Upon the commencement of the client’s care provision, providers should undertake an initial assessment in order to identify their needs and gain baseline data for the person.
The goal of assessment is to gain a multi-dimensional understanding of the client by exploring their medical, physiological, social and psychological functioning. By taking the time to thoroughly examine each aspect of the client’s life, you will be able to identify any issues, minimise risks and maximise their quality of life (VIC DoH 2015).
The Victorian Department of Health has developed a template for conducting a comprehensive assessment of older adults in health and aged care. This assessment includes:
Each of these assessments should be done so comprehensively. Further risk screening and assessments may also be completed during the initial assessment, such as a falls risk, malnutrition risk and pressure injury risk assessment. It is important that each of these areas are also part of the ongoing assessment with the person.
Once care has commenced, the client should continue to be assessed on a regular basis in order to identify any changes in their condition, needs, and goals.
Ongoing Care Discussions
Care providers should have regular conversations with their clients in order to determine the appropriate level of care required for each individual. The goal of these discussions is to:
Help the provider effectively manage the client’s care; and
Ensure the care and services being provided are meeting the client’s needs.
The following topics should be discussed in these conversations:
The client’s resident agreement;
The client’s accommodation agreement;
The client’s extra services agreement (if needed);
The safety and effectiveness of the care services being provided;
Any risks to the client’s health and wellbeing; and
The client’s needs, goals and preferences (including advanced end-of-life planning, if they wish).
The results of these discussions should be documented in the client’s agreements (DoH 2020).
Your organisation may use some of the following documentation in order to maintain information about clients and their needs:
Resident Lifestyle Profile: Includes the necessary information to develop a comprehensive care plan for the client, including their history, background, likes/dislikes, hobbies etc.
Resident Abilities Assessment Form
Resident Unmet Need/Intervention/Strategies Form
Resident Attendance Form
Resident Participation Form: Documents the activities a client has participated in and the level at which they participated.
(Quality Aging n.d.)
Your facility may utilise a ‘resident of the day’ program to assess whether each client’s needs are being appropriately met. Generally, each client would be reviewed at least every month (Quality Aging n.d.).
When assessing a client’s needs, it is important to keep the following in mind:
Understand the client’s perspective;
Consider that older clients may require more time and breaks when completing formal assessments;
Ensure the client’s communication needs are being met and they are provided with assistance if required (e.g. interpreters, hearing aids);
Do not assume the client knows why they are being assessed - explain why certain tests are being undertaken or certain questions asked;
Establish the client’s cognitive status as soon as possible so that the assessment can be conducted accordingly;
Be aware of depressive symptoms (e.g. minimal eye contact, non-committal responses);
Consider any cultural differences and provide support (e.g. cultural liaison officers, First Nations health workers) if required; and
Build rapport with the client.
Applying Clinical Skills
When conducting assessments, it is important to consider the elements of effective clinical decision-making:
Considering the patient’s situation;
Using observation and questions to gather information and cues;
Processing the information (what does it mean?);
Identifying problems and issues (what does the information suggest?);
Establishing goals and deciding what actions should be taken;
Evaluating outcomes; and
Reflecting on the process.
(VIC DoH 2014)
Therapeutic communication involves prioritising the client’s wellbeing by providing them with support and information while maintaining professional distance and objectivity. It comprises a range of techniques, including:
Deliberate silence, which gives both parties an opportunity to process the conversation;
Acceptance (affirming that you are acknowledging what the patient has to say);
Recognising the client’s behaviour rather than complimenting (which may come across as condescending);
Offering time and attention;
Giving broad conversation openings (e.g. ‘What’s on your mind today?’);
Asking for clarification if the client says something ambiguous or unclear;
Placing events in time in order to gain a clearer understanding of the whole picture (e.g. asking when something happened);
Making observations that may help elicit explanations or information from the client (e.g. ‘You look tired’);
Encouraging the client to describe their perceptions;
Summarising what the client has told you and checking to ensure you have understood them correctly;
Encouraging clients to reflect (which may help them think of solutions on their own);
Focusing on certain topics or statements, encouraging the client to discuss them further;
Confronting (disagreeing, challenging assumptions or presenting reality) can be helpful if used correctly, and once trust has been established with the client;
Voicing doubt; and
Offering hope and humour.
(Rivier University 2017)
Practising person-centred care is a key component of the assessment process, as clients should be empowered to actively participate in future planning and decision-making. Clients should be provided with adequate information and opportunities to ask questions so that they can make informed decisions about the direction of their care. Utilising person-centred care improves client satisfaction and the quality of the services delivered (ACSQHC 2019; Better Health Channel 2015).
The ongoing assessment of clients’ needs is an essential component of care, as outlined in the Aged Care Quality Standards. In order to provide an appropriate level of care to all clients, it is important for care providers to work closely with clients to regularly discuss and evaluate whether the services provided are adequate.