Introduction to assessment

Assessment is a broad term that applies to the collection of information that allows for the identification of risks and diagnoses. It is about describing and understanding the important issues for a person during their hospital stay to keep them safe, prevent them getting worse and to correct whatever has caused them to present to hospital. Comprehensive, refers to the consideration and integration of all the important issues.

A comprehensive multidimensional interdisciplinary assessment leads to the ability to develop a care plan that is patient-centred. Clear consensus as to how this should be undertaken in an Australian hospital context is lacking [6].

Assessment is frequently not a linear process. Assessment, care planning and discharge planning processes are inter-related and a change in one of these may prompt a need to re-visit the others. This section will demonstrate the relationship between assessment, care planning and discharge planning when preventing and managing functional decline during hospitalisation.

A key challenge with this domain is the lack of a gold standard in assessment and screening tools for older people. Research has confirmed the value of comprehensive assessment in the management of older people [6], however there are many methods currently in use. In the absence of a gold standard, this section covers the intended outcomes for assessment, which then informs the processes within health services that support an older person throughout their health care journey.

A broad approach is required to ensure that a person entering health services receives the right care, at the right time and in the right place.

It is anticipated that health services will vary in their approach to providing screening and assessment of older people. The commonality across all health services is the need to ensure that practices and processes maximise the identification and management of the functional decline of older people, across all domain areas. This suggests that organisations review current practices to streamline assessments to ensure older people are not being asked the same questions by several people. Rather, that the right questions are being asked at the right time.

At all times during assessment, it is essential that a person-centred approach is used.

For the purposes of The toolkit, this section aims to provide tools that can be used for screening and assessment of the risk of functional decline of older people in hospital settings. The section does not purport to address all types of assessment or provide discipline-specific or diseasespecific assessment tools. Domain specific sections of The toolkit may contain more specific tools for screening or diagnostic tools.

Like the Person-centred practice section of this toolkit, assessment applies across all the domains. The main purpose of this section is to illustrate ways that identify the need for more detailed assessment of an older person's functional ability. This will lead to identifying what the possible next steps should be, which may be a comprehensive assessment, more in-depth assessment of a particular domain or a discipline specific assessment.

In choosing preferred tools to use within your health service, you would need to evaluate what is currently used and identify areas for improvement in both practice and processes to support best practice in this domain.

Why is assessment important for older people in hospital?

Assessment will support the proactive management of functional decline of older people during a hospital admission. Screening and assessment should clearly link with a person's inpatient care planning and discharge planning. These should be continually reviewed throughout the person's admission as their preferences and needs are more clearly understood.

Comprehensive assessment provides a framework to ensure all areas of potential risk are covered, including often under recognised areas, such as depression and delirium.

Within the current context of brief length of stays within the acute setting, rapid identification of risks is critical to ensure that safe and effective pathways are developed for managing the needs of older people.

• Understand an older person's preferences and needs.
• Understand the needs of an older person's family or carers.
• Understand an older person's pre-admission status.

Further information

Refer to A guide for assessing older people in hospitals [6].

When, with whom, and by whom, should screening and assessment be undertaken?

Screening

Screening is a filtering process that aims to identify the presence of health problems, or risk of a health problem occurring. Screening identifies people who would benefit from further assessment. Person-centred screening is conducted in partnership with patients and their families or carers.

Screening can be repeated at any time during an episode of care, particularly if there is a change in health status [6].

Screening is crucial to detecting and preventing functional decline across all domains.

Screening or assessment should trigger appropriate action and follow-up.

Examples of screening tools include:

InterRAI Screen Functional Assessment Screening Tool (FAST) Vulnerable Elders Survey (VES-13) Community Assessment Risk Screen (CARS).

Comprehensive assessment

Comprehensive assessment can be undertaken by any member of the interdisciplinary health care team who has sufficient knowledge and skills. Ideally it should be completed within the patient's first 24 hours in hospital.

Examples of comprehensive assessment tools include:

InterRAI Comprehensive Assessment Tool: Acute Caulfield Hospital Interdisciplinary Assessment Tool (IDAT).

How should the information collected during screening and assessment be used?

Screening should be used to:

• Identify people who would benefit from more comprehensive assessment and management processes.
• Identify issues or risks that require more complex diagnostic assessment.
• Establish an older person's pre-morbid level of functioning.

Comprehensive assessment should be used to:

• Get to know the patient in detail.
• Identify the nature of problems identified through the screening process.
• Prescribe appropriate risk minimisation, interventions and management strategies.
• Minimise further decline and maximise functional independence.
• Reduce risks.
• Facilitate care planning and effective discharge planning, starting at presentation.

For screening and assessment to be effective, the information obtained must be used to develop appropriate treatment, care and management strategies to reduce identified risks and promote a return to an optimal level of functioning. A well-planned and streamlined documentation system is essential for effective utilisation of the information obtained during screening and assessment.

Again, there is no gold standard in care planning. Consideration needs to be given to documentation, team communication and planning, clinical handover and other activities that will streamline communication across the health care continuum. This may include the transfer of older people from acute to sub-acute settings, or within acute settings from one ward to another.

A care plan is developed and implemented following the initial assessment and is updated following reviews of progress or changes in the patient's status. The aim of a care plan is to meet the individual patient's needs and goals. This may include therapeutic interventions, education and communication within, and between, the team and ongoing service providers or services to ensure that functional independence is maximised throughout hospitalisation and on discharge. It is provided to all relevant parties with the patient's consent.

Each patient will have different needs and expectations identified during the person-centred assessment processes. An interdisciplinary approach to care that actively consults and collaborates with the patient and their family or carers will promote the best possible outcomes.

For working instructions, supporting documentation and evaluation of an interdisciplinary documentation system in a sub-acute hospital, refer to the documents outlining the Interdisciplinary documentation system used at Caulfield Hospital, Alfred Health:

Interdisciplinary documentation system: Work instructions Interdisciplinary documentation system: Evaluation Functional Maintenance Care Plan.

Clinical handover documentation can also contribute to effective treatment, care and management:

Clinical handover sheet.

How do I know if effective screening and assessment is occurring?

File audits can be used to help measure whether screening and assessment are being completed adequately in a health service. The quality of the screening and the assessment can be measured by the quality of the care planning and the discharge plan.

Patient and carer satisfaction surveys can also be used to measure the quality of the screening, assessment, care planning and discharge planning processes. Examples of patient and carer satisfaction surveys can be found in the Person-centred practice section of The toolkit.

Further information

Please refer to the following audit tools and databases. Instructions and an explanation of their use are included within the documents: Functional maintenance screening and assessment file review audit tool Functional maintenance screening and assessment file review audit databases Pre-intervention staff survey Staff survey databases.

Model for screening and assessment of older people in hospital

Case study

Scenario 1

Mrs Bennett is admitted to a cardiac ward and treatment includes a range of medications and observation to determine her tolerance to treatment. Maureen, or one her siblings, visit Mrs Bennett daily. Mrs Bennett and her six adult children are a close-knit family. It is difficult for nursing staff to answer all their questions.

Over the first four days of Mrs Bennett's stay, nursing staff observe and Mrs Bennett reports increasing incontinence. During the day she regularly leaks urine and sometimes does not reach the toilet in time. She complains of tiredness because she needs to use the toilet during the night. Nursing staff explain that this is a common side effect of the Lasix prescribed to treat her condition.

Mrs Bennett has two falls in her room.

Nursing staff assess that Mrs Bennett needs more time to adjust to her condition and treatment, access continence aids and learn to manage the side effects of treatment.

After four days of treatment Mrs Bennett's original symptoms abate. The ward medical officer examines her, assesses her as stable and recommends discharge.

For further information about Mrs Bennett's needs, assessments are sought from the ward physiotherapist and the hospital psychology department.

During her assessment, the physiotherapist notes that Mrs Bennett uses furniture to steady herself as she moves around her room. Mrs Bennett tells the physiotherapist that she doesn't feel confident anymore and is frightened of falling again. The physiotherapist identifies postural hypotension and recommends against discharge due to the risk of falls, Mrs Bennett's gait instability and decline in her mobility.

The following day, a hospital psychologist visits Mrs Bennett and finds she is not ready to be discharged and is anxious and at risk of depression in reaction to the side effects of her treatment. She assesses Mrs Bennett as rightly concerned that she will not be able to manage at home. She is worried about falling, embarrassed about her incontinence and is anxious about the possibility of increased dependence on her daughter.

Over the next week Mrs Bennett is provided with a walking frame and other aides. Nursing staff provide and explain continence aids to Mrs Bennett. The psychologist talks to Mrs Bennett and Maureen about her adjustment to the treatment. Medication for depression and anxiety are discussed but Mrs Bennett says she'd like some time 'to see how it goes' before she adds more medication (and further possible side effects) to her regime.

Mrs Bennett is eventually discharged home. Mrs Bennett and her daughter are provided with material about a range of community supports including Meals on Wheels, her local council's home-help service and district nursing.

At home it takes Mrs Bennett several months to adjust to her new circumstances. She has several further falls that result in bruising. Eventually a community-based service is engaged which recommends some home modifications such as a handrail in the bathroom.

Scenario 2

Using the following strategies from The toolkit:

Patient and family-centred care: A hospital self-assessment inventory Advancing practice of patients and family centred care: How to get started Caulfield Hospital Interdisciplinary Assessment Tool (IDAT) Berg Balance Scale Tinnetti Assessment Tool: Balance For tools, refer to Minimising the risk of falls and falls injuries - Guidelines for acute, sub-acute and residential care settings (Tools supplement) At a ward meeting early in Mrs Bennett's admission, nursing staff discuss how to engage collaboratively with Mrs Bennett's large family. The ward social worker uses the hospital's Patient and family centred care: A hospital self-assessment inventory and approaches Mrs Bennett and Maureen to discuss how the hospital staff can work effectively with Mrs Bennett and her family. A family meeting is planned to occur before discharge

After Mrs Bennett responds to treatment and the side effects emerge each member of the assessment team keeps each of the domains in view with an initial emphasis on:

• The medication and side effects; looking at Mrs Bennett's prescribed medications, types, dosage and timing of administration.
• The balance between treatment benefits of symptom abatement versus falls risk and continence issues.
• Resolution of the hypotension, again to address falls risk.
• Need for continence aids.
• Mrs Bennett's psychological discomfort at her changed functioning and her need for immediate and ongoing support.

Each of the professionals confers as necessary to make adjustments to Mrs Bennett's treatment regime. The physiotherapist and the medical officer work particularly closely with Mrs Bennett to find the best balance between treating symptoms and minimising side effects. This is done over 24 hours.

Mrs Bennett's medications are adjusted to find a combination that minimises the hypotension and incontinence. Particular effort is made to eliminate nocturia because Mrs Bennett finds that tiredness especially impacts her mood. She learned in her earlier experience of depression after her husband's death that if she 'gets a good night's sleep' she is more able to manage 'whatever comes (her) way'.

Measures taken to address Mrs Bennett's risk of falling in hospital include a commode chair in her room for night use and the physiotherapist provides a walking frame and some training to familiarise Mrs Bennett. Mrs Bennett maintains her mobility in hospital.

Mrs Bennett's family request a family meeting, which is held on the ward within 24 hours of the request. The medical officer and physiotherapist attend and the social worker convenes. With Mrs Bennett's permission, the staff report on her condition and the challenge of treating her symptoms while minimising the side effects and risks. Family members ask a lot of questions.

Prior to discharge, a discharge summary is sent to Mrs Bennett's General Practitioner (GP) to explain what happened and asks the GP to continue to monitor Mrs Bennett.

By the time Mrs Bennett is discharged, the incontinence has been reduced but Mrs Bennett still chooses to use pads as a failsafe. A regimen has been devised whereby she takes medication early in the morning and only needs to get up once in the night to go to the toilet. Dosages are reduced to minimise the hypotension. The risk of falls is reduced but arrangements are made for an assessment for some modifications at home (a rail in the bathroom and toilet) to further reduce risk.

Each of these strategies contributes to alleviating Mrs Bennett's anxiety and she leaves hospital relatively confidently.

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