Stage 2: clinical assessment
Our guidance can help you give advice by highlighting areas to consider and standards of care.
Chronic heart failure in adults: diagnosis and management
1.1.5 People with heart failure should generally be discharged from hospital only when their clinical condition is stable and the management plan is optimised. Timing of discharge should take into account the wishes of the person and their family or carer, and the level of care and support that can be provided in the community.
Multimorbidity: clinical assessment and management
1.3.4 Use an approach to care that takes account of multimorbidity for adults of any age who are prescribed 15 or more regular medicines, because they are likely to be at higher risk of adverse events and drug interactions.
1.3.5 Consider an approach to care that takes account of multimorbidity for adults of any age who: are prescribed 10 to 14 regular medicines,are prescribed fewer than 10 regular medicines but are at particular risk of adverse events.
Falls in older people: assessing risk and prevention
1.1 Preventing falls in older people.
1.1.1 Case/Risk identification.
1.1.1.1 Older people in contact with healthcare professional should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s.
1.1.1.2 Older people reporting a fall or considered at risk should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance.
1.1.2 Multifactorial falls risk assessment.
1.1.2.1 Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a healthcare professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention.
1.1.2.2 Multifactorial assessment may include the following: identification of falls history,assessment of gait, balance and mobility, and muscle weakness, assessment of osteoporosis risk, assessment of the older person's perceived functional ability and fear relating to falling, assessment of visual impairment, assessment of cognitive impairment and neurological examination, assessment of urinary incontinence, assessment of home hazards, cardiovascular examination and medication review.
1.1.6 Home hazard and safety intervention.
1.1.6.1 Older people who have received treatment in hospital following a fall should be offered a home hazard assessment and safety intervention/modifications by a suitably trained healthcare professional. Normally this should be part of discharge planning and be carried out within a timescale agreed by the patient or carer and appropriate members of the health care team.
1.1.6.2 Home hazard assessment is shown to be effective only in conjunction with follow up and intervention, not in isolation.
Patient experience in adult NHS services
1.5 Enabling patients to actively participate in their care.
Intermediate care including reablement
1.1.1 Ensure that intermediate care practitioners: develop goals in a collaborative way that optimises independence and wellbeing adopt a person-centred approach, taking into account cultural differences and preferences.
1.1.2 At all stages of assessment and delivery, ensure good communication between intermediate care practitioners and: other agencies people using the service and their families and carers.
1.1.3 Intermediate care practitioners should: work in partnership with the person to find out what they want to achieve and understand what motivates them to focus on the person's own strengths and help them realise their potential to regain independence build the person's knowledge, skills, resilience and confidence learn to observe and guide and not automatically intervene, even when the person is struggling to perform an activity, such as dressing themselves or preparing a snack support positive risk-taking.
Emergency and acute medical care in over 16s: service delivery and organisation
1.1.5 Provide nurse-led support in the community for people at increased risk of hospital admission or readmission. The nursing team should work with the team providing specialist care.
1.1.6 Provide multidisciplinary intermediate care as an alternative to hospital care to prevent admission and promote early discharge. Ensure the benefits and risks of various types of intermediate care are discussed with the person and their family or carer.
Home care: delivering personal care and practical support to older people living in their own homes
1.1 Ensuring care is person centred.
1.1.1 Ensure services support the aspirations, goals and priorities of each person, rather than providing 'one size fits all' services.
1.1.2 Ensure support focuses on what people can or would like to do to maintain their independence, not only on what they cannot do. Recognise: that people have preferences, aspirations and potential throughout their lives and that people with cognitive impairment and those living alone might be at higher risk of having unmet social care‑related quality of life needs or worse psychological outcomes.