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Chapter 4: Assessment

What is Assessment?

The purpose of assessment is to identify the needs and aspirations of the individual in order to inform decisions about treatment, care and support for drug or alcohol users. It usually takes the form of one-to-one discussions between the staff member and the individual. If the assessment process is working effectively, the individual should be a full participant and understand and agree the goals of treatment, care and support.

Effective assessment is an ongoing process, not a one-off event. It seeks to identify the range and level of needs of the individual, not only drug or alcohol misuse problems but also health, social and economic circumstances. It explores the individual's attributes and aspirations. The outcome should be informed decisions about treatment, care and support that are regularly reviewed and revised as necessary. Ongoing assessment helps both service users and service providers to measure progress against agreed goals and supports transition to another type of service when appropriate.

As a result of the assessment process, the individual should understand the purpose of assessment and:

• know where he/she is going and why
• receive the 'right' services
• know how and when progress is being made

The Rationale: Why is Assessment Important?

An effective assessment process is at the core of effective service delivery and co-ordination. Assessment is the key to establishing with the individual as complete a picture as possible of their needs and their state of readiness to change in order to provide the most appropriate service/s likely to promote a positive outcome. Without this information, the individual may be referred to a service that does not match their needs and aspirations, leading to disillusion and drop-out from services.

The Wider Context

In the wider health and social care arena, there is an increasing emphasis on broader assessment to encompass the wide range of health and social needs of individuals. For example, the World Health Organisation ( WHO) defines it as:

"(Assessment is) a process designed to reach a thorough understanding of a person's problems in the overall context of his or her life with the object of developing a treatment plan that stands the best chance of being helpful."

Parental Substance Misuse

Since 2002 and the publication of Getting Our Priorities Right (Scottish Executive) there has been an increase in awareness and action regarding drug and alcohol misusing parents. This has required substance misuse services to develop closer working relationships and communication with a range of services, some of which were previously unfamiliar in terms of joint working.

The issue of parental substance misuse must be monitored throughout the client's treatment journey, and continual risk assessment is a multi-agency responsibility. In keeping with the person-centred ethos of Integrated Care, all decisions made about how best to support drug-using parents and safeguard the needs of their children should be discussed openly with the client, raising issues of concern and offering support at the earliest opportunity.

A range of guidance documents are now available providing practical guidance and information for practitioners including:

• Getting Our Priorities Right (Scottish Executive, 2002)
• For Scotland's Children: Better Integrated Children's Services (Scottish Executive, 2001)
• It's Everyone's Job To Make Sure I'm Alright - Report of the Child Protection and Audit Review (Scottish Executive, 2002)
• The Caleb Ness Inquiry Report (Edinburgh and Lothians Child Protection Committee, 2003)
• The Charter for Children and Standards Framework (Scottish Executive, 2004)
• Hidden Harm: Responding to the Needs of Children of Problem Drug Misusers (Advisory Council on the Misuse of Drugs, 2003)

Carers Assessment

The Carers (Recognition and Services) Act 1995 was introduced to cover the assessment of the ability of carers to provide care. It was the first time that legislation had attempted to specifically address the needs of carers and the first steps towards defining the rights for carers.

Its key purpose was to provide legal recognition of carers and to support carers through the community care assessment process. Carers were able to request an assessment for themselves, within the assessment process for the service user.

The purpose of a carer's assessment is for them to discuss with the social work department what help they need with caring, as well as any help that would maintain their own health and achieve a balance between caring and other aspects of their life, such as work and family commitments.In addition to examining the support they may need to look after someone, the assessment can be useful to:

• Explore with a professional (someone who is not part of the family or close to them) how the carer feels about caring.
• Provide them with information on benefits and support, such as carers groups.
• Explore whether they want to stay in work or return to work and how to make this happen.
• Look at how caring may affect them in the future and what help they might need.
  (Adapted from Carers Scotland: Your guide to a carer's assessment available at http://www.carerscotland.org/Information/Helpwithcaring/Carersassessmentguide)

The Carers (Recognition and Services) Act 1995 can be found at www.opsi.gov.uk/acts/acts1995a.htm

The Assessment Process

The development of an effective assessment process at local level for people with drug or alcohol misuse problems will take place within the wider context of Joint Future and specifically, SSA. In this chapter, we set out key areas to be addressed, and principles and elements of effective practice identified from the evidence collected.

Levels of Assessment

Drug or alcohol users frequently come into contact with a wide range of agencies at different stages in their treatment or recovery. A drug or alcohol user may, for example, present at a Housing Department, Employment Service or Benefits Agency. In those settings, the opportunity to identify the nature and extent of a drug or alcohol problem is probably limited. This can lead to frustration and disappointment when a first contact is followed by an in-depth, lengthy assessment. During the course of treatment, a referral to a specific service may lead to a more detailed assessment. In line with Joint Future guidance, three levels of assessment may be appropriate:

• simple assessment (or screening)
• comprehensive assessment
• specialist (or in-depth) assessment

The Models of Care for Treatment of Adult Drug Misusers: Update 2006 (National Treatment Agency for Substance Misuse, 2006) highlighted that the three levels of assessment (screening, triage and comprehensive assessment), outlined in the original Models of Care Report published in 2002, have been found to be 'meaningful and useful'.

The guidance on both drug and alcohol services suggests that it may be appropriate to capitalise on the opportunity of a first contact by conducting a simple assessment (or screening) to ensure an appropriate referral is made. This first level assessment could be described as the 'gateway' into a process of care. It should be a helpful, non-threatening experience designed to encourage the individual to engage in a more in-depth exercise and ultimately promote the development of a therapeutic relationship. The data collected at this stage is likely to be relatively basic, probably socio-demographic information, perhaps cursory information about their drug or alcohol use and its likely impact on the individual's ability to access services. Simple assessment could allow access to low level services, e.g. harm reduction advice and information. In addition, it may involve an element of brief opportunistic intervention with the intention of engaging or preparing individuals for treatment.

Comprehensive assessment may be used in health and social care settings when the individual has made a direct approach or has been referred by another agency. This assessment could cover more detailed information on drug or alcohol use and other factors such as housing, employment, health and benefits. This assessment should allow some decisions about treatment, care and support to be made, or whether it is appropriate to refer an individual elsewhere.

The Models of Care Update 2006 report highlights that a comprehensive assessment may be carried out by more than one member of a multi-disciplinary team in order to assess different areas of client need. It also recommends that a full risk assessment be conducted. In addition, it stipulates that comprehensive assessment is an ongoing process and lists the following situations in which it should be undertaken:

• An individual requires structured and/or intensive intervention.
• An individual has considerable psychiatric and/or physical co-morbidity.
• An individual presents a significant level of harm to self or others.
• An individual has contact with multiple service providers.
• An individual has a history of disengagement from treatment services.
• An individual is pregnant or has children 'at risk'.

Specialist (in-depth) assessment may be appropriate when a client has been referred to a specialist agency, or has moved on from entry-level assessment. This assessment would cover in detail the nature and extent of drug or alcohol use, physical and psychological health, personal and social skills, social and economic circumstances, previous treatment episodes and assets and attributes of the individual.

What should it cover?

SSA was designed to be a layered process, building on existing information in a structured way that makes it appropriate to the individual's need at the time. Certain information should be collected at each stage of this three-tiered assessment process. These are described by Joint Future as core data sets; Personal Information core data set and Assessed Need core data set. Details of the content of these are set out in Annex 1.

Simple assessment should cover:

The 21 items included in the Personal Information core data set.

Comprehensive assessment should cover:

The 12 sub-headings listed under the Assessed Need core data set, including detailed assessment of:

• Presenting problem
• Primary drug profile
• Secondary drug profile
• Injecting behaviour
• Signs and symptoms of oversedation or withdrawal
• Risk to self or others, including dependent children

Specialist assessment should cover

Detailed assessment of all data items included under the 12 sub-headings of the Assessed Need core data set.

Who can assess?

The Joint Future Unit ( JFU) has produced a useful breakdown of who could undertake an assessment within the three levels. This could be adapted by ADATs and partner agencies at a local level.

There are some aspects of the role of assessors within the different levels of assessment to consider:

• what kind of referral they can make
• whether they have any decision-making powers in relation to treatment and care
• whether they have any authority to commit resources

The Models of Care Update 2006 document also highlights the importance of practitioners only carrying out assessments in accordance with their qualifications and competence, and the need to use the expertise of colleagues when necessary.

Recent Updates

Since the publication of the original Integrated Care document and Joint Future guidance, a number of subsequent reports had provided additional evidence and advice on this topic.

Effective Interventions Unit: Young People with, or at Risk of Developing, Problematic Substance Misuse: A Guide to Assessment

The Guide to Assessment report ( EIU, 2004) for young people with, or at risk of developing, problematic substance misuse emphasises that one of the most important elements of effective assessment is the sharing of information with young people and with other individuals involved in their assessment. It stipulates that this is a vital area for action in order to ensure that the assessment process is effective for young people, and that it leads to appropriate and relevant treatment, care and support.

Some of the main problems with services identified by young service users in For Scotland's Children: Better Integrated Children's Services (Scottish Executive, 2001) included the ' need to repeat the same information to each agency', ' the absence of mutual awareness among service providers' and ' services pulling in different directions'. While the problems identified by service providers were their ' failure to communicate, co-operate or work together'. These findings were supported by the results of consultations with practitioners which formed part of the evidence base for the Guide to Assessment ( EIU, 2004), which also identified multiple assessment and poor information sharing as a considerable problem for young people and agencies.

Delivering for Mental Health

The recommendation made in the draft report of Delivering for Mental Health (Scottish Executive, 2006) in Section 9: Screening and Identification is as follows:

' All substance misuse and mental health agencies should have assessment processes which identify co-morbidity systematically to match care appropriate to level of need.'

This document highlighted several screening and identification tools that should be used in different situations by staff at all levels and in all settings, stipulating that they are reliable

and have been validated in identifying substance misuse and mental health problems. The table below shows the tool to be used according to each situation.

Further information about these tools can be found in Closing the Gaps - Making a Difference: Commitment 13 available at http://www.scotland.gov.uk/Publications/2007/12/10141643/18.

The report emphasises that, when properly applied, these tools can identify when further specialist assessment by qualified and trained staff is necessary. It also mentions that, because different agencies have different referral policies, it is important to ensure that clients remain in contact with the original agency until clear transfer arrangements have been made.

In addition, this report highlighted the central role of Primary Health Care teams in identification, care co-ordination and treatment, and emphasises the need to develop this role through engagement and support.

Key Principles and Elements of Effective Practice: Assessment

1. Working with the individual

Service users and their carer should be, and feel that they are, central to the assessment and identification of their needs. Service providers should ensure that they have clear processes for planning and conducting formal assessments at pre-determined intervals and that the service user and their carer are provided with adequate notice and detail of these processes. The principles of these are set out below.

An effective assessment process focuses on the individual. It should be:

• needs-led, not service-led, resource-led or unnecessarily time-consuming
• ongoing, not a one-off event
• part of the overall care process

An effective assessment process should encompass:

• the gathering of information about the type and level of needs, attributes and aspirations of the individual
• the development of a profile of the individual
• communication of the assessment outcome to appropriate providers
• an action plan, agreed with the individual and other agencies as necessary that identifies appropriate goals and the services likely to meet the assessed needs
• regular review and monitoring with reassessment at agreed intervals

The assessment process should cover the current position and highlight any changes in an individual's circumstances and needs. This commonly includes collecting information on personal, family and social circumstances, physical and psychological health, offending behaviour and injecting-related risk behaviour for drug using clients. It should also cover:

• clients' goals
• clients' expectations
• strengths
• support

The process should have a clear time frame. The service user needs to be aware of the proposed length of time involved to complete the assessment process as this appears to have an impact on level of motivation and retention in treatment.

Effective assessment requires the full involvement and participation of the individual at every stage, as far as possible, through:

• The development of a two-way dialogue to ensure that the individual understands the purpose of the assessment and that the assessor has fully understood the information offered by the individual. From the staff's perspective, it is crucial that they are satisfied that they understand the service user's own perceptions about their needs and problems.
• Encouraging ownership by the individual: for example, by the use of tools that support self-assessment. The individual should have at least an equal share in the process and the outcome. There should also be an opportunity to record disagreement and agreements.
• Openness to ensure that the individual knows: who is involved in the assessment; what issues are being discussed and by whom; what judgement is being made about the type; and level of their needs.

Service users should be able to participate at every stage if they wish. As well as being an active participant in the assessment process, it should also be made clear that they have a role in setting the agenda for consultations and feel that assessment is something that is done with them not to them.

Staff should be trained in the agreed skills and competencies to be able to build a trusting relationship with the individual and carry out assessment effectively. As far as possible, training should be multi-agency. This training should emphasise the therapeutic value of assessment as an intervention in its own right, increasing self-awareness, self-efficacy and motivation to change. Assessment is much more than a data collection process.

2. Assessment practice and procedures

Drug or alcohol users come into contact with a wide range of services at different stages of their treatment, care and support. It may be pragmatic to have different levels of assessment to meet the presenting needs of the client; to reduce the risk of over-long initial assessments; and to make the most effective use of time and resources.

Assessment tools can help to guide and structure discussion between staff and individuals. Such tools commonly collect information on the individual's drug or alcohol use, risk behaviour and health, social and economic circumstances. There is a need for tools that are tried and tested and fit for purpose. Careful consideration should be given to deciding whether an appropriate tool already exists and could be used with no or minor modification for the task in hand.

Self-reporting and collateral reporting are important and vital sources of information in assessing the impact of substance misuse on an individual.

3. Working with other agencies

Agencies should agree the core information that they are willing to transfer to ensure a smooth transition for the drug or alcohol user and reduce duplication. Guidance on informed client consent will need to be observed. There should also be agreement about the sharing of more detailed information from a third-level or service specific assessment. There may be particular concerns about information sharing in rural areas where communities are smaller and closer.

The ADAT, working with agencies, should draw up clear, strict protocols to support information sharing between agencies, as well as guidance on information sharing for clients.

4. From assessment to planning and delivery of care

Based on the assessment, an Action Plan should be developed with the individual. This Action Plan should be produced after discussion and agreement between the individual and staff who have worked with him/her. Where possible, it should include service providers who are able to provide the appropriate treatment, care and support. It should draw on the outcome of assessment tool(s), self-assessment by the individual, and the judgement of staff.

The Action Plan should recognise the needs, attributes and aspirations of the individual. It should offer a systematic way of supporting the individual to make progress towards agreed goals at a pace suitable for him/her and enable provider(s) to design and deliver the appropriate treatment, care and support 'package'.

Outline Framework for an Assessment Process for Drug or Alcohol Users

While this framework covers some of the ground already set out in the main body of the chapter, its aim is to provide more detail on the key principles and components of the assessment process.

Principles of Assessment

• It must be open.
• It must be fair and accurate.
• It must be focused on the individual and not designed to accommodate the organisational structures or administrative practices of an agency.
• It must respect confidentiality.
• It must encourage full participation and ownership by the individual.
• It must aid progression.

It should also:

• Be continuous but not repetitive.
• Be given adequate time and care.
• Be carried out by competent and well-trained staff.
• Be designed to allow the transfer of accurate, relevant and up-to-date information.

The objectives of the assessment process:

• Identification of the type and level of need and the attributes and aspirations of the individual.
• Agreement jointly with the individual, and other service providers as appropriate, of an action plan for treatment, care and support.
• Agreed goals and arrangements for review and reassessment.
• Communication of the outcome of the assessment process to the appropriate providers and the arrangement of matching provision.

The elements of the assessment process:

• The assessment exercise.
• The profile.
• The action plan.

An assessment should be carried out:

• At initial contact.
• Regularly - but not too often.
• At every transition between services.
• After critical events.

What should it cover?

Simple assessment should cover:

The 21 items included in the Personal Information core data set.

Comprehensive assessment should cover:

The 12 sub-headings listed under the Assessed Need core data set, including detailed assessment of:

• Presenting problem.
• Primary drug or alcohol profile.
• Secondary drug or alcohol profile.
• Injecting behaviour.
• Signs and symptoms of oversedation or withdrawal
• Risk to self or others, including dependent children

Specialist assessment should cover:

Detailed assessment of all data items included under the 12-sub headings of the Assessed Need core data set.

Outcome of the Assessment

(a) The Profile

From the assessment process, a profile of the individual could be created to cover:

• The type and level of needs, drug or alcohol treatment, social support, life skills.
• Particular circumstances, e.g. family problems, emotional and behavioural problems, debt, which are likely to create barriers to progress.
• The individual's aspirations and attributes, with particular attention to positive experiences in the past.
• Goals - short-term and longer-term.

(b) Action Plan

The Action Plan draws together the outcomes of the various stages of the assessment process. It should be produced after discussion between the individual and staff who have worked with him/her and, where possible, the service providers who are able to provide treatment, care and support. It should draw on the outcome of assessment tool(s); self-assessment by the individual; the judgement of staff; and the profile.

The Action Plan should recognise the needs, attributes and aspirations of the individual. It should offer a systematic way of supporting the individual to make progress towards agreed goals at a pace suitable for him/her and enable service provider(s) to design and deliver the appropriate treatment, care and support 'package'.

The action plan should specify:

• The goals.
• The agreed treatment approach for drug or alcohol use and the service provider.
• The actions to address other problems, e.g. housing, family support, offending behaviour, personal and social skills, education and training needs.
• What the key tasks are for each party and how they will be reviewed and assessed.
• What will constitute progress and how it will be measured?
• Dates for reviewing progress, who will be involved and the format.
• The main contact.

(c) Ongoing assessment and review

This should cover progress made by the individual towards goals including:

• Improvements in health.
• Improvements in family and social functioning.
• Reducing criminal behaviour.
• Reducing drug or alcohol use.
• Improvements in self esteem and motivation.
• Movement towards employability.

The individual should be offered the opportunity for self-assessment where possible as well as taking into account the use of assessment tools and professional judgement.

A planned review should take place at regular intervals to ensure that the care plan is revised to take account of changing needs and circumstances and that service providers are meeting needs appropriately and the agreed quality standards.

(d) Training

Staff should have access to regular training in the competencies appropriate to the level of assessment that they are engaged in. There should be opportunities for multi-disciplinary training at national and local level to support the development of joint working and information sharing.

(e) Supervision and governance

Services providers should operate systems of governance that ensure that clients continue to receive the right services to meet their needs. This would include regular supervision of staff and case record audit, as well as service-user consultation and satisfaction questionnaires wherever practicable. The NTA published guidance on Supervision and Appraisal in July 2004 that sets out general principles of good practice in these areas. http://www.nta.nhs.uk/publications/documents/nta_supervision_and_appraisal_2004_ddsp6.pdf

Actions Points: Assessment

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