Older people with multiple conditions should have named care coordinator, says Nice

Older people with multiple long-term conditions and social care needs should have named care coordinators to ensure that services join up around them and their needs are met promptly.

That was among the recommendations made to local authorities, providers and the NHS by the National Institute for Health and Care Excellence’s (Nice) in a guideline issued today on older people with social care needs and multiple long-term conditions.

Key roles

Nice said that the care coordinator’s roles would include:

• playing a lead role in the assessment process.
• liaising with all health and social care services working with the person, including those delivered by the voluntary and community sectors.
• identifying unmet needs and discussing with the person how these could be met.
• ensuring the person has continuity of care, including, wherever possible, receiving personal care from people known to them.
• ensuring effective response to the person’s needs in times of crisis.

It named social workers as among the groups of professionals who could take on the role, along with nurses and community and voluntary sector staff.

Integrated care planning

The guideline says that care plans should incorporate the full range of people’s needs including medical, psychological, emotional, social, personal, sexual, spiritual and cultural needs, sight, hearing and communication needs and environmental care needs. As well as the person themselves, care plans should be developed with all professionals or agencies supporting them.

Where a person is likely to have eligible needs for social care or may need to go into a care home, professionals should consider referring them for a specialist clinical assessment by a geriatrician.

The guideline also envisages older people with multiple conditions having “community-based multidiscplinary support” from a team of professionals potentially including community pharmacists, physiotherapist, social worker, occupational therapist or psychiatrist.

Care Act requirements

Nice’s guidance is voluntary though the Care Quality Commission takes it into account when assessing adult social care services. But much of the guideline reflects what is required or expected of local authorities under the Care Act but extends this across health and social care.

For example, the guideline says that assessments of and care planning for older people with multiple conditions should always involve the person and, if appropriate, their carer, and take account of their strengths, needs and preferences, in line with the Care Act. Care plans should also be updated at least annually, as set out in the Care Act statutory guidance.

Care home recommendations

There are also a specific set of recommendations for care homes supporting older people with multiple conditions, including to:

• Ensure that people have a choice of things to eat and drink during the day, including outside of meal times.
• Ensure that people are physically comfortable, for example by allowing them to control the heating in their rooms.
• Encourage social contact and opportunities for education, entertainment and meaningful occupation, including by building links with the wider community and through use of technology.

The guideline also stresses that care homes should provide information on charges for self-funders and publicly-funded residents and set out what residents are entitled to, and whether this would change if their funding status was altered.

This reflects longstanding concerns that self-funders are having to subsidise low rates paid by local authorities for their residents.