Quality statement 3: Named care coordinator

Quality statement

Older people with multiple long-term conditions and eligible social care needs have a named care coordinator.

Rationale

Having a named care coordinator can help older people with multiple long-term conditions and eligible social care needs to get the help they need from the health and social care system. The care coordinator plays a lead role in the care planning process, and supports older people to obtain the services they need, when they need them. They also ensure that the older person and their carers have the information they need to manage the older person's conditions and plan for the future.

Quality measures

Structure

a) Evidence of local arrangements to ensure that older people with multiple long-term conditions and eligible social care needs have a named care coordinator.

Data source: Local data collection.

b) Evidence of a locally agreed specification of the role and functions of the care coordinator.

Data source: Local data collection.

Process

Proportion of older people with multiple long-term conditions and eligible social care needs who have a named care coordinator.

Numerator – the number in the denominator who have a named care coordinator.

Denominator – the number of older people with multiple long-term conditions and eligible social care needs.

Data source: Local data collection.

Outcome

Satisfaction among older people with multiple long term conditions and eligible social care needs with support to help them manage their long-term health conditions.

Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as local authorities, general practices and community care providers) ensure that older people with multiple long-term conditions and eligible social care needs have a named care coordinator. Providers ensure that staff working with an older person support the role of their care coordinator by contributing to care planning, sharing information about the person and agreeing joint working arrangements.

Health and social care practitioners (such as district nurses, social workers, occupational therapists, GPs and voluntary sector practitioners) ensure that they know who the care coordinator is for an older person with multiple long-term conditions and eligible social care needs, and share information with them. If they are assigned as the care coordinator, they ensure that they carry out the role in accordance with the locally agreed specification.

Commissioners (such as local authorities and clinical commissioning groups) ensure that there is local agreement on the role and responsibilities of a care coordinator, and that all health and social care staff support the care coordinator by contributing to care planning, sharing information and agreeing joint working arrangements.

What the quality statement means for people using services and carers

Older people with more than 1 long-term condition who need social care services should know the name of a person in the team that supports them who is their care coordinator. The care coordinator is the main contact for everyone involved in the older person's care, including their family and carers, and will support them to manage their conditions and live as they choose.

Source guidance

Definitions of terms used in this quality statement

Multiple long-term conditions

A long-term condition is defined as one that generally lasts a year or longer and impacts on a person's life. Examples include arthritis, asthma, cancer, dementia, diabetes, heart disease, mental health conditions, stroke, and hearing and sight loss. Multiple means a person has more than 1 condition. The impact and symptoms of these conditions can fluctuate, and people may or may not need to take medicines for their conditions.

[NICE guideline on older people with social care needs and multiple long-term conditions]

Eligible social care needs

Local authorities have a duty to meet people's social care needs that fulfil the criteria in the Care Act 2014. When determining a person's eligibility for social care, local authorities must consider 3 conditions:

  • Condition 1: The adult's needs for care and support arise from or are related to a physical or mental impairment or illness and are not caused by other circumstantial factors.

  • Condition 2: As a result of the adult's needs, the adult is unable to achieve 2 or more of the following outcomes:

    • managing and maintaining nutrition

    • maintaining personal hygiene

    • managing toilet needs

    • being appropriately clothed

    • being able to make use of the adult's home safely

    • maintaining a habitable home environment

    • developing and maintaining family or other personal relationships

    • accessing and engaging in work, training, education or volunteering

    • making use of necessary facilities or services in the local community, including public transport, and recreational facilities or services

    • carrying out any caring responsibilities the adult has for a child.

  • Condition 3: As a consequence of being unable to achieve these outcomes, there is, or there is likely to be, a significant impact on the adult's wellbeing.

[The Care and Support (Eligibility Criteria) Regulations 2014]

Named care coordinator

The named care coordinator is the person from among the group of workers providing care and support designated to take a coordinating role. This could be, for example, a social worker, practitioner working for a voluntary or community sector organisation, or lead nurse.

The named care coordinator acts as the first point of contact and takes responsibility for:

  • engaging local community health and social care services, including those in the voluntary sector

  • ensuring referrals are made and are actioned appropriately

  • giving people and their carers information about what to do and who to contact in times of crisis, at any time of day or night

  • ensuring an effective response in times of crisis

  • ensuring there is continuity of care with familiar workers, so that wherever possible, personal care and support is carried out by workers known to the person and their family and carers

  • ensuring people and their carers have information about their particular conditions, and how to manage them

  • knowing how to access specialist knowledge and support about particular health conditions

  • involving carers and advocates.

[NICE guideline on older people with social care needs and multiple long-term conditions, glossary and recommendations 1.2.1 and 1.5.12]