Table 3 Educational needs assessment matrix
From: Designing a complex intervention for dementia case management in primary care
Tasks | Competencies required | Risks to avoid | Tools required |
|---|---|---|---|
Identify PWD from practice list | Knowledge of local IT systems or links with practice staff with such knowledge | ||
Review medical records of PWD +/- carer, noting any gaps and involvement of other possible support systems | Interpretation of medical and nursing records, and knowledge of local dementia services | Checklist or data extraction form | |
Liaise with other professionals who know the PWD to learn their perspectives on individual or family needs | Knowledge of local services and agencies | Accept professional assumptions about PWD and carer needs, too readily | |
Engage with PWD +/- carer to identify their main concerns or unmet needs , update or fill in gaps in medical records | Communication skills, particularly with difficult topics (diagnosis itself, prognosis, BPSD, continence, anxiety) | Stigmatisation | Semi-structured conversation schedule? |
Person-centred (respects autonomy), non-judgemental | Duplicating assessments | Accurate information | |
Triggering fears (inspection, judgement, loss of control, interference) | |||
Mapping support available to and wanted by PWD & carer. Analyse information obtained with PWD & carer, | Analysis and recording, and knowledge of local resources. System-building, increasing efficiency | Antagonising existing carers and support workers | Matrix of available support and current needs |
Awareness of confidentiality, family dynamics, adult safeguarding, sensitivity of financial issues, taboos (continence) | Just signposting – must act and do | ||
Analyse information obtained with other relevant practitioners (e.g.GP, social worker, care home key worker) | Dialogue, shared decision-making, interagency communication, ability to seek agreements on data sharing | ||
Function as ‘connective tissue’ | |||
Prioritisation: assess need for action in terms of ‘intensive’, ‘maintenance’ and ‘holding’(for those already being case managed by other agencies) | Decision making, recording skills, risk assessment, prioritisation | Create work for others | Definitions of intensive, maintenance & holding |
Promoting problem-solving by PWD & carers | |||
Health maintenance & promotion skills | |||
Create a personal care or support plan with PWD & carer, and initiate actions (see JD for examples) | Problem-solving approach | Promising more than can be delivered | Care plan proforma? Agreed by all stakeholders? |
Verbal and written communication skills, negotiation | |||
Organise systematic follow-up to review outcomes of actions | Organisational skills, use of electronic reminder systems | Duplicating others’ work, not fitting into current local plans for service changes | |
Tapering down involvement if needs reduced, stepping up when necessary |