Recommendations

1.1.1

Health and social care practitioners should consider referring older people with multiple long-term conditions to the local authority for a needs assessment as soon as it is identified that they may need social care and support.

1.1.2

Consider referral for a specialist clinical assessment by a geriatrician or old‑age psychiatrist to guide social care planning for older people with social care needs and multiple long‑term conditions:

whose social care needs are likely to increase to the point where they are assessed as having a significant impact on the person's wellbeing
who may need to go into a nursing or care home.

1.1.3

When planning and undertaking assessments for older people with social care needs and multiple long‑term conditions, health and social care practitioners should:

always involve the person and, if appropriate, their carer
take into account the person's strengths, needs and preferences
involve the relevant practitioners to address all of the person's needs, including their medical, psychological, emotional, social, personal, sexual, spiritual and cultural needs; sight, hearing and communication needs; and accommodation and environmental care needs
ensure that if a person and their carer cannot attend an assessment meeting, they have the opportunity to be involved in another way, for example in a separate meeting or through an advocate (this is in addition to the statutory requirement for advocacy set out in the Care Act 2014)
give people information about the services available to them, their cost and how they can be paid for.

1.1.4

Advise carers of older people with social care needs and multiple long‑term conditions about their right to a carer assessment, and assessment for respite care and other support (see the NICE guideline on supporting adult carers for recommendations on identifying, assessing and meeting the caring, physical and mental health needs of carers).

1.1.5

Recognise that many older people with social care needs and multiple long‑term conditions are also carers, but may not see themselves as such. Ask the person if they have caring responsibilities and, if so, ensure they are offered a carer's assessment (see the NICE guideline on supporting adult carers).

1.2 Care planning

Coordinating care

1.2.1

Ensure that older people with social care needs and multiple long‑term conditions have a single, named care coordinator who acts as their first point of contact. Working within local arrangements, the named care coordinator should:

play a lead role in the assessment process
liaise and work with all health and social care services, including those provided by the voluntary and community sector
ensure referrals are made and are actioned appropriately.

1.2.2

Offer the person the opportunity to:

be involved in planning their care and support
have a summary of their life story included in their care plan
prioritise the support they need, recognising that people want to do different things with their lives at different times, and that the way that people's long‑term conditions affect them can change over time.

1.2.3

Ensure the person, their carers or advocate and the care practitioners jointly own the care plan, sign it to indicate they agree with it and are given a copy.

1.2.4

Review and update care plans regularly and at least annually (in line with the Care Act 2014) to recognise the changing needs associated with multiple long‑term conditions. Record the results of the review in the care plan, along with any changes made.

Planning care collaboratively

1.2.5

Ensure care plans are tailored to each person, giving them choice and control and recognising the inter‑related nature of multiple long‑term conditions. Offer the person the opportunity to:

address a range of needs including medical, psychological, emotional, social, personal, sexual, spiritual and cultural needs, sight, hearing and communication needs and environmental care needs
address palliative and end‑of‑life needs
identify health problems, including continence needs and chronic pain and skin integrity, if appropriate, and the support needed to minimise their impact
identify the help they need to look after their own care and support, manage their conditions, take part in preferred activities, hobbies and interests, and make contact with relevant support services (see the section on delivering care)
include leisure and social activities outside and inside the home, mobility and transport needs, adaptations to the home and any support needed to use them.

1.2.6

Discuss managing medicines with each person and their carer as part of care planning.

1.2.7

Write any requirements about managing medicines into the care plan including:

the purpose of, and information on, medicines
the importance of dosage and timing and implications of non‑adherence
details of who to contact in the case of any concerns.

For more information on managing medicines, see the NICE guidelines on medicines optimisation and managing medicines in care homes.

1.2.8

Develop care plans in collaboration with GPs and representatives from other agencies that will be providing support to the person in the care planning process.

1.2.9

With the person's agreement, involve their carers or advocate in the planning process. Recognise that carers are important partners in supporting older people with social care needs and multiple long‑term conditions.

1.2.10

Ensure older people with social care needs and multiple long‑term conditions are supported to make use of personal budgets, continuing healthcare budgets, individual service funds and direct payments (where they wish to) by:

giving them and their carers information about different funding mechanisms they could use to manage the budget available to them, and any impact these may have on their carer
supporting them to try out different mechanisms for managing their budget
offering information, advice and support to people who pay for or arrange their own care, as well as to those whose care is publicly funded
offering information about benefits entitlement
ensuring that carers' needs are taken fully into account.

1.2.11

Ensure that care plans enable older people with social care needs and multiple long‑term conditions to participate in different aspects of daily life, as appropriate, including:

self‑care
taking medicines
learning
volunteering
maintaining a home
financial management
employment
socialising with friends
hobbies and interests.

1.2.12

Ensure that care plans include ordinary activities outside the home (whether that is a care home or the person's own home), for example shopping or visiting public spaces. Include activities that:

reduce isolation because this can be particularly acute for older people with social care needs and multiple long‑term conditions (see the section on preventing social isolation)
build people's confidence by involving them in their wider community, as well as with family and friends.

1.3 Supporting carers

1.3.1

In line with the Care Act 2014 local authorities must offer carers an individual assessment of their needs. See the NICE guideline on supporting adult carers for recommendations on identifying, assessing and meeting the caring, physical and mental health needs of carers. Ensure that carer assessment recognises the complex nature of multiple long‑term conditions and their impact on people's wellbeing.

1.3.2

Check what impact the carer's assessment is likely to have on the person's care plan.

1.3.3

Support carers of older people with social care needs and multiple long-term conditions to explore the possible benefits of personal budgets and direct payments, and how they might be used for themselves and for the person they care for. Offer the carer help to administer their budget so that their ability to support the person's care or their own health problems are not undermined by anxiety about managing the process.

1.3.4

For recommendations on helping carers to access support services and interventions, including carer breaks, see the NICE guideline on supporting adult carers.

1.4.1

Build into service specifications and contracts the need:

to direct older people with social care needs and multiple long‑term conditions to different services as needed
for seamless referrals between practitioners, including the appropriate sharing of information
to make links with appropriate professionals, for example geriatricians in acute care settings.

1.4.2

Ensure there is community‑based multidisciplinary support for older people with social care needs and multiple long‑term conditions, recognising the progressive nature of many conditions. The health and social care practitioners involved in the team might include, for example, a community pharmacist, physiotherapist or occupational therapist, a mental health social worker or psychiatrist, and a community‑based services liaison worker.

1.4.3

Health and social care practitioners should inform the named care coordinator if the person has needs that they cannot meet.

1.4.4

Named care coordinators should record any needs the person has that health and social care practitioners cannot meet. Discuss and agree a plan of action to address these needs with the person and their carer.

1.5 Delivering care

Providing support and information

1.5.1

Health and social care providers should ensure that care is person‑centred and that the person is supported in a way that is respectful and promotes dignity and trust.

1.5.2

Named care coordinators should review people's information needs regularly, recognising that people with existing conditions may not take in information when they receive a new diagnosis.

1.5.3

Consider continuing to offer information and support to people and their carers even if they have declined it previously, recognising that long‑term conditions can be changeable or progressive, and people's information needs may change.

1.5.4

Inform people about, and direct them to, advocacy services.

1.5.5

Health and social care practitioners should offer older people with social care needs and multiple long‑term conditions:

opportunities to interact with other people with similar conditions
help to access one‑to‑one or group support, social media and other activities, such as dementia cafés, walking groups and specialist support groups, exercise and dance.

Supporting self‑management

1.5.6

Health and social care practitioners should review recorded information about medicines and therapies regularly and follow up any issues related to managing medicines. This includes making sure information on changes to medicines is made available to relevant agencies.

1.5.7

Social care practitioners should contact the person's healthcare practitioners with any concerns about prescribed medicines.

1.5.8

Social care practitioners should tell the named care coordinator if any prescribed medicines are affecting the person's wellbeing. This could include known side effects or reluctance to take medicines.

1.5.9

Health and social care providers should recognise incontinence as a symptom and ensure people have access to diagnosis and treatment. This should include meeting with a specialist continence nurse.

1.5.10

Health and social care providers should give people information and advice about continence. Make a range of continence products available, paying full attention to people's dignity and treating them with respect.

1.5.11

Health and social care providers should give people information about services that can help them manage their lives. This should be given:

at the first point of contact and when new problems or issues arise
in different formats which should be accessible, including through interpreters (see the section on making information accessible).

Ensuring continuity of care and links with specialist services

1.5.12

Named care coordinators should take responsibility for:

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
engaging local community health and social care services, including those in the voluntary sector
ensuring people and their carers have information about their particular conditions, and how to manage them
knowing where to access specialist knowledge and support, about particular health conditions
involving carers and advocates.

Care in care homes

These recommendations for care home providers are about ensuring that care and support addresses the specific needs of older people with social care needs and multiple long‑term conditions in care homes. For recommendations about delivering care at home, see the NICE guideline on home care.

1.5.13

Identify ways to address particular nutritional and hydration requirements.

1.5.14

Ensure people have a choice of things to eat and drink and varied snacks throughout the day, including outside regular meal times.

1.5.15

Ensure the care home environment and layout are used in a way that encourages social interaction, activity and peer support, as well as providing privacy and personal space.

1.5.16

Ensure people are physically comfortable, for example by allowing them control over the heating in their rooms.

1.5.17

Encourage social contact and provide opportunities for education, entertainment and meaningful occupation by:

making it easier for people to communicate and interact with others, for example by reducing background noise, providing face‑to‑face contact with other people, using accessible signage and lighting
using a range of technologies such as IT platforms and Wi‑Fi, hearing loops and TV listeners
involving the wider community in the life of the care home through befriending schemes and intergenerational projects
offering opportunities for movement.

1.5.18

Build links with local communities, including voluntary and community sector organisations that can support older people with social care needs and multiple long‑term conditions, and encourage interaction between residents and local people of all ages and backgrounds.

1.5.19

Make publicly available information about:

tariffs for self‑funded and publicly‑funded care
what residents are entitled to and whether this could change if their funding status or ability to pay changes.

Make available a statement for each person using services about what their funding pays for.

1.6.1

All practitioners should recognise that social isolation can be a particular problem for older people with social care needs and multiple long‑term conditions.

1.6.2

Health and social care practitioners should support older people with social care needs and multiple long‑term conditions to maintain links with their friends, family and community, and identify if people are lonely or isolated.

1.6.3

Named care coordinators and advocates should provide information to help people who are going to live in a care home to choose the right care home for them, for example one where they have friends or links with the community already.

1.6.4

Health and social care practitioners should give people advice and information about social activities and opportunities that can help them maintain their social contacts, and build new contacts if they wish to.

1.6.5

Consider contracting with voluntary and community sector enterprises and services to help older people with social care needs and multiple long‑term conditions to remain active in their home and engaged in their community, including when people are in care homes.

1.6.6

Voluntary and community sector providers should consider collaborating with local authorities to develop new ways to help people to remain active and engaged in their communities, including when people are in care homes.

1.7.1

Those responsible for contracting and providing care services should ensure health and social care practitioners caring for older people with social care needs and multiple long‑term conditions are assessed as having the necessary training and competencies in managing medicines.

1.7.2

Ensure health and social care practitioners are able to recognise, consider the impact of, and respond to:

common conditions, such as dementia, hearing and sight loss and
common care needs, such as nutrition, hydration, chronic pain, falls and skin integrity and
common support needs, such as dealing with bereavement and end‑of‑life and
deterioration in someone's health or circumstances.

1.7.3

Make provision for more specialist support to be available to people who need it, for example, in response to complex long‑term health conditions, either by training practitioners directly involved in supporting people, or by ensuring partnerships are in place with specialist organisations.

Terms used in this guideline

Local authority needs assessment

The process by which a local authority works with a person to identify their needs and the outcomes they would like to achieve to maintain or improve their wellbeing. The local authority's aim is to determine how it should respond to meet the person's needs.

Multiple long‑term conditions

In this guideline, 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 and stroke. Multiple means a person is living with more than 1 condition. The impact and symptoms of these conditions can fluctuate, and people may or may not need to take medication for their conditions.

Named care coordinator

The named care coordinator is one of the people 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.

Older people with social care needs and multiple long-term conditions

Guidance