, multi-professional team assessment. They can be performed as a basis for eligibility alone, or can provide a holistic view of the client’s needs for thorough care planning, including risk management. They can be based on primarily medical information or on a multi-dimensional basis. They can be performed in one step or in multi-stage phases. They can also provide information on quality issues, client preferences, and evaluation and follow-up.
In several countries, there are now practical suggestions on how to go about the assessment process. In the United Kingdom, there is the ‘single assessment process’, which also suggests instruments to use (see Department of Health, Web links). In the Netherlands, there are now detailed eligibility criteria and forms. However, many consider these to be expensive and bureaucratic. The New Zealand government specifies when to carry out the assessment, at which levels, for which client groups, and with which instruments (see NZGG, Web links). For some national initiatives on the use of standardised assessment data on older people, see the articles on Canada, Iceland, Italy, and the United Kingdom on the Milbank website (see Web links).
The first question to ask is what systems need to be in place. In many countries, much effort has been made at the national level to agree on how a person with minimal to extensive needs, in one or several domains, can be supported through public funding, by balancing existing resources and interacting with informal carers, volunteers and NGOs. This requires comprehensive information on both needs and services. In integrated care, however, less emphasis has been focused on this area to date. During the implementation process it is important to relate to and discuss at the managerial level, as well as in the team, the following issues:
This section looks at the assessment instruments that are available, and the reasons for using methodologically developed instruments. During the past 15–20 years, there has been much clinical research on the methodological issues of needs assessment (Applegate et al 1990, Fletcher 1998, Morris et al 1997). It has addressed questions such as:
Based on this, there is little reason to use instruments or techniques that are not described in the literature. Using such instruments often produces better care (involving the client and informal carers as part of the process) and better data to use for management and surveillance at local, regional and national level.
A needs assessment is a procedure that involves one or several skilled professionals holding person-centred conversations with older people and their carers to identify problems, and to provide cost-effective services when appropriate. This process is facilitated by the use of validated and reliable instruments and scales to determine in a multi-dimensional way the client’s needs and preferences that require support. Using standardised and structured instruments and scales also simplify comparisons between agencies, regions and nations.
An integrated needs assessment is the preferred option when several funding bodies or providers have to deliver care to an individual and therefore need to consider the benefits of using the results of the comprehensive assessment to optimise the resources used, whoever carries out the services or provides the care. This calls for a discussion – or at least, a common policy – on how to look at needs from different angles, so as to optimise the resources.
Integrated needs assessments may produce a number of challenges for the integrated care manager, such as:
These questions do not have simple answers but must be discussed at the local level, between managers, and also between the team members and different professionals. Attempting to answer them is a large part of the learning process when developing structures for integrated care.
Irrespective on how the assessment process is outlined, only one part of the procedure is to use instruments – the main part of the assessment should always be made up of broad dialogue between client and carers.
The next issue is which domains of needs should be addressed in the assessment. The comprehensive picture of client needs related to human functioning tends to fall into the following domains:
Ideally, a needs assessment will cover all these domains, which means taking behavioural, social, medical and psychological functions into consideration, as well as the social and physical context, such as availability, strengths, preferences of informal care, housing conditions, transportation needs and household needs. Even if a client’s needs change over time, it is important to keep in mind this dynamic approach of needs.
The assessment needs to be comprehensive and accurate, and there are several instruments that enable organisations to fulfil the required criteria (see The implementation process). However, it is also a process that takes place within the context of the time and circumstances in which it is carried out, so it must not to be seen as a static ‘solution’.
It is also important to consider the balance between the resources used to carry out the assessment and the information gathered. Using information that is already available from other sources is usually very important, and this will be more readily available in the future as more information technologies continue to develop. Clients are rarely concerned about which payer or provider gathers the information, but they do prefer not to have to provide it several times over.
To guarantee the quality of the information gathered during the needs assessment, the process should be followed by care interventions documented in the care plan. (Indeed, organisations should collect only information that calls for some kind of action or service provision.) The interventions identified may include responsibilities or requirements for the client, the client-support system or the physical environment. The service provider can then establish the care plan, even if this is not the same organisation that carried out the assessment. The crucial thing is that the information is shared between all parties, while taking into account the individual’s right to privacy.
The World Health Organization’s International Classification of Functioning, Disabilities and Health (World Health Organization 2001) covers broad areas of functioning, and provides listings of domains that can be included in the needs assessment process. These are not a model for the assessment procedure in themselves, and require other instruments to be used to decide which criteria to use (see the list below). Furthermore, it is important to carry out ‘cross-walks’ (comparisons of item concepts and descriptions of functional levels) between instruments that have already been tested and those that have been recently developed and not yet tested. Using this approach saves resources in the long run and sometimes helps organisations to discard instruments earlier in use.
Make sure the instrument:
An optimal managerial instrument should help the staff provide professional care planning, by supporting the client’s integrity and autonomy while at the same time providing evidence-based information about the manager’s units, as well as information that can be used at the national and international level, to enable reliable comparisons between units, regions and nations.
One useful instrument is the Resident Assessment Instrument (RAI). This instrument fulfils many of the criteria above, providing a structured, standardised assessment that triggers and supports care-planning activities for the individual, while also providing information for the manager. It exists in about 20 languages and is used in more than 30 countries. Another instrument mentioned in the recent literature and with its own website is EasyCARE Version 2004. This instrument is a compilation of several scientific scales but is not directly linked to the care planning process. (For details of both these instruments, see Web links)
Finally, it must be remembered that no instrument, however good, provides a complete answer to the needs of an older person. Clinical intuition and experience are also very important, and for this reason continuing education for the assessors is crucial. This education may be highly formalised or less so, but it must consist of information being shared between different professionals and participation in team conferences on care planning. See also Staff, below.
It is important to have a clear policy on which staff members are involved in the assessment, and how they will be trained and supported. If an assessment procedure is new to an organisation, it is not always easy to implement, particularly in integrated care, since many different professional and cultural aspects have to be taken into consideration. When developing a needs assessment for integrated care, the team must decide who will be primarily responsible and who will co-ordinate the information gathering – particularly if the care is divided between different budgets.
This is one of the most difficult aspects of integrated care. However, it is certainly not impossible as long as:
Whether they work alone or in a multi-professional team, the assessors need suitable tools, training in how to use them, and a broad view of what a client might need (Landi et al 2001). The training materials that are available within the various off-the-shelf assessment instruments provide good instructions on how to perform reliable assessments (see References and further reading).
The task of training the assessors in integrated care has both positive and negative sides. There may be negative inter-professional reactions to the content and level of the assessment but, on the other hand, the strength of an integrated team is that it has various competencies readily available that can lead to a broader training option than in other organisations. This is also a help since clinical judgement alone may not be sufficiently accurate to discriminate between those who have needs and those who do not.
Finally, by providing adequate training and supporting the use of a comprehensive needs assessment, the manager will enable staff to have more direct interaction with the client. This can free up more of the manager’s time for strategic planning, rather than supporting the day-to-day activities.
An assessment process in integrated care that has been newly implemented has to be monitored and evaluated in various ways, and a number of questions must be raised about diverse issues such as clinical and caring outcomes, cost-effectiveness, client satisfaction and staff satisfaction. Managers need to consider:
To answer these questions, managers need to collaborate with other actors on the local, regional or national level. These could include research or survey institutes to create client surveys or epidemiological studies, or software companies that could provide computerised support to the managers.
The final test of the needs assessment is whether it enables the client’s situation to improve. Here, we must consider the long-term and short-term effects of the care planning, based on the assessment process. However, in integrated care as well as in more traditionally organised care, there is a lack of knowledge on the outcomes of care, and more research in this area is needed.
Unfortunately, but not unexpectedly, there are a number of barriers to the needs assessment process in integrated care. It is not always easy to bridge the different concepts of needs, balance social and health care needs, and promote the idea of a strong interaction between most sections in a multi-dimensional approach to care needs.
If the assessment is performed by someone outside the integrated team, this could be a barrier to care planning. So someone needs to act as a guide, to help the client through the system. This could be carried out by one of the team members, acting as contact person.
Another obstacle is professional narrow-mindedness – the idea that ‘others should not bother with my client or patient’. This negative attitude could also live longer if double, or even triple assessments on the same client, using different assessment instruments and different main concepts, are allowed. This prevents the integration care and the needs assessment alike. This problem can be exacerbated if there is more emphasis on the services provided than on the needs that trigger those services. This often prevails more in the areas or domains where well-accepted instruments or scales are lacking. There is an ongoing need for more instruments that focus on clients’ social, existential and spiritual needs rather than on the medical and functional aspects of their lives.
A further barrier relates to legislation. Within one country there may be different laws calling for different approaches, and different budgets responsible for different needs. In many countries, social care is supported by the family, and support is available from society only if no family is available. In most countries, on the other hand, health care tends to be state-funded.
A further legislative barrier is that of privacy. Some countries have data protection laws that prevent different organisations having access to information held by other organisations. However, if the client does not object, this is usually simple to solve by obtaining the client’s permission.
Finally, even if the clients agree to their information being shared, if there is a lack of infrastructure to enable this to take place, this will be a barrier too. This could be the case if there are different computerised record systems that do not communicate with each other, or the level of complexity, if computerisation varies between different players. The flow of information may be hindered not only between the same levels of care, but also between different levels. A lack of integration between decision-making bodies that address people’s different needs can also hinder the process of using the needs assessment as a base for integrated care, and thus providing services in a cost-effective way, based on equity.
Needs assessments should be covered by legislation specifying when, and how, an assessment should be performed. Legislation supporting eligibility assessments already exists in many countries, but not in all. A comprehensive needs assessment can also support informal and voluntary carers by looking at issues such as what type of care is needed, and how it should be provided. However, no information should be gathered that does not influence the individual user’s care.
Needs assessment is relevant only when clients ask for it, or if they request care and services that can be delivered only after assessment. Where the client is unable to make the request themselves, their carer or a professional may make it on his or her behalf. However, unless there is a risk of the client causing danger to their environment and he or she is not willing to co-operate, a consent is always required. Further, the client’s privacy should be safeguarded. There should also be an opportunity for the client to challenge a decision and/or to complain about the procedure or the assessor to an independent body. However, this also calls for the use of common instruments. Beyond the legal support, the best support to needs assessment in the integrated care environment is professional open-mindedness within the team.
The main goal of needs assessment is to provide cost-effective, high-quality care that is client-centred and client-acknowledged. However, it also enables better evaluation of total resource use in relation to aggregated care needs of an area or a region. The technologies around the needs assessment process are, as a whole, relatively new to care providers, but today, the tools are there, and they can be used by the integrated care manager if they are implemented with care. By so doing, the three competing perspectives of client needs, client demands and preferences, and services provided will soon overlap, making better use of available resources.
Achterberg W, van Campen C, Margriet A, Kerkstra A, Ribbe MW (1999). ‘Effects of the Resident Assessment Instrument on the care process and health outcomes in nursing homes. A review of the literature’. Scandinavian Journal of Rehabilitation Medicine, vol 31:3, pp 131–37.
Aminzadeh F, Dalziel WB (2002). ‘Older adults in the emergency department: a systematic review of patterns of use, adverse outcomes, and effectiveness of interventions’. Annals of Emergency Medicine, vol 39:3, pp 238–47.
Applegate W, Blass JP, Williams TF (1990). ‘Instruments for the functional assessment of older patients’. New England Journal of Medicine, vol 322:17, pp 1207–14.
Bath P, Philp I, Boydell L, McCormick W, Bray J, Roberts H (2000). ‘Standardized health check data from community-dwelling elderly people: the potential for comparing populations and estimating need’. Health and Social Care in the Community, vol 8:1, pp 17–21.
Challis D, Hughes J (2002). ‘Frail old people at the margins of care: some recent research findings’. British Journal of Psychiatry, vol 180, pp 126–30.
Fleming K, Evans JM, Weber DC, Chutka DS (1995). ‘Practical functional assessment of elderly persons: a primary-care approach’. Mayo Clinic Proceedings, vol 70:9, pp 890–910.
Fletcher A (1998). ‘Multidimensional assessment of elderly people in the community’. British Medical Bulletin, vol 54:4, pp 945–60.
Hawes C, Mor V, Phillips CD, Fries BE, Morris JN, Steele-Friedlob E, Greene AM, Nennstiel M (1997). ‘The obra-87 nursing home regulations and implementation of the resident assessment instrument: effects on process quality’. Journal of the American Geriatrics Society, vol 5:8, pp 977–85.
Jedeloo S, Witte LP de, Schrijvers AJP (2002). ‘Quality of regional individual needs assessment agencies regulating access to long term-care services: a client perspective.’ International Journal of Integrated Care, vol 2. Available at: www.ijic.org.
Landi F, Onder G, Tua E, Carrara B, Zuccala G, Gambassi G, Carbonin P, Bernabei R (2001). ‘Impact of a new assessment system, the MDS-HC, on function and hospitalization of homebound older people: a controlled clinical trial’. Journal of the American Geriatrics Society, vol 49:10, p 1288–93.
Morris J, Murphy K, Nonemaker S (1995). Long Term Care Resident Assessment Instrument User’s Manual for Version 2.0 (1995/2002). US Department of Health and Human Services, Health Care Financing Administration. Distributed through the National Technical Information Service, Springfield, Virginia.
Morris JN, Fries BE, Steel K, Ikegami N, Bernabei R (1999). RAI Home Care (RAI-HC) Assessment Manual For Version 2.0; Primer on Use of the Minimum Data Set-Home Care (MDS-HC) Version 2.0 and the Client Assessment Protocols (CAPs). Boston: Hebrew Rehabilitation Center for Aged.
Morris JN, Fries BE, Steel K, Ikegami N, Bernabei R, Carpenter GI, Gilgen R, Hirdes JP, Topinkova E (1997). ‘Comprehensive clinical assessment in community setting: applicability of the MDS-HC’. Journal of the American Geriatrics Society, vol 45:8, pp 1017–24.
Perkins E (1991). ‘Screening elderly people: a review of the literature in the light of the new general practitioner contract’. British Journal of General Practice, vol 41:350, pp 382–85.
Philp I, Newton P, McKee KJ, Dixon S, Rowse G, Bath PA (2001). ‘Geriatric assessment in primary care: formulating best practice’. British Journal of Community Nursing, vol 6:6, pp 290–95.
Won A, Morris J, Nonemaker S, Lipsitz L (1999). ‘A foundation for excellence in long term care: The Minimum Data Set’. Annals of Long Term Care, vol 7:3, pp 92–97.
World Health Organization (2001). International Classification of Functioning, Disabilities and Health. Geneva: WHO.
www.cms.hhs.gov/medicaid/mds20 – website of the US government agency, Centers for Medicare and Medicaid Services. The link takes you directly to more information on the legally mandated assessment strategies.
www.dh.gov.uk – website of the UK Department of Health. For detailed information on the single assessment process, go to the policy and guidance section, within the health and social care topics, and select ‘social care’.
www.interrai.org – website of the Resident Assessment Instrument (RAI).
www.milbank.org/reports/interrai – website of Milbank foundation. Under ‘reports’, go to the online version on Implementing the Resident Assessment Instrument: case studies of policymaking for long-term care in eight countries.
www.nzgg.org.nz – website of New Zealand Guidelines Group. For information on the assessment process, look under ‘gerontology’ within the ‘guidelines/publications’ section.
www.sheffield.ac.uk/sisa/easycare – website of the assessment instrument EasyCARE.