Single Shared Assessment Indicator of Relative Need: Operational Guidance Users Handbook

SINGLE SHARED ASSESSMENT - INDICATOR OF RELATIVE NEED
OPERATIONAL GUIDANCE USERS' HANDBOOK

RUM - RESOURCE USE MEASURE OVERVIEW REPORT

This was an article which was produced for the Nuffield Database of Good Practices "Community Care Works". They published this on their website during February 2004. This document outlines the development and early implementation of the RUM and for that reason we have referred to RUM instead of SSA-IoRN throughout.

The Joint Future Unit at the Scottish Executive is charged with the RUM development and implementation. The RUM Project Team with information specialists within the Information and Statistics Division (ISD) of the Common Service Agency (part of NHSScotland) provides us with a progress report on the development and implementation in the first 5 sites, as part of the phased roll out over 2004-06.

Introduction

This article is an overview of the development and early implementation of the Resource Use Measure (RUM). The article will describe some of the achievements made in gaining practitioner and management involvement and buy-in to the RUM process, and discusses some of the identified benefits that are expected to accrue from the RUM in the longer term. The RUM is currently in the early stages of a phased roll out across Scotland in line with the Next Steps Letter, February 2003 requiring RUMs to be completed for older people over 65 years following their Single Shared Assessment (SSA).

As understanding and knowledge of the benefits and application of RUM increases it is hoped that participation and involvement in this exciting and innovative development will extend across Scotland.

Key areas

• Background/Development

• Joint Future Agenda

• Single Shared Assessment

• RUM - What is it?

• Development and early implementation phase

• Completion of the RUM

• SSA implementation process issues

• Wider context

• Ultimate aims and goals

• Review of early implementation

• RUM- operational guidance to support roll-out

• Quality Assurance

• Training

• Using RUM for planning

• Conclusion with snapshot of experiences

Background/Development

RUM for older people had its origin in the recommendations of the Royal Commission on Long Term Care (October 2000). The response by the Scottish Executive to the report of the Royal Commission and the subsequent Chief Nursing Officer's Report published in January 2001, provided the authority for the initial development work. Originally, RUM was conceived as a possible measure of the level of resource use in relation to free nursing care.

However, during the course of the development phase, the initial work to create a robust measurement tool, the emphasis changed from a measure of resource use to a measure of relative need. The outcome is a RUM as a standardised process which "falls out" of the Single Shared Assessment of individual need, with minimal extra effort by the practitioner carrying out a SSA. The RUM provides a summary classification of overall relative need. The RUM will provide a standardised measure of need which practitioners/managers can use to support strategic planning, caseload management and, through time, to record comparisons and trends.

The development of the RUM was led by the Scottish Executive Joint Future Unit in partnership with information specialists within the Information and Statistics Division (ISD) of the Common Service Agency (part of NHS Scotland), and a range of practitioners and managers delivering older peoples services in Scotland.

Joint Future Agenda

The context for RUM is within the Joint Future Agenda which aims to improve people's lives, improve services and improve outcomes. At the heart of the Joint Future Agenda is the service user, who has a right to an assessment of their needs. The outcome of which may result in a range of "seamless services" across agencies which could allow them to remain at home in the community. Within the Social Work Scotland Act 1968 (as amended) by the Community Care and Health Scotland Act 2002, the responsibility for the assessments of need for community care services, lies with the local authority.

Single Shared Assessment

Circular CCD8/2001 on Single Shared Assessment (SSA) reinforced the definition of a SSA as "the subset of community care assessments which must be shared with one or more agency". All 32 partnership areas across Scotland have developed shared assessment frameworks. SSA is the first step for service users towards having their community care needs met. The service user will have a full needs assessment and care plan which will be provided following the SSA process. In terms of care management and review processes, there will be ongoing support provided to the service user.

RUM - What is it?

The RUM is a standard tool that classifies individuals into 9 groups according to their level of relative need. It comprises 12 questions covering 5 characteristics, i.e. activities of daily living, personal care, food and drink preparation, mental well-being and behaviour and bowel management (Section 4). The RUM draws on the information a practitioner will already have gathered from an individual's assessment of need. The practitioner will complete the RUM on completion of the SSA. By drawing on the good quality information on the individual's needs and characteristics identified in the SSA practitioners are readily able to respond to the specific RUM questions. We recommend that the RUM is applied by the lead practitioner following the assessment when sufficient information has been gathered to inform the individual's care plan. It is important to emphasise that the RUM is only applicable to older people over 65 years. The RUM is not a substitute for an assessment of individual need, and it should not influence the individual's care plan.

The 9 RUM groupings range from A (low need) to I (high need). The RUM group is assigned by practitioners scoring their response to the questions contained within the RUM. The RUM group should be re-calculated when there is a review of the SSA, or significant change in the situation requiring a re-assessment. This means the care pathways for the older person which are mapped through the assessment and review process, can also be tracked with a RUM scoring of relative need.

Development and Early Implementation Phase

During the development phase, 2 questionnaires were designed and tested with a range of questions relating to the assessment of need. A single final questionnaire was then developed, tested and subsequently refined into the RUM tool. The development phase lasted just over 2 years, and involved an interactive process with the direct experience of front-line practitioners and their managers, crucial to the final design.

The first phase involved initially 4 partnership areas increasing to 9, in the design and testing of the 2 pre-RUM questionnaires. The testing of the single prototype RUM questionnaire involved 29 teams from 24 partnership areas.

At the end of the completed development phase a detailed RUM project report was prepared and this, along with the recommendations, was presented to and accepted by Ministers in August 2002. The Circular CCD9/2002 confirmed the requirement of all partnership areas to use the Resource Use Measure (RUM) to inform the planning process.

Incremental implementation across Scotland commenced in January 2003 with 5 partnership areas: Orkney, Perth and Kinross, East Renfrewshire, South Lanarkshire and Glasgow.

In September 2003 follow up with the other partnership areas was undertaken in order to establish timescales and targets to achieve full implementation across Scotland in line with the Ministerial decision. Between January to March 2004, briefings are being undertaken with partnership areas to provide an update on the RUM implementation to facilitate roll out plans. It is anticipated full roll out will be achieved by 2006, with partnerships becoming directly involved over the next 2 years.

There is a major exercise to provide updated information from the current implementation process to inform partnerships of the benefits of the RUM. Inevitably there are many misconceptions and concerns about RUM, but it is anticipated that with proper information and understanding, these reservations can be alleviated. Effective communication is vital for this and with information being regularly updated on the JFU website, publication of information within the "Database of Good Practice" and input into a range of forums and networks underway, it is hoped that good progress can be made.

The 12 questions in the RUM tool cover the broad areas of relative need for example in terms of mobility, bowel management. Previously described in earlier paragraph how RUM is scored.

Completion of the RUM

The RUM tool is fundamentally a questionnaire covering the main areas from the assessment of need which results in groupings into relative need. The aim is to integrate the RUM fully within the SSA process. In time, this will be achieved through the development of appropriately integrated IT systems. The practitioner would complete an SSA and the RUM questions would be populated from this data. The ability to achieve this level of sophistication is the challenge ahead for the e-Care developments.

Across the 5 early implementation sites different SSA tools are in use and the RUM tool is both manually and electronically completed.

At present there are 2 main approaches to completing the RUM that can be described.

1. Practitioners fill in the RUM Questionnaire manually following the SSA being completed. This takes approximately 3-5 minutes, and is easily completed following the full needs assessment. The practitioner manually calculates the scores which are added to give the overall RUM grouping. This information is then attached to the SSA record and entered manually on to an Excel spreadsheet for overall comparisons and planning uses at the locality level.

2. SSA and RUM integrated through Carenap application. This has been developed with SEMA Schlumberger and piloted in the Western Isles. This will enable practitioners to complete SSA and RUM as a single sequential process. Similarly the SWiSplus development in South Lanarkshire also has the RUM questionnaire integrated within the SSA process. A range of questions require to be completed, or will move to default and a score of 1 allocated.

The future should be a SSA process with RUM integrated, resulting in a pre-populated RUM calculation. This is the ultimate aim, is beginning to take shape, but will not be available in the short term to assist implementation.

The Issues and Challenges of Implementation

The experience from the 5 implementation sites over the last 12 months has been invaluable. Practitioners and managers continue to be involved in the development and consolidation of the RUM tool. The Learning Network established in June 2003 brought together key people involved from the early implementation sites to share knowledge and address implementation issues. From the experience gained, it is clear that the Learning Network has been a major driving force consolidating SSA and RUM as an integrated process.

The issues which have been addressed at the Learning Network, supported by small task groups and consultation processes, have been wide ranging. Over the last 6 months an Action Plan to support the development and implementation schedule was developed identifying key objectives, targets and timescales for completion. The aim has been to document lessons from early use of the RUM and compile the guidance for operational implementation to assist with roll out plans from April 2004.

Practitioners and managers have continued to raise issues and offer solutions to resolve issues arising from the use of the RUM, with the objective of finalising operational guidance that is relevant and meaningful. The Learning Network has underlined the developing and evolving nature of the process, along with the commitment from the Scottish Executive to continue to listen to the experience from the front line.

SSA Implementation Issues

One major issue, raised consistently during the implementation process, is the direct relationship between the SSA process and the RUM tool. The practitioners and managers involved have confirmed the main concerns is to ensure the SSA process is right. Completion of the RUM tool is relatively straightforward if the SSA process is appropriate.

The issues around RUM implementation have been reflected in the experience of SSA implementation. The 5 early implementation sites have different approaches to SSA. Two partnership areas follow the Scottish Executive's definition of SSA in CCD8/2001 and RUMs are not completed for every older person referred for a needs assessment. Three partnership areas interpret the guidance more widely and use the SSA core documentation for all assessments. Consequently they are completing RUMs for every older person who has an assessment of need.

The guidance on SSA is not prescriptive as to a model and aims to facilitate local needs. The current consultation process on the Joint Performance Information and Assessment Framework (JPIAF) which aims at providing key performance measurements on assessment, has raised similar issues of consistency and standardised definitions for measuring performance. The JPIAF will define how to count SSAs but will not dictate how SSAs should be carried out.

In support of the RUM implementation an investigation was undertaken in terms of the implementation of Direct Access to Services by older people across Scotland. The findings confirmed that variation across partnership areas to RUM implementation was primarily a consequence of different approaches to SSA implementation. In the light of this variation it is as yet unclear how consistent comparable data at national level for comparison purposes can be assured.

Wider Context

Joint Future has moved from theory to delivery over the last year. The Joint Future Implementation and Advisory Group (JFIAG) has set out the expectations for delivery, enhanced by Mr Tom McCabe's (Deputy Minister for Health and Community Care) initiative to "re-invigorate Joint Future", that focuses in particular on moving from process and systems to outcomes for people who use services and their carers. Maintaining the momentum and delivering the results of Joint Future is essential. Achieving the full roll out of RUM, in tandem, to support that agenda is crucial. SSA is the centre of Joint Future. It needs to be effective in its own right; but it also has to dovetail with other key components such as joint resourcing and joint management to deliver speedier access to services and more effective results. Delivering on RUM across 32 partnerships in this complex environment is a challenge, but one that we intend to achieve.

Consequently the aim of the Scottish Executive through the direct work by the RUM Project Team within the Joint Future Unit is to support, encourage and facilitate this harmony. This will be achieved through the co-ordination of the key components of the wider agenda. The SSA and RUM Learning Networks will become a more integrated model, within the broader Joint Future Agenda.

The overall linkages between SSA, RUM, e-Care and Data Standards are also becoming clearer as a result of this work. The consultation process on the RUM-ICADS (Integrated Care Assessment Data Summary) has also highlighted the need for the effective inter-relationship across the major components, which influence and directly bear on the Joint Future Agenda.

RUM-ICADS aims to provide a national dataset which will facilitate local and national planning of services for Older People. The RUM grouping on its own strength does not provide the whole picture of needs. Therefore, the broader context has been set within the RUM-ICADS. Key components include gender, date of birth, carer involvement, service provided, geographical area which has an overall objective in terms of achieving a more standardised approach to data gathering. The e-Care developments for the next stage of the Modernising Government Funding (MGF3) bids requires a consistent data standards model integral to the system. The current work with the RUM-ICADS consultation process, the JPIAF consultation process, SSA experiences and RUM implementation are all informing this broader base.

Ultimate Aims and Goals

Through the development of a RUM-ICADS national dataset, which is informed by a service user's assessment of need and their relative needs grouping (RUM score) there will be an opportunity to map out across Scotland the full needs of older people who have a SSA. Ultimately this information should facilitate service delivery, service design, commissioning and re-development of services to ensure the balance of care is appropriately targeted at the needs of older people.

It is acknowledged RUM is not the only factor in this broader planning and strategic framework, however, it is a crucial and key component. Therefore, the Scottish Executive through requiring partnership areas to implement RUMs at locality level, are ensuring the benefits of the 3 years of development work is maximised.

The RUM Project Team are fully committed to this development and integrated approach. In order to raise the profile on the RUM, its potential, value and uses an approach to promote RUM is being adopted. Further information and details are available on the website ( http://www.scotland.gov.uk/about/HD/CCD2/00017673/Home.aspx ), or through direct contact with the team.

A national conference is being planned for early spring 2004 to promote the Joint Future Agenda, reviewing current progress and the way ahead. RUM is integral to this agenda, and it is hoped, by word of mouth, direct experience, increased awareness and direct evidence of the benefits of RUM will result in the broader participation and involvement of partnership areas within this very stimulating and encouraging piece of work.

Review of Early ImplementationWe have commissioned a study of the experience of the 5 early implementation sites. This work commenced in October 2003 and the final report is due at the end of January 2004. This work will review the processes involved in the implementation of RUM, highlighting the areas of good practice, the problems encountered and how they were dealt with.

An Executive Summary and full report of the research findings will be available through the Scottish Executive publications website ( www.scotland.gov.uk/publications/recent.aspx ).

RUM Operational Guidance to Support Roll Out

We will provide RUM operational guidance to support the roll out and assist implementation generally. The reference and guidance for practitioners and managers will be covering a broad range of issues. The framework to assist implementation will be available in a ringbinder file in order to update and review over the phased roll out 2004-06. The information will be gathered from the experiences of the 5 implementation sites.

Quality Assurance

The quality assurance process incorporated within the operational guidance was devised from the experiences during the implementation process. Local partnership areas will be developing their own QA arrangements across a range of areas. However, in order to ensure the validity and reliability of the RUM data, it is intended to develop a national QA process to monitor and validate the RUM tool throughout implementation and roll out.

The summary report from the QA experience of the 5 implementation sites is already available on the JFU website. This has the experience from the 5 sites detailed and key areas to be considered are reported.

Training

Throughout the process of the RUM roll out and implementation process there has been regular training provided and delivered from the joint Scottish Executive and ISD team. Within the Resource Pack the full briefing and training notes to facilitate roll out plans are included.

It is intended to provide training for local trainers to support the future roll out plans. The experience from 5 implementation sites has confirmed RUM training should be integral with SSA training and delivered at locality level by the partnership areas.

Using RUM for Planning

The uses of RUM as a Planning Tool Initial Scoping Paper, November 2003 was updated for the Learning Network in February 2004. Work is being progressed with each of the 5 implementation sites with the RUM Project Team and ISD to support the localities.

There has been work undertaken across all the areas and examples of using RUM for planning will be provided within the RUM operational guidance. Orkney have been using the RUM data to inform their Older People's Strategy, January 2004. Perth and Kinross have been developing work around direct access to services through the analysis of the RUM data. South Lanarkshire Council is considering the use of RUM data within local teams and practises and council/health partnerships particular interest in planning uses around hospital discharges.

All 5 implementation sites are interested in comparisons of RUM groupings in the community settings and care homes, age groupings and RUM scores, and level of carer input. This work has also been directly related to the RUM-ICADS developments, which will pilot the broader national dataset in the 5 partnership areas from April 2004.

Conclusion

The RUM is an important part of the wider implementation of Joint Future. It is new. It is different; and it has both its admirers and its critics. Its development has been successful due to a combination of commitment at the centre from the Executive and the high level of commitment and support locally from front line operational staff. We thank in particular the practitioners and managers from the early development phase and the current implementation phase for all the hard work. It is to their credit, despite other pressures, competing priorities and often the lack of IT systems (resulting in paper based approaches), that the RUM roll out has progressed. There are many challenges ahead, but we are determined to see RUM as part of the mainstream of community care in Scotland.

This is the view from the Joint Future Unit. What have the implementation sites to say.

Snapshot of Experiences

Perth & Kinross - comments

"The huge benefit to the development of RUM that the Learning Network has had. I am really impressed at the involvement of practitioners on the ground and the way that the Scottish Executive RUM Project Team have taken on board all the issues that they (the practitioners) have raised and actually set time aside and action planned how to address them. This gives staff a real feeling of 'being able to make a difference at a strategic level' as well as encouraging a feeling of ownership of new projects." - Iona Lancaster, January 2004.

Orkney - comments

"We were allowing for 5 minutes to complete a RUM but in practice it takes less than 3 minutes on paper. Doing it on the computer now will be much quicker as the calculations are automatic (and more accurate!).

"We knew that dependency levels at home were growing and care packages were costing more. It was such a relief to be able to evidence that the levels of need were actually commensurate with the needs of people in Care Homes.

"RUMS have helped us evidence the different dependency profiles in our care homes and following the next stage of the pilot we hope it can be used in planning staffing levels for new projects.

"The benefits to us in planning new services is that we can make comparisons between localities to evidence need, we can compare dependency levels with the age profile and we can now record change in dependency levels from our baseline to inform future plans." - Fiona Cowan, January 2004.

South Lanarkshire

"South Lanarkshire Council Partnership implemented RUM in one rural locality and are in the process of rolling out throughout the rest of the partnership area as an integral part of SSA. Social work and health staff were positive about the potential benefits, the score supporting what they knew intuitively especially when seeking and evidencing the need for high care packages. Because within SLC the RUM scoring is integrated into our electronic needs assessment recording system, the implementation went smoothly. Health staff are using the paper score until their own electronic system is ready, but as was anticipated the bulk of RUM scores at this stage are undertaken by Council staff.

For local managers and planners the Quality Assurance exercise highlighted areas within both our Single Shared Assessment processes and our interpretation of definitions that needed fine tuning. The unexpected benefit of RUM implementation was an opportunity to create clearer guidelines and definitions at an early stage. We also have found that staff, so long as the process is kept clear and simple at a time of significant demand on them from other directions, are more than able to embrace the RUM factor and have been keen to contribute both locally and through the RUM Learning Network to the creation of a more robust questionnaire and guidance."

East Renfrewshire

"The RUM Learning Network was a very positive experience involving frontline practitioners. There was a feeling of being actively involved in shaping policy and the RUM tool/voices being heard and comments being included. Informed and informing an inclusive process.

"We derived great benefit from the Scottish Executive's analysis about what we are doing in planning terms. This is a useful partnership for the team and the planning information from RUM will be used to inform local development." - Miriam Jackson, East Renfrewshire.

Glasgow South West

"Response from the team is mixed, and there is more work to be done to progress SSA and RUM integration through an IT solution. There are difficulties with implementation in a larger area and this needs to be recognised and supported. Practitioners need to see the relevance of RUM in terms of their own caseload, in order to take ownership of the process." - Willie Munro, Glasgow South West.

Glasgow North

"In the north of Glasgow it has taken longer to come to terms with SSA and RUM as an integrated process. This has been a long struggle for staff, however staff can now see benefits and are hoping it will have and impact on the services and resources for their clients. Staff are now quite confident using RUM with SSA." - Ian McAlpine, Glasgow North.

The benefits are real, the challenges are strong, but we are fully committed to achieving the Joint Future Unit objectives for improving the services users experience. It is hoped the overview will encourage other practitioners to become involved in this very challenging and stimulating agenda.