Adult Social Care
Customer Pathway
Case Management
Guide
This guide has been produced as a reference document to
support team members from across the customer pathway
to ensure work is handled consistently for older people and
service users with a physical disability. It covers the remit
for Access, Enablement, Hospital Team, Care Management
(including Scheduled Review Team) and Brokerage.
Customer Journey Overview
ScreeningAssessment
Access Hospital
Enablement
Potential? Yes Enablement Signpost out Quickheart RAS Ongoing care needed? Support Plan Brokerage No Yes
Specialist Assessment and Complex RAS if required
Customer Pathway Principles
These statements are intended to act as a guide to ensure work is correctly actioned at the most effective point:
■ If a worker feels that a query/referral has passed to the wrong team,
the case should be fed back to the correct team through an ATM or higher from team to team. Building the integrity and consistency of the pathway is key and work should be routed without delay to the relevant team and should not be actioned by the incorrect team.
■ Cases should be closed promptly and the closing summary completed
on CareFirst to aid effective management of any follow up contacts.
■ If you are uncertain as to how to redirect a referral/query for action,
phone the relevant team first and gain agreement/location to refer on to, this will prevent cases “pinging” through the pathway.
■ Unplanned or emergency respite requests are managed by Access
team, if the support plan/review does not make provision for the respite then Access will assess as necessary, gain approval and advise brokerage to set up the service.
■ Brokerage can only accept pre-approved/authorised requests for
support. Support plans or packages of care must have been approved before activities issued to Brokerage to action.
■ A change in circumstances or change in need is not the same as a
statutory scheduled review. The Scheduled Review team within Care Management Services handle planned statutory annual reviews and whole home safeguarding reviews.
■ If a service users circumstances or needs change this is initially handled
in Access/Enablement by a combination of stabilising the emergency and re-assessment/delivery of enablement/updating the support plan to incorporate the new circumstances then 6 week review. At this point it may be appropriate to contact the statutory review team to indicate the priority that should be placed on any pending annual review.
Access
Overview
■ To provide information, advice and guidance to residents, carers,
health and social care professionals across all client groups, including learning disability and mental health (covering new and existing SU’s). This includes signposting to external organisations/services/ Independent Living Resource Centre and directing service users to the web e.g. Advice and Information and Marketplace
■ Determine eligibility
■ Screening assessments, to support effective transition of the referral to
Enablement, sensory impairment worker or CMS as appropriate
■ Identifying and actioning urgent safeguarding issues, within 24 hours ■ Assessment (assisted self assessment Quickheart RAS) and
associated follow up to stabilise emergency/crisis situations
■ Undertaking assessments for simple equipment and minor adaptations
Timeframes
■ Priority 1 – within 48 hours: urgent manual handling and palliative,
urgent respite
Access
Activities
■ Arranging crisis intervention care, Occupational Therapist and Social
Worker as required by the presenting issue
■ Short term intervention high need/high manual handling risks/OT
(Priority 1)
■ Simple equipment and minor adaptations provision through ILRC ■ Assessment and approval for emergency and unplanned respite ■ Signpost or invite to ILRC tutorial equipment for non FACS eligible
enquiries
■ Direct provision of services via screening tool e.g. provision of basic
equipment, day care, issuing prescriptions and ICES requests
■ Determine whether alerts should be managed within the Safeguarding
process, completion of initial fact finding, implementation of interim protection plan within 24 hours, onward referral to CMS
■ Change in circumstances and change in need, screen for urgency,
stablise the case then consider potential for enablement referral or referral to CMS for ongoing intervention
■ Manual handling assessments
■ Assessments for palliative care where there is an urgent need (Priority 1) ■ Assessment and specialist support for people with visual and hearing
impairment which includes provision of simple equipment, employment support and mobility training
■ 6 week reviews for SU’s who receive support planning from Access
Overview
■ Access point for adult social care within the hospital
■ Responsible for assessment and signposting to ensure right support is
in place post discharge
Timeframes
■ Working within Section 2 (notification that an individual has been
admitted to hospital) and Section 5 (notification of discharge) timeframes. The hospital has to give minimum of 24 hours notice of discharge.
Activities
■ In-patient assessment for SU’s ongoing social care needs ■ Referrals to Enablement for community discharges
■ Assessment to support individuals who need residential or nursing
home support following hospital admission
■ Safeguarding, raising the alert for safeguarding issues originating
outside of hospital, completing the full safeguarding process for safeguarding issues arising during hospital stay
■ Engagement with allocated social workers across the pathway about
individual SU’s needs
■ Completion of Continuing Care Assessments
Enablement
Overview
■ Short term intervention (typically four but up to six weeks support) to
maximise an individual’s ability to live independently
■ Functional assessment to identify types, levels and expected timeline
of interventions completed and progress closely monitored throughout the service
■ Identifying and actioning urgent safeguarding issues within 24 hours
Timeframes
■ Assessment within 7 days
Enablement
Activities
■ Enablement Workers deliver service as guided by Enablement Plans,
work in conjunction with OTs, Enablement Officers and SWs to enable service user to do as much as they can for themselves
■ Community referral received from Access (completed screening
tool) followed by an assessment by Enablement, OT, SW, EO as appropriate
■ Hospital discharge referrals received directly from Hospital team with
social worker or OT assessment
■ Change of circumstances or change in need referrals from other
Pathway Teams or Brokerage (requests for increase to care package)
■ Service users with an ongoing care need, Enablement will complete
assisted Self Assessment (Quickheart RAS), support plan with handoff to brokerage
■ Service users with no ongoing care need, review completed and
service ended
■ 6 week reviews for SU’s who receive support plan from Enablement
team and the hospital teams
■ Residential/nursing placements for service users discharged from the
Magnolia Unit
■ Determine whether alerts should be managed within the Safeguarding
process, completion of initial fact finding, implementation of interim protection plan within 24 hours, onward referral to CMS
Care Management
including the Scheduled Review Team
Overview
Specialist OT, SW and review team to provide support for older people and physically disabled service users requiring ongoing SW/OT input to meet their assessment and review needs.
Remit of team includes:
■ Safeguarding investigation and action ■ Continuing Health Care
■ Acquired brain injury ■ Sensory (complex) ■ Complex dementia
■ Legal Challenge/Judicial Review ■ Appointeeship
■ Complex family circumstances ■ Transition (children/adults) ■ OT – Major Adaptations ■ Paediatric OT
■ MCA/DOLS, Court of Protection ■ Residential/nursing care placements ■ Multiple conditions/diagnosis
Care Management
including the Scheduled Review Team
Timeframes
■ Safeguarding, 5 days to complete initial strategy meeting or discussion ■ New client assessment 28 days
Activities
■ Complex support planning
■ Long term placement into residential/nursing care home and self
funders in residential care requiring financial support
■ OT major adaptations/major equipment
■ Provision of ongoing professional input into complex cases, in these
instances a case will remain open to an allocated social worker
■ No recourse to public funds and assessment of needs ■ Scheduled statutory reviews
■ Safeguarding process including whole home investigations/reviews ■ Care Management will complete assisted Self Assessment (Quickheart
RAS), specialist assessment/complex RAS as required and support plan with handoff to brokerage
■ 6 week reviews for SU’s who receive support plan from CMS team ■ Implementing the ‘moving on’ procedures for Transition cases
Overview
■ Negotiate between individuals and service providers, purchase
services, monitor capacity, quality and price, identify providers who may assist customers with recruiting PAs and other relevant support
■ Broker and Practitioner work together to manage risk and put in place
appropriate services to meet outcomes
■ Team has knowledge and awareness of wide range of community
services to support service users needs, drawing on tools e.g. Marketplace as required
■ Provide brokerage advice and information to self funders on request ■ Support service user to set up Direct Payment arrangements
Timeframes
■ Support plans implemented within 5 working days ■ Referrals from Brokerage completed within 48 hours
Brokerage
Activities
■ Implement support plans
■ All service provision except for residential and nursing care is made
through Brokerage
■ Implementing approved/planned respite i.e. 4 weeks in a year as part
of a support plan
■ Bespoke packages commissioned through DP process to give choice
to users
■ Advice to self-funders and signposting and Marketplace
■ Administration to set up direct payments for service users with their
preferred payment mechanism
Glossary of Terms
Term Description
Authorisation/
Approval Support plans, personal budgets and placement requests must be approved before being finalised, this is normally competed by a Team Manager or panel process depending on the team and costs involved.
CareFirst Activity Activities are used to record that a task has been undertaken or provide a reminder to do a task and a date it is required by. Activities should be used for all requests for action or authorisation for another team, individual or manager.
CareFirst Message Messages are sent internally to other Workers or Teams in CareFirst. Messages can be system-generated e.g. when an Activity or Event is reassigned. Manually produced messages should be used rarely as they can easily be missed by the intended recipient. Activities should be used when reassigning or referring work.
ILRC Independent Living Resource Centre, for individuals assessed as requiring equipment. They can try it out before installation/purchase to make sure they get the correct equipment for their needs in the demonstration kitchen, bedroom and bathroom areas, including the latest assistive technology and Telecare.
Observations A chronological record of events on a clients CareFirst record. This should not duplicate activities or assessment information but should confirm key
Term Description
Panel Authorisation process to approve a support plan and personal budget for a service user, will involve Team Manager or above depending on costs involved.
Prescription Issued by Trusted Assessor or OT to enable service user to collect a prescribed simple aid to daily living (piece of low level equipment) from an approved supplier.
RAS – Resource
Allocation System LBE has two different RAS’s. The main one used by Access and Enablement teams is the Quickheart online self assessment tool and RAS. This is used in an assisted self assessment between the service user and assessing officer as the main assessment tool for clients who need an on going service. This tool produces the indicative budget to commence support planning. If a clients needs are not able to be identified by this tool, a specialist assessment and complex RAS will be completed. It is normally only service users being supported by CMS that would trigger this process.
Referral Request for social care support or services. Anyone wanting to make a referral to social care will need to complete a Screening Tool over the phone with a member of the Access Team.
Screening Tool The questionnaire completed by an Access Screening officer at point of referral/contact to gather sufficient information to know how best to progress the individuals request.
Specialist
Assessment To be completed if the Quickheart RAS is unable to cover all of a service users needs. Once complete the worker will complete the Complex RAS to calculate the individual’s personal budget.
