Having a needs assessment

In order to support older people to live well and as independently as possible, there are times when they will have their needs assessed.

This enables the older person, their family and health care providers to better understand the support that is required, and to ensure the right care and support is in place. Providers from across the Southern health system are committed to helping you, or your members of your family/whanau, maintain health and independence in your community and home.

How do I arrange a needs-based assessment?

Aged care and needs assessment is a district-wide initiative provided by Dunedin, Southland and rural hospitals to older people who need assistance to live comfortably in their own home. Support services are arranged by Te Whatu Ora Southern Care Co-ordination Centre (CCC).

Your doctor, the hospital treating you or another health professional, will send a referral to the Clinical Coordinators at the CCC in Dunedin or you may refer yourself. Phone 0800 627 236 or email SouthernDHBCCC@southerndhb.govt.nz to get in touch with the CCC. Providing your referral meets the eligibility criteria for services, the CCC will forward your referral to the appropriate service in your area for assessment.

This will be either a Te Whatu Ora Southern Needs Assessor or a Home and Community Support Service (HCSS) provider (Access Homehealth, Healthcare NZ, Royal District Nursing Service NZ) who will contact you. The assessments are an opportunity to discuss with you and your family/ whanau the level of support needed and determine any urgent needs. The assessment may take up to two hours.

You are encouraged to have a family/whanau member present with you during the assessment so that your health, disability and other needs can be best understood by the assessor.

What happens during the assessment?

The assessments are carried out by either a Te Whatu Ora Southern Clinical Needs Assessor (CNA) or HCSS Clinical Coordinator (CC). CNAs and CCs are qualified health professionals. They will use a laptop computer during the assessment to record information. CNAs and CCs will work with you and your family/ whanau to identify your health needs and goals.

Your goals will be personal and individual to you and could include managing your pain, being able to prepare a meal, or being able to regularly attend a community social group.

Your Clinical Needs Assessor or Care Coordinator will ensure your Support (Care) Workers have the training they need to help you, which could include assistance with activities such as housework, exercise or showering and dressing (note, this is an example of services not an exclusive list). You will be advised as to what services will be provided.

What happens after your assessment?

There will be ongoing reviews of your care plan to make sure it is appropriately supporting you to live independently and enjoy life.

What support services are available?

Support services are available to people over 65 years who need assistance to live comfortably in their own home. Support services are also available to people needing post-hospital discharge care and palliative care. Residential care is available to those who meet the criteria for this level of care.

These services are available to anyone living in the Te Whatu Ora Southern region. These are some of the health services the Te Whatu Ora Southern can coordinate:

• Domestic assistance (home help) and personal assistance

• Carer support

• Respite care

• Community activities

• Meals on Wheels

• Residential care.

All these support services are provided by organisations within the community and are managed by the Te Whatu Ora Southern.

There are also a range of services available to you through Primary Care/your GP practice, Te Whatu Ora Southern and there many services available in the wider community. Your Needs Assessor or Clinical Coordinator may recommend and refer you to other services with your consent. Examples include:

• Community/District nursing
• Rehabilitation services
• Social work
• Occupational and Physio Therapy
• Falls and fracture prevention services
• Community groups

David and his daughter Ros share their experience of Needs Assessment and community supports in this video below:

There are a large number of services provided by private organisations and community groups available. Here is a link to our community resource book which has a number of these services included:

Your privacy and rights:

Te Whatu Ora Southern acts in accordance with the Health Information Privacy Code 1994 and the Code of Health and Disability Services Consumer Rights.