Health and Social Care Joint Working

Governing Principles of Joint Working

Glossary of Terms

• Activities of Daily Living - Tasks that people carry out to look after themselves and their home, and participate in work and leisure activities.
• Acute Services - Clinical medical and surgical treatment provided mainly in hospitals. Acute Hospital Trusts are management units in charge of the hospitals providing these services and are responsible to the Department of Health.
• Advocacy - Process of representing the cause and/or acting on behalf of another person, enabling them to express their opinions.
• Assessed Needs - The needs of an individual that have been identified as a result of an Assessment. In the case of Social Services subject to Eligibility Criteria (click here to see Fair Access to Care Services)
• Assessment - The process whereby the needs of an individual are identified and their impact on independence, daily functioning and quality of life are evaluated so that appropriate care can be planned. It identifies problems and includes all relevant viewpoints. It should be self-contained and time limited culminating in the clear identification of needs and the objectives for how these needs will be met. Where services might be required by more than one agency, multi-agency assessments may be undertaken.
• Care Manager - Someone who:
  • Formulates and co-ordinates the care plan
  • Co-ordinates the commissioning of services and people
  • Monitors quality
  • Reviews outcomes
  • Audits against care standards
  • It responsible for overseeing the care package
  • Is the link/named person for individuals with complex social and health care needs
• Care Package - A group of services brought together to achieve one or more objectives of a Care Plan.
• Care Pathway - An agreed and explicit route taken by individuals through Health and Social Services. It should encompass agreements between respective professionals, to determine when and where, treatment and care will take place.
• Care Plan - Is a written statement of service(s) an individual can expect to receive following an assessment of need to achieve the desired outcomes identified and providing a review date and other details.
• Care Programme Approach (CPA) - The form process for assessing needs for services for people with sever e mental health problems prior to or after discharge from hospital.
• Carer - Somebody who provides substantial care on a regular basis for another individual aged 18 or over.
  • Formal Carer is a person whose job it is to provide personal care and support to a service user.
  • Informal carer is a person, such as a relative or friend who provides personal care and support to an individual.
• Care Record Book - A record log book that is kept in the client's home, which holds a summary of information required for those involved in that person's care package. The book also consists of log pages, which people can use to share information, observations, etc.
• Client and Patient - click here to see Service User
• Clinical - Relating to disease, including disease and symptom management and involves clinical practitioners and interventions.
• Community Care - The provision of services and support to people who need such services to be able to live independently in their own homes, or in homely surroundings (including residential and nursing homes).
• Comprehensive Assessment - A comprehensive assessment draws together all previous assessment information, which is added to relevant specialist assessments needed to gain a comprehensive view. This type of assessment is required where the level of support and treatment likely to be offered is intensive or prolonged, including permanent admission to a care home, intermediate care at home or a substantial package of care at home.
• Consent - Permission that is given by an individual for a course of action to be taken.
• Contact Assessment - The first contact between an individual and professionals which establishes the nature of the presenting problem and whether there are other potential wider needs. Basic personal information is taken or verified.
• Day Care - Provided within Centres to which users travel or are transported. Service providers will vary from statutory agencies such as Health or Social Services to the independent and voluntary sector, and may cater for users with high dependency needs in conjunction with home care and residential provision, and be integral to an intermediate care programme.

  Alternatively day care, particularly within the voluntary sector may offer social stimulation and be part of a preventative programme aimed at combating a move towards functional dependence, and offering carer relief on a structured basis.

• Day Hospital - Care provided within a hospital setting to which users travel or are transported. Service provided for patients requiring assessment, treatment or rehabilitation may follow an in-patient episode, to prevent admission or further progress with rehabilitation.
• Discharge - Releasing an individual from hospital, clinic or a programme of treatment.
• Delayed Discharge - Situation when a service user is in hospital and ready for discharge, but whose discharge is delayed is delayed for a variety of reasons.
• Direct Payments - Payments made by Social care and health services that enable users the opportunity of purchasing and organising their own care services as an alternative to having them directly provided by Social care and health services.
• Domain - Areas of need that are assessed within the overview assessment tool, being part of the holistic assessment that is the Single Assessment Process. Sub-domains relate to the components of a domain.
• Eligibility Criteria - The criteria used by councils and health providers to determine whether a person is eligible for service provision. The criteria will take into account the service user's needs and the resources available. (Click here to see FACS).

  Eligibility covers both whether any service will be offered and, if it is, what service, their volume, and (where relevant) frequency.

• Extra care Housing - A style of housing and care for individuals that falls between established patterns of sheltered housing and accommodation, and care provided in more traditional residential care homes. Also known as Very Sheltered Housing.
• Fair Access to Care Services/Eligibility Criteria (FACS) - The principle that Social Services departments should operate within one eligibility decision for adults seeking social care support. This eligibility criteria is based on a national framework which prioritises risks faced by individuals into four bands, and authorities are expected to adopt these bands in determining their own criteria, with an emphasis on a preventative approach to adult social care.

  Eligibility should be determined following assessment and should support the principle enshrined in the Single Assessment Process.

• Independence - Managing everyday living skills to maximise ability, taking account of the support available and needed.
• Independent Sector - Includes both private and voluntary social care providers, who may be contracted to provide services on behalf of statutory agencies.
• Intermediate Care - As defined in HSC 2001/001 of 19/01/01, intermediate care meets the following criteria:-
  1. Targeted at people who would otherwise face unnecessarily prolonged hospital stays or inappropriate admission to acute inpatient care, long term residential care or continuing NHS inpatient care.
  2. Provided on the basis of a comprehensive assessment resulting in a structured individual care plan that involves active therapy, treatment or opportunity for recovery.
  3. A planned outcome of maximising independence and typically enabling service users to resume living at home.
  4. Time limited, normally no longer than six weeks
• Joint Funding - Where two or more agencies, usually Health and Social care and health services agree to share the cost of running a project or service.
• Key Holder - A person authorised to keep another person's key.
• Learning Disability - Having a significantly reduced ability to understand new or complex information or to learn new skills, or having a reduced ability to cope independently, which started before adulthood and has a lasting effect on a person's development
• Long Term Conditions - Refers to support services provided over a prolonged period of time or on a permanent basis to individuals who have difficulties associated with long term illness, or disability
• Multi-Agency - A group of representatives from different organisations working together towards a common goal.
• Named Professional - Someone who provides a service and:
  • Formulates the care plan
  • Monitors quality
  • Reviews outcomes
  • Audits against care standards
  • It responsible for overseeing the care package
  • Is the link/named person for individuals with complex social and health care needs
• Needs -
  • Presenting need refers to needs that are reported by individuals or others on their behalf
  • Identified needs refers to needs, which have been identified as a result of an assessment.
  • Unmet needs are identified needs, which cannot be met for a variety of reasons.
• NHS Fully Funded Continuing Health Care - This is care provided to clients with complex intensive health care needs and inputs that is arranged and funded solely by the NHS.
• NHS Funded Nursing Care - The determination of the level of trained nursing input a client receives in a nursing home. There are three bands: low, medium, high. The Primary Care Trust makes this payment towards the cost of the care.
• Out of Hours Service - A specific service to operate outside regular office hours to provide either a direct service where necessary, or offer advice, guidance or re-routing to more appropriate services.
• Outcome - The end result of the service provided, which can be used to measure the effectiveness of the service for the individual.
• Overview Assessment - Assessment that explores all or most of the domains of the Single Assessment Process, which may be able to fully identify and describe assessed needs, or alternatively trigger an in-depth/ specialist assessment. It is carried out if the professional involved in the contact assessment believes the individual's needs require a more rounded assessment.
• Patient - Click here to see Service User.
• Person Centred Approach - An approach to assessment of need that puts the individual at the centre of the process and is based on their views and wishes.
• Person Centred Planning - The Valuing People strategy requires services to adopt this discrete approach that supports people with learning disability to be fully involved in deciding how to use their abilities and meet their needs for support. It is not Care Management.
• Providers - An individual or organisation providing a health, social care or housing service.
• Rapid Response Service - A specific service designed to respond rapidly to prevent hospital admission and to facilitate early discharge from A & E.

  This is a time limited service, up to 72 hours for patients who are medically manageable by GP's.

• Re-assessment - A re-evaluation of the needs of a service user, prompted by either a scheduled review, or a contact indicating a change in their circumstances.
• Referral - A formal request for an assessment of a person's needs.
• Referrer - A person contacting agencies about carrying out an assessment
• Registered Nursing Care Contributions- An assessment of the determination of need of a service user, that means that they require a level of care requiring the involvement of, and supervision by, a qualified nurse. There are 3 banding levels that determine the financial contributions that health will make to the care of the service user.
• Reimbursement - The Community Care (Delayed Discharges) Act, relates to the responsibilities of Social Services Departments in making arrangements for the assessment of patients within acute hospitals and organising services to facilitate their discharge.

  To initiate this process the hospital issues a Section 2 notice, where a service user is in need of a community care service and requires assessment.

  A Section 2 notification gives Social Services a minimum of 3 days in which to assess and arrange services.

  A Section 5 notification confirms:-

  • a clinical decision that transfer is appropriate,
  • a multi-disciplinary team decision inclusive of Social Services input which supports the clinical decision and the patient is ready and safe to transfer.

  A Section 5 notice confirms proposed discharge date, and failure of Social Services to organise services to facilitate discharge makes them liable to reimburse the hospital for each day discharge is delayed. The notice under Section 5 gives 24 hours written advice of the discharge date.

• Residential Accommodation - May take the form of either nursing, or residential care home, that provides 24 hrs care to individuals who, on assessment, have been assessed as no longer being able to be supported at home. Residential accommodation can be either long or short stay.
• Respite Care - Designated beds within residential home and hospital settings, available usually on a pre-planned basis to allow a short period of care, often to provide carer relief/support.
• Review - This refers to re-assessment of service user's needs and issues, and consideration of the extent to which services are to meet the stated objectives, achieve the desired outcomes and respond to changes in circumstances or service criteria.
• Risk Assessment - The assessment of a person's health, their safety, well being and their ability to manage essential daily routines and the impact this has on carers and staff.
• Self Funding - When an individual has sufficient funds and is able to make arrangements for and pay privately for their care services.
• Service User - An Individual who is in receipt of services from health, social care or housing services.
• Specialist Assessment - An assessment undertaken by either a health or social care professional.
• Valuing People - A Government White Paper published in March 2001, which detailed the national development of services for people with learning disabilities.