Care Management
Review Process - Practice Guidance
Practice Guidance for the Revised Review Process
and the Review Form SS3(P)
Lead Officer - Sally Slade Joint Agency Health & Social Care Manager-Exeter PCT (Older People/Disabilities)
(Rev Nov 2005 )
Contents
1. Purpose of Reviews
2. Principles Underpinning the Review Function
3. Re-Contact
4. Review Practive
5. The Desk Top Review
6. Face to Face Reviews
7. The Review Process
8. Nursing Home Reviews
9. Other Specialist Assessment
10. Sensory Services
11. CareFirst
12. Performance and Targets
13. Accountability
Appendix A - Desk Top Planned Review Process
Appendix B - Indicators for Different Types of Review
Appendix C - Review Process
Appendix D - Draft Process for Joint Reviews for Nursing Placements within Localities
Appendix E - CPA and Revised Review Process
Appendix F - Issues to consider for Locality Review Action Plans
Appendix G - Specialist Assessments for Learning Disability Services Clients
Four flowcharts, two detailing aspects of the review process from a practice decision view point, and two taking a more process orientated overview.
1. Purpose of Reviews
1.1 The primary function of a review is to:
Check the level of risks arising from an individual's needs and circumstances and the extent to which the services are helping to manage the risks, including the service user's / carer's / service provider's views about current services.
- Check the quality, efficiency and effectiveness of all services being provided in managing identified risks.
- Check the carer's situation and arrange a carer assessment as appropriate.
- Apply FACS eligibility and evidence this on an SS14.
- Confirm or amend the current care plan or lead to case closure.
Note:Monitoring a care package / individual service user’s situation or a particular service is different to a review and must not be recorded as a review on CareFirst. This includes monitoring a new service, such as a residential placement, after six weeks, or a Time Limited Services check.
Note:It is important to remember that a review is a function that is undertaken to check the primary tasks set out in 1.1. Forms are the mechanism by which information is gathered in a structured and inclusive way to inform the primary review outcomes set out in 1.1 above.
2. Principles Underpinning the Review Function
The practice principles underpinning reviews are set out in the SAP / CPA Guidance and the FACS eligibility criteria guidance including Matching Needs and Services.
2.1 The guiding principles are to:
- Involve the service user / carer.
- Involve service providers / other agency staff as appropriate.
- To determine the type (Desk Top or Face to Face) and frequency of the review on the basis of the complexity of the care plan and services, together with the level and predictability of the individual’s needs and risks.
- To seek a level of information that is proportionate to the complexity of the care plan and services, together with the level and predictability of the individual’s needs and risks.
2.2 All service users with an ongoing service or services must be reviewed at least once every 12 months. This includes service users receiving Direct Payments.
2.3 The documentation used should reflect keeping things as simple as appropriate to the individual’s situation, reducing unnecessary bureaucracy for service users / carers, service providers and care management / business resources staff.
2.4 Services may, therefore, be closed without the need for a Face to Face review where there is agreement to do so by all those involved. It is good practice to discuss and agree a phased withdrawal of services with the service user / carer.
2.5 Following either an assessment or a review resulting in ongoing services arranged by Social Services, care management staff must identify the review date and type.
2.6 Time Limited Services do not need a review to end services. (Please refer to the latest versions of the Time Limited Services Practice Guidance and the CareFirst System Time Limited Service Guidance 030.)
3. Re-Contact
3.1 Not all re-contacts need a re-referral, reassessment or review. Where a service user requests changes to the care plan / current services, the Help Desk worker / manager must make a judgement whether the request can be managed within the previously assessed needs or whether there is a need to reassess the situation.
3.2 Many such requests should be managed within the previously assessed needs and agreed without the need for re-referral, review and reassessment. For example, contact about replacing existing equipment should not trigger a referral or reassessment; a request to have one of an agreed serious of respite stays should not trigger a referral or reassessment.
3.3 Situations that will lead to re-referral, reassessment and review are:
- Where the review date is overdue.
- Where the review date is due within three months of the re-contact.
- Where significant changes are being described about a person's previously assessed needs and / or the type and level of care package required to meet the needs. For example, high levels of risks, an unpredictable / unstable situation or a complexity of needs and services.
When there is the need to re-refer, reassess and review the situation, the reassessment (at whatever level), should incorporate the review function from a practice perspective and cover the primary review functions set out in Section 1.1.
3.4 When there is the need to re-refer, reassess and review, there is no need to complete any additional paperwork other than that required for the appropriate level of reassessment for the individual’s situation and an SS3(P). The assessment documentation may be used to record the review outcomes.
3.5 For contacts resulting in a reassessment, a referral and the review details must be recorded on CareFirst.
3.6 Where a personally care managed service user contacts Social Services due to changes in needs or circumstances, this should be passed to the named care manager, either directly via the telephone or noted on an SS4(a). The care manager must then make a judgement whether the request can be managed within the previously assessed needs or whether there is a need to reassess the situation. The majority of situations should be managed without the need for reassessment and review.
3.7 For the small number of PCM cases requiring a reassessment, a referral and the review details must be recorded on CareFirst. The reassessment must fulfil the review criteria (see Section 1.1). There is no need to complete any additional paperwork other than that required for the appropriate level of reassessment for the individual’s situation and an SS3(P).
3.8 For all cases, a new review date of up to 12 months from the reassessment's outcome should be input on CareFirst and the Care Plan (normally the SS2) and other documents updated accordingly (unless the case is to be closed).
3.9 Where the reassessment identifies changes / risks that require a specialist assessment, as long as all the other review criteria have been fulfilled, the review can be completed prior to the specialist assessment's completion.
4. Review Practice
4.1 The majority of people will require a review date of 12 months. However, where the care plan and services are complex and the individual’s needs and risks are unpredictable or at a high level (often PCM cases); good practice suggests the need for a more frequent review timescale.
4.2 The analysis and evaluation of the information provided by the service user, carers, service providers and other agency staff is a critically important stage of the review process and must be used to inform decision making about the review outcomes as set out in Section 1.1.
The review information must also address issues concerning:
- The person’s financial situation, including benefits.
- Direct Payments - either raising it as an option or checking how it is being used by the person.
- The ethnicity details are on CareFirst. If it is blank or 'Not Stated', check with the person and add / amend as appropriate.
- Funded Nursing Care and NHS Continuing Health care (where relevant).
4.3 There are two types of review: Desk Top reviews (see Section 5) and Face to Face reviews (see Section 6).
4.4 Where there is no contact with Social Services within the previous 12 months resulting in significant changes to the care plan and current services, the review will be undertaken on the planned date using either the Desk Top or Face to Face approach and recorded using the review documentation.
4.5 All individuals in Care Homes will receive face to face reviews. The majority of planned reviews will be undertaken using the Desk Top approach. Appendix B provides some examples of when to use the Desk Top or Face to Face review approaches.
4.6 Cases being transferred from Personal Care Management to Help Desk Services (as either Care Coordination or Self Care Management) will require a review. This may be either Face to Face or Desk Top, depending on the person’s situation and care plan. The review forms will be used to record this.
Where there has been a recent assessment or review which has planned for case transfer from PCM to Help Desk, there is no need to review again on the agreed transfer date if the circumstances have remained the same. In these circumstances, use the front of an SS6 and pass to Business Resources to transfer the case on CareFirst (see SS6 guidance for more details).
4.7 Where a review identifies changes / risks that require a specialist assessment (for a PCM or Help Desk case), the person undertaking the review is responsible for requesting the specialist assessment. This may be done using either an SS6 or SS2(a) and any other relevant paperwork that evidences the need for the specialist assessment. There is no need for a re-referral. In these circumstances, the review can be completed as long as all the other primary review outcomes set out in Section 1.1 above have been fulfilled.
Note: When a personal care manager identifies the need for a specialist assessment during monitoring work, there is no need to record a re-referral or review. The specialist assessment work will be undertaken within the ongoing monitoring situation. See the separate guidance on specialist assessments for PCM cases.
5. The Desk Top Review
5.1 This will be undertaken at least annually by review care managers for planned reviews where: - The person is not in a Care Home
- The person is able to communicate effectively by telephone or in writing or there is some one else appropriate to support or undertake this task such as family, advocate, carer.
- The needs are within the context of a stable or predictable situation, for example, Care Co-ordination.
- There is no legal order or policy requiring named, allocated worker.
- The FACS eligibility can be determined through Desk Top process.
5.2 A Face to Face review may be required in a small number of cases following the Desk Top approach where this review identifies:
- Major changes in an individual’s circumstances / health that require further clarification beyond that which can be obtained by telephone call to service users / carers / service providers / other agency staff.
- There is ongoing disagreement about the outcome of the Desk Top review.
- There is insufficient information to decide on the FACS eligibility despite further telephone calls.
In these circumstances, the Practice Manager should decide the most appropriate action for the individual situation. This may include further telephone clarification or a face to face visit by the review care manager or, if necessary, a different worker.
6. Face to Face Reviews
6.1 A Face to Face review at the planned review date (without a Desk Top review being completed first) may be required where:
- The person is unable to communicate effectively by telephone or in writing for example due to sensory / cognitive impairment or language and there is no one else appropriate to support or undertake this task such as family, advocate, carer.
- The case is Personally Care Managed, the care manager identifies this level of review is required and / or there is no one else appropriate to support or undertake this task such as family, advocate, carer.
- The person and / or carer is, or appears to be, at serious risk.
- The person's services / care plan are complex .
- The person is in a Care Home.
7. The Review Process
The review process for both Desk Top and Face to Face planned reviews involves:
- Sending (for Desk Top reviews) or taking (for Face to Face reviews) the Your Review form (SS3), to the service user / carer, together with relevant leaflets appropriate to the person's situation, such as the Support for Carers leaflet (Ref 6) or the Direct Payments leaflet (Ref 8). Business Resources staff will assist with this task (Desk Top only).
- Where the person is unable to communicate in writing and there is no-one else appropriate to assist them, consideration should be given to undertaking the Desk Top review over the telephone.
- The service user completing and returning the review form to the review care manager within two weeks of receipt (Desk Top only).
- Chasing any non-returns. Business Resources staff will assist with this task (Desk Top only).
- Obtaining service providers / relevant other agency staff views either by email / in person or telephone call using the Service Provider Review Details form (SS3(SP)). Business Resources staff will assist in sending the SS3(SP) to the service providers. This can be by e-mail when the agreed e-mail policy allows this to happen.
Note:Business Resources are not responsible for obtaining the service provider's views. - Assessing and evaluating the information provided by the service
user / carer / service provider / relevant other agency staff. This may include the review care manager obtaining further information from some / all parties by follow up telephone calls or in person. - Ensuring Direct Payments are raised as an option as appropriate.
- Referring non-residential service users to the FAB team if their financial situation has changed. For service users in a care home placement whose financial situation has changed, the care manager will need to submit a new SS280 to Client Finance Services.
- Applying the FACS eligibility criteria and completing an SS14.
- Agreeing the next steps with the Practice Manager, service
user / carer. - Confirming / amending (increase / stay same / decrease) the current care plan or closing the case. (See the bullet point below.)
- Recording the outcome of the review on the Care Plan (SS2). An SS2(a) or SS6 can be used to add detailed analysis if required.
- Where there are significant changes to, or closure of, services, agreeing with the Practice Manager / service user / carer / service provider a date for the changes to commence, appropriate to individual's situation.
- Care management staff completing the Review Process form (SS3(P)).
- Where review care managers are competent and skilled, they will update CareFirst. Where this is not the case, Business Resources staff will assist with this task.
- Amending all appropriate forms, such as the care plan, contracts and so on.
- Ensuring that paper copies are placed on file. Business Resources staff will assist with this task.
- Sending copies of relevant forms / letters to service users / carers / service providers as appropriate to the situation. Business Resources staff will assist with this task.
Note:Where there is contact with Social Services within the 12 months resulting in significant changes, the review must be incorporated into the reassessment process. (See Section 9 below.)
8. Nursing Home Reviews
See Appendix D.
9. Other Specialist Assessment
9.1 When an existing Help Desk client contacts Social Services and the outcome is the need for a specialist assessment to consider, for example, a major adaptation, complex moving and handling needs, or the need for a large piece of equipment due to mobility difficulties, the assessing staff member must undertake the review function as part of the reassessment using the approach set out in Section 3. There is a requirement to fully and holistically assess an individual's situation as part of the decision making process for these situations.
9.2 The reassessment should incorporate the review function from a practice perspective and cover the primary review functions set out in Section 1.1. The review will be completed as long as all the primary review outcomes in Section 1.1 have been fulfilled.
9.3 Re-contacts for all other situations should be managed as part of care management and not as a specialist assessment.
9.4 When Learning Disability Services request a specialist assessment from an Adult Services worker (normally an OT), this will only be undertaken if the Learning Disability client's CareFirst record is accurate and up-to-date. See Appendix G for details.
10. Sensory Services
10.1 Due to the number of specialist sensory workers within Devon, where existing service users contact Social Services and the sole outcome is the need for a specialist sensory assessment, it has been agreed that the sensory service will not undertake the review function as part of the reassessment unless the sensory workers are operating in a personal care management role. Separate guidance will be issued for sensory assessments.
11. CareFirst
11.1 All changes must be recorded on CareFirst by either the review care manager or Business Resources staff using the agreed process. For input details relating to reviews, see the latest version of CareFirst Guidance Note 036.
12. Performance and Targets
12.1 It is expected that 70% of all planned reviews will be undertaken using the Desk Top approach and 30% using the Face to Face approach.
12.2 It is expected that, on average, care management staff will take:
- Up to one hour to complete a Desk Top review.
- Up to three hours to complete a Face to Face review.
12.3 As part of the Locality Action Plans (see Appendix F), Operations and Practice Managers are responsible for setting and achieving the following targets, based on the performance management information about reviews in the Locality:
- The number of reviews per WTE review care manager per month.
- The number of reviews per locality per month.
- The number of Face to Face reviews.
12.4..Using the agreed reports from CareFirst, the following Adult Service Division information will be available on a quarterly basis:
- % of overdue reviews per division / locality / team / individual.
- % of reviews per division / locality / team / individual that are:
- Undertaken using the Desk Top approach.
- Undertaken using the Face to Face approach.
- % of Desk Top reviews per division / locality / team / individual that result in a Face to Face review.
- Adult Services Division / locality / team performance against PAF D40.
12.5 Desktop Reviews (when completed by post) will be completed within 20 working days of being sent.
12.6 Reviews must be undertaken at least annually.
12.7 Service users and carers will be notified in writing of the outcome of the review within 15 days of the completion of the review.
12.8 This information will be reported to Locality Managers on a quarterly basis as part of the normal management information reporting process.
13. Accountability
13.1 The Locality Managers have overall responsibility for ensuring all Locality staff follow this process and that targets are achieved and linked to management of performance. In addition, they must agree the Locality Action Plan.
13.2 Operations Managers are responsible for:
- Ensuring the review process is in place within the Locality, is consistently applied and understood by managers and staff by means of the Locality Action Plan. The Action Plan must be regularly monitored, updated, actioned and communicated.
- Ensuring reviews are prioritised alongside other care management activity in the Locality and that review care management time is ring fenced at the appropriate level for this purpose
13.3 Practice Managers are responsible for:
- Contributing to the Locality Action Plan for implementation of the review approach.
- Monitoring team performance against county wide agreed standards and targets using the agreed reports from CareFirst.
- Communicating team performance to team members.
- Taking action to ensure targets are achieved.
- Ensuring the efficient and effective use of resources.
- Ensuring clear process to manage concerns about individual care management team members' performance.
- The application of the review process by the staff they manage.
- The quality of review practice. This includes information gathering, analysis and decision making, applying FACS, and the involvement of service users / carers / service providers.
- Decision making about the need for Face to Face reviews (either planned or as part of a reassessment).
- Accuracy and timeliness of recording.
13.4 Care Management staff (Referral Co-ordinators, review care managers, Help Desk and Personal Care management staff) are responsible for:
- Undertaking quality reviews using the agreed county wide process, including information gathering, analysis and decision making.
- Working in partnership with the service user, carer, providers and other agency staff to inform the review outcome and communicate the decisions to all parties.
- Adequate information gathering to enable informed decision making using the agreed tools.
- The robust application of FACS to ensure the most efficient and effective use of resources and evidencing this on an SS14.
- Achieving the agreed standards and targets using the agreed reports from CareFirst.
- Accurate and timely recording, including the completion of an SS3(P).
- Accurate and timely input to CareFirst (where competent).
13.5 Business Resources staff will support the Review Process and in particular are responsible for:
- Contributing to the Locality Action Plan for implementation of the review approach.
- Printing of the CareFirst Due and Overdue Review report (DR6) and passing to the relevant person.
- Maintaining the ‘Desktop Review Tracking’ spreadsheet until a CareFirst procedure can be implemented.
- Sending the Your Review form (SS3), the SAP Current Services and Treatment form (SAP4 - when available) to the service user / carer together with relevant leaflets, for example, carers leaflet, direct payments leaflet to support the Review Process.
- Chasing any non-returns to support the Review Process.
- Collating relevant paperwork for the care management staff.
- The accurate and timely input of information to CareFirst, as appropriate.
- Ensuring that paper copies are placed on file, as appropriate.
- Sending out appropriate forms and letters on completion of the review.
13.6 Service Providers are responsible for:
- Notifying Social Services of any significant changes to a person's situation or health to ensure efficient and effective use of resources.
- Advising where services are no longer required or where the service user may not meet the FACS eligibility criteria.
- Contributing to the review process using the relevant tools.
- Accurate and timely completion of the Service Provider Review Details form (SS3(SP)).
- Returning the SS3(SP) form to Social Services within two weeks of receipt.
- Working in partnership with the service user, carer, and care management staff to inform the review outcome.
Appendix A - Desk Top Planned Review Process 
(25KB - pdf help)
Appendix B - Indicators for Different Types of Review (23KB - pdf help)
Appendix C - Review Process (18KB - pdf help)
Appendiix D - Draft Process for Joint Reviews for Nursing Placements within Localities (18KB - pdf help)
Appendix E - CPA and Revised Review Process (24KB - pdf help)
Appendix F - Issues to consider for Locality Review Action Plans (24KB - pdf help)
Appendix G - Specialist Assessments for Learning Disability Services Clients (23KB - pdf help)
Four flowcharts, two detailing aspects of the review process from a practice decision view point, and two taking a more process orientated overview.
- Practice Decisions Flowchart - Desktop or Face-to-Face (18KB - pdf help)
- Practice Decisions Flowchart - Monitoring and Re-Contact (24KB - pdf help)
- Planned Review Flowchart (15KB - pdf help)
- Re-Contact Flowchart (24KB - pdf help)
Eight examples of pre-completed SS3(P)s, plus notes to explain and accompany these. These pre-completed SS3(P)s represent how the forms should be completed for common scenarios, four of which are planned reviews and four of which are unplanned reviews. These are examples only. It would be impossible to try and map a completed SS3(P) for every possible scenario. Hopefully we have chosen the most common situations.
This is the list of the eight examples
These are the eight pre-completed SS3(P)s. Please print these back-to-back, otherwise you will not be able to match the fronts with the backs!
