3. Pathways and Processes
This theme focuses on the manner by which older people and informal carers enter and leave care processes. It gives examples of the processes that need to be in place to address needs. Pathways and processes go hand-in-hand: a pathway refers in a longitudinal way to the diversity of settings the older person and informal carer will encounter from the moment they enter LTC to the time they leave it. Processes refer to all professional activities that take place in and at the interface of the organisations involved or at the service delivery level.
3.1 Accessing services
At a certain point in their lives, many older people will require care. This is a crucial phase in which the needs of the older person and the informal network are identified to ascertain which needs can be met, to what timescale, in what ways, where and by whom. Examples of how pathways and processes work must include at least one of the following key issues:
- Case finding through routine screening services (eg preventative home visits)
- Transfer of information to users and carers and about users and carers between services or agencies
- The older person’s and carers’ interests and involvement which should consider rights, information, choice, and entitlements
- How services deal with diversity and equality of access, considering culture, gender and class to counter discrimination
- Performance management/indicators that relate to service access
- Ethical guidelines
3.2 Assessing needs
Once in the LTC system, needs must be assessed and then reassessed at regular intervals to identify and provide the correct pathways and processes through LTC to make sure there is a good fit between professional input and needs. Examples must provide a description of how assessment for eligibility of services/benefits as well as within organisational structures is operating and include at least one of the following key issues:
- Multidisciplinary assessment (protocols, tools and instruments)
- Assessment tools and instruments (older peoples’ and/or informal carers’ needs), protocols
- Follow up of needs assessment (transfer of information)
- Older peoples’ and/or informal carers’ rights: information, shared decision making, consent, privacy regulations, complaints, second opinion
- Dealing with diversity (cultural, socio-economic inequalities)
3.3 Discharge, terminating professional contacts
At a certain time contact is terminated or a new care setting is chosen. In many cases the main responsibility of care delivery is transferred to another service or professional; in some cases to the informal care network. In a small number of cases the older person regains independent living. Examples must include at least one of the following key issues:
- How professional and/or informal follow-up is properly communicated, available and well prepared
- How older people's and carers’ rights are ensured (user-friendly information, shared decision making, consent to care, privacy regulations, complaints, second opinion)
- How information (files, care plan) and responsibilities are transferred (logistics issues)
- How information to and dialogue with older people and their informal network are facilitated, and how capacities are enabled and strengthened
- How funding of next stage care and service delivery is ensured
- How outcomes are assessed
3.4 Interdisciplinary work
LTC requires interdisciplinary working, as needs of older people and their informal care networks are usually complex. Often these professionals work in different organisational structures. This raises a number of issues regarding how interdisciplinary and inter-organisational work can best be ensured in order to foster a common understanding of comprehensive pathways. Examples must include a description and evidence of at least one of the following key issues:
- Fostering a culture of collaboration (requirements, training, team building)
- Inter-professional exchange/development/agreement about views on care and pathways
- Transfer of information (joint care plans, registers/files)
- Accountability, responsibilities, dealing with hierarchies and professional-cultural clashes
- New ways of involving older people and/or informal carers
