Complex Care at Home: What to Have Ready Before the Assessment

When a family, case manager or integrated care board starts looking at complex care at home, the first assessment is where everything gets decided. The more prepared you are, the faster a safe, personal care plan can be put in place.

Why the complex care assessment matters

Complex care covers needs that go beyond routine personal care, such as tracheostomy care, ventilation, PEG feeding, epilepsy, spinal injury or an acquired brain injury. Every care plan we write is built around one person, so the assessment needs a full picture of their health, their routine and the people around them. At First Active 365 Homecare, our nurse led team assesses within 48 hours, and there is a nurse behind every care plan.

What to have ready

You do not need a perfect folder. You do need the essentials in one place:

• A current medication list, including doses and timings.
• Recent discharge summaries, care plans or clinical letters.
• A list of equipment already in the home, and who services it.
• Details of any funding route, such as NHS Continuing Healthcare, a personalised health budget or local authority funding.
• Contact details for the GP, community nurses and any specialist teams.

Talk about the day, not just the diagnosis

A diagnosis tells us what someone needs clinically. A normal day tells us what good care looks like. Think about when they wake, how they like to be supported, what they eat, who visits and what makes them laugh. For children and young people, include school, therapy sessions and family routines. Our team wants to hear the small details, because they are usually what makes a placement work.

Questions to ask any complex care provider

• Who will lead the care plan, and are they a registered nurse?
• How are carers trained and signed off for the specific clinical tasks needed?
• What happens if a carer is ill or a shift falls through?
• How often is the plan reviewed, and who do we call out of hours?
• Can you share how you communicate with case managers and families?

What happens after the assessment

Once the assessment is done, the care plan is written and agreed with you, then carers are matched to the person’s needs and personality. Plans are reviewed as needs change, because complex needs rarely stand still.

Talk to us

If you are a case manager, ICB or family member planning complex care at home, we would be glad to help. Call 03333 222 365 or email Bookings@fa365homecare.co.uk.