Skip to main content

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