Assessing the mental health needs of older people
Seddon D & Robinson C (2001) Carers of older people with dementia: assessment and the Carers Act Health and Social Care in the Community 9 (3) pp.151-158
Aims and method
This research sought to examine how care managers assess carer's needs and the carers' qualitative experience of the assessment process. 32 care managers and 64 carers of older people with dementia in 4 Welsh unitary authorities were interviewed between 1997 and 1999.
Knowledge of the Carers Act
Care managers' insight and understanding of the Carers Act was limited and there was a lack of established policy at local level. Carers' knowledge of the Act was also very limited and most were unaware of their rights to individual assessment. 88% of carers had not been informed of their right to an individual assessment when the person with dementia was assessed.
Interpreting Act Guidance
Care managers were not familiar with the Carers Act Practice Guidance and interpretations were inconsistent. Many equated 'regular and substantial care' with practical and supervisory help without adequately considering the personal and psychosocial dimension of caring. Comprehensive assessment remained client-focused and addressed the practical aspects of caring.
Assessment procedures and parameters
Although care managers recognized the benefit of the carer assessment process they were not proactive in making carers aware of their rights to assessment. A separate assessment was often seen as time-consuming and an addition to the administrative load. There were also limited opportunities to carry out a separate, confidential carer assessment and some managers felt that the user assessment encompassed carer need.
Carers were unfamiliar with the term assessment and were often unclear about the status of the care manager's visit, not realizing that it was a needs assessment. The purpose and process of assessment was not being made explicit to carers.
Care managers maintained that the assessment framework did not address coping strategies, relationship dynamics and other commitments. Focus was often on the carer's ability rather than their willingness to continue caring. Carers reported that the assessment process remained task-oriented and client-focused, addressing primarily the physical and cognitive functioning of the person with dementia, and lacked confidence in the care manager's ability to assess their needs.
Carer involvement and recognition
There was a significant gap between the policy of carer involvement and present practice. Carers reported being unsure about the precise role of the care manager, and the nature of their relationship with the care manager varied considerably.
Care managers suggested that carer involvement in assessment could be facilitated by:
- Establishing a relationship of mutual respect and trust between care manager and carer
- Communicating clearly the purpose and process of assessment and the organizational issues involved in its implementation
- Reinforcing the importance of the care-giving role and contextualise the carer's involvement
- Encouraging carers to reflect on discussions
- Avoiding the use of technical terms
- Where possible ensuring continuity of assessor
Policy states that carers need to be recognized as expert partners in the assessment and caring process. Carers possess interpersonal, crisis management, coping, practical and organizational skills and have exceptional biographical knowledge of the person they care for. However, 63% of carers interviewed felt that the care managers ignored their skills and strengths.
Results of the assessment and the care plan should be confirmed in writing but only 11% of carers had received a written copy of these documents and 78% only had a verbal agreement.
Monitoring and review
Care managers conceded that monitoring and review processes needed development and that only a few cases were actively care managed. Reviews were most commonly precipitated by a crisis. 74% of carers interviewed reported that their needs had not been reviewed following assessment. Many were not confident that a change in circumstances (such as a deterioration in their health) would prompt a review.
Conclusion and recommendations
The findings suggest that carers and care managers have limited knowledge of the Carers Act.
This research reveals 5 areas for improvement:
- Carer recognition. Carers must be recognized as individuals, independent of the person they care for. Professionals must acknowledge and develop carers' skills and specialist knowledge and affirm their sense of competency.
- Information. Carers need clear up-to-date information about their rights and the assessment process if they are to be empowered to make informed decisions.
- Parameters of assessment. The task-oriented system of assessment has important limitations. A flexible framework for the separate assessment of carer need is required, integrating fully the practical, personal and psychosocial aspects of caring. Carers need written copies of an assessment and care plan which explicitly identifies their contribution. Carers' willingness to continue caring should not be assumed.
- Monitoring and review. Care-giving is an ongoing process, with ever-changing demands, and must be closely monitored and regularly reviewed. Service development plans need to incorporate unmet carer need.
- Staff training and development. Local authorities should produce an unambiguous written strategy relating to carers and the Carers Act, with an explicit interpretation of 'regular and substantial care'. Staff need to be continually briefed on local priorities. Joint ownership between health and social services of carers' needs should underpin all strategies.