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SDS Care Management Pathway

SDS Care Management Pathway. Barry Scrase Project Manager J u l y 2 0 1 2. SDS Pathway Assessment. New service users. SDS Starts. Existing service users. Multi Agency Transitions Team. Information for SDS shared with individual (including SDS Questionnaire).

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SDS Care Management Pathway

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  1. HSC Transformation SDS Care Management Pathway Barry Scrase Project Manager J u l y 2 0 1 2

  2. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  3. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  4. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan HospitalSocial Work Team Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  5. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  6. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review Short Term Services6-week involvementSTAR Action Plan STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  7. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  8. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  9. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  10. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team Carer’s Deflator Question asked Carer’s Assessment offered NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  11. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility Practitioner completes assessment on PARIS including information from carer. NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  12. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts Indicative Personal Budget agreed with Team Manager NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  13. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Financial assessment Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  14. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Copy of assessment to service user and copy of carer’s assessment to carer Support Planning(next slide) Financial assessment Indicative Personal Budget agreed with Team Manager YES Interim services Review(separate process) Interim services

  15. SDS PathwayAssessment New service users SDS Starts Existing service users Multi Agency Transitions Team Information for SDS shared with individual (including SDS Questionnaire) Existing service users receiving a review STAROverview Assessment eligibility YES YES Short Term Services6-week involvementSTAR Action Plan Eligibility Screening Hospital Social Work Team NO NO Visit from practitioner to complete assessor’s view on SDS Questionnaire and commence Practitioner Assessment Carer’s Deflator Question asked Carer’s Assessment offered Care Direct YES Overview Assessment eligibility NO Practitioner completes assessment on PARIS including information from carer. Carer’s Assessment If taken up Signposting to other services and contacts NO Eligibility for service assessed Support Planning(next slide) Copy of assessment to service user and copy of carer’s assessment to carer Financial assessment Indicative Personal Budget agreed with Team Manager YES Review(separate process) Interim services

  16. SDS PathwaySupport Planning Individual Develop Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Family/Carer Team Manager authorises Independent Planner NO Review(separate process) Risk Risk CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan Not robust Differences of view CDF agrees Case Discussion Forum Informservice user YES back to plan NO

  17. SDS PathwaySupport Planning Develop Plan Individual Develop Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Family/Carer Team Manager authorises Independent Planner NO Review(separate process) Risk Risk CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan Not robust Differences of view CDF agrees Case Discussion Forum Informservice user YES back to plan NO

  18. SDS PathwaySupport Planning Individual Develop Plan SW/ARC with funding Team Manager discuss to agree Support Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Family/Carer Team Manager authorises Independent Planner NO Review(separate process) Risk Risk CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan Not robust Differences of view CDF agrees Case Discussion Forum Informservice user YES back to plan NO

  19. SDS PathwaySupport Planning Individual Develop Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Team Manager authorises Family/Carer Team Manager authorises Independent Planner NO Review(separate process) Risk Risk CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan Not robust Differences of view CDF agrees Case Discussion Forum Informservice user YES back to plan NO

  20. SDS PathwaySupport Planning Individual Develop Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Family/Carer Team Manager authorises Independent Planner NO Review(separate process) Review(separate process) Risk Risk CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan Not robust Differences of view CDF agrees Case Discussion Forum Informservice user YES back to plan NO

  21. SDS PathwaySupport Planning Individual Develop Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Family/Carer Team Manager authorises Independent Planner NO Risk Review(separate process) Risk Risk Over indicative budget CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan Not robust Differences of view Differences of view CDF agrees Case Discussion Forum Informservice user YES back to plan NO

  22. SDS PathwaySupport Planning Individual Develop Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Family/Carer Team Manager authorises Independent Planner NO Review(separate process) Risk Risk CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan Not robust Differences of view CDF agrees Case Discussion Forum Case Discussion Forum to decide Informservice user YES back to plan NO

  23. SDS PathwaySupport Planning Individual Develop Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Family/Carer Team Manager authorises Independent Planner NO Review(separate process) Risk Risk CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan Not robust Differences of view CDF agrees Informservice user Case Discussion Forum Informservice user YES back to plan NO

  24. SDS PathwaySupport Planning Individual Develop Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Family/Carer Team Manager authorises Independent Planner NO Review(separate process) Risk Risk CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan CDF agrees Not robust Differences of view CDF agrees Case Discussion Forum Informservice user YES back to plan NO

  25. SDS PathwaySupport Planning Individual Develop Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Family/Carer Team Manager authorises Independent Planner NO Review(separate process) Review(separate process) Risk Risk CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan Not robust Differences of view CDF agrees Case Discussion Forum Informservice user YES back to plan NO

  26. SDS PathwaySupport Planning Individual Develop Plan Social WorkerARC/CPN Summary Plan SW/ARC/CPN Put onto PARIS SW/ARC with funding Team Manager discuss to agree Support Plan YES Family/Carer Team Manager authorises Independent Planner NO Review(separate process) Risk Risk CASE DISCUSSION FORUM FUNCTIONConsistencyEnablingSolutions optionsPublish learningDecisionsRisk enablementConsider cost Not enough information Over indicative budget back to plan Not robust Differences of view CDF agrees Case Discussion Forum Informservice user YES back to plan NO

  27. Any Questions?

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