Eligibility Criteria for Community Care (Adults) Policy

East Dunbartonshire Health and Social Care Partnership (HSCP) is responsible for determining where there is a need for the provision of community care support and how such need should be met.

Assessment of need is a two-stage process: first the assessment of needs and then, having regard to the results of that assessment, whether the needs of that person call for the provision of support.

The use of eligibility criteria applies to this second stage of the assessment process. They are used to determine whether a person assessed as needing community care requires statutory support to be put in place in order to meet those needs. Eligibility criteria are also used as a means of managing overall demand for community care within the finite resources available.

The purpose of this policy is to establish clarity on how eligibility criteria operate in East Dunbartonshire. The policy also aims to serve as a guide for staff and as a reference document for elected members, customers and members of the public.

This policy should be viewed within the overall context of the Fair Access to Community Care (Adults) Policy.

This policy applies to all service users over the age of 16 but excludes young people over the age of 16 where a designated children’s service continues to be provided. The policy applies to planning for children and young people who are leaving school and will subsequently be subject to the adult community care policy environment.

This policy does not apply to carers, as defined by the Carers (Scotland) Act 2016, for whom a separate Carers Eligibility Criteria Policy applies.

East Dunbartonshire Health and Social Care Partnership’s responsibilities to adults (aged over 16) and older people are set out in the following legislation, policies and operational mechanisms, which are subject to change:

• The Social Work Scotland Act 1968
• The NHS and Community Care Act 1990
• Community Care and Health (Scotland) Act 2002
• Chronically Sick and Disabled Persons Act 1970
• Mental Health (Care and Treatment) (Scotland) Act 2003
• Adults with Incapacity (Scotland) Act 2000
• The Regulation of Care (Scotland) Act 2001
• The Adult Support and Protection (Scotland) Act 2007
• Children (Scotland) Act 1995
• Data Protection Act 2018
• Freedom of Information (Scotland) Act 2002
• The Human Rights Act 1998 and Equality Legislation
• The Social Care (Self Directed Support) (Scotland) Act 2013
• The Equality Act 2010
• The Mental Health (Scotland) Act 2015
• The Carers (Scotland) Act 2016.

• Single Shared Assessment Form/Specialist Assessment Forms
• Outcome Focused Support Plan
• Review of Support Plan
• Assessment and Support Management Procedures
• Risk Enablement and Working with Risk Procedures
• Non Residential Charging Policy
• Fair Access to Community Care (Adults) Policy (2023)
• Eligibility Criteria for Adults and Young Carers Support (2021).

Eligibility criteria are a method for deploying limited resources in a way that ensures that resources are targeted to those in greatest need, while also recognising circumstances where lower level intervention can sometimes halt the deterioration of people in less urgent need of support.

These eligibility criteria recognise ‘risk’ as the key factor in the determination of eligibility for community care services. Where a customer is eligible, the urgency of that risk should be kept in focus in determining how and when to respond to their support needs.

The principles guiding practice in this policy are that supports provided or funded by East Dunbartonshire Health and Social Care Partnership are intended to:

• Retain, support and promote maximum independence
• Intervene no more than absolutely necessary
• Compensate for the absence of alternative support or complement existing support
• Take full account of the risk to the customer if the support is not provided
• Take account of the individual’s personal, community and family assets – personal: financial, skills, experience; community: clubs, libraries, church; family: friends, informal carers, circles of support.

Consideration should only be given to providing support when:

The customer is unable to meet the need themselves and they do not have access to adequate support from the assets described above;
No other statutory agency has a duty to meet that need;
Failure to respond to that need would place the customer in a situation of unmanageable or unreasonable risk.

The eligibility criteria address both the severity of risks and the urgency of intervention to respond to risks. Some levels of risk will call for services or other resources as a high priority whilst others may call for some services/resources, not as a high priority but managed and prioritised either as a short term intervention or on an ongoing basis. Some may not call for any social care intervention as engagement in local community activities or services provided by the third sector may be the most appropriate way of addressing the need. In other circumstances the assessment may indicate a potential requirement for service provision in the longer term which requires to be kept under review. As part of the assessment and support planning process, it is for relevant practitioners undertaking assessment to consider how each individual’s needs match against eligibility criteria in terms of severity of risk and urgency for intervention. The eligibility framework prioritises risks into four categories: critical, substantial, medium and low.

It is not appropriate simply to place customers who require support in a date order queue. Response to need will be informed by the continuing systematic review of each customer’s needs, including consideration of how urgently service provision is called for and what interim measures may be appropriate pending a more permanent response.

In managing access to finite resources, the Health and Social Care Partnership will focus first on those people assessed as having the most significant risks to their independent living or wellbeing. Where people are assessed as being in the critical or substantial risk categories their needs will generally call for the immediate or imminent provision of support. Those customers will receive that support as soon as reasonably practicable and, in the case of people in need of personal or nursing care services, not later than six weeks from the confirmation of need for the service.

Where eligibility is determined to fall into the moderate category, the response of Social Work Services will be to provide the individual with advice/information and/or to signpost towards direct access to community resources. Exceptions can be made where the absence of statutory social work involvement will lead to an aggravation of the individual’s needs resulting in greater expense to the local authority on a later occasion. In these circumstances a short term intervention focussed on rehabilitation and enablement can be offered. Interventions of this nature will not normally continue beyond a six-week period, but this may be extended if the benefits for so doing are demonstrable, explicitly time-limited and authorised by senior management.

Where eligibility is determined to fall into the low category, the response of Social Work Services will be to provide the individual with advice/information and/or to signpost towards direct access to community resources.

The effect of the HSCP’s eligibility criteria is that only services that reduce an individual’s risk to a moderate level will normally be subject to statutory funding.

The arrangement of any services will continue to depend on the availability of budget and resources. Therefore, if an individual is to be given priority within the eligibility criteria, and the cost of the support package is below the cost limitations, those authorising the provision of supports will still be required to have assurance that resources are available to meet the eligible need.

This policy adopts the four categories of risk within the Scottish Government’s National Eligibility Framework.

Risk Level

Critical risk

Indicates that there are major risks to an individual’s independent living or health and well-being likely to call for immediate or imminent intervention and/or provision of social care support.

Substantial risk

Indicates there are significant risks to an individual’s independence or health and well-being likely to call for immediate or imminent intervention and/or provision of social care support.

Moderate risk

Indicates there are some risks to an individual’s independence or health and well-being. These may call for the provision of some social care support managed and prioritised on an on-going basis or they may simply be manageable over the foreseeable future support provision with appropriate arrangement for review.

Low risk

Indicates there may be some quality of life issues but low risks to an individual’s independence or health and well-being with very limited, if any, requirement for the provision of social care support. There may be some need for alternative support or advice and appropriate arrangements for review over the foreseeable future or longer term.

Urgency

Immediate: required now or within approximately 1 to 2 weeks

Imminent: required within 6 weeks

Foreseeable future: required within next 6 months

Longer Term: required within the next 12 months or subsequently

The following information provides definitions of risk factors for each of the bands in the national eligibility framework adopted by the Partnership.

Critical

• Serious harm or neglect has occurred or is strongly suspected and client needs protective intervention by social care services
• Major health problems which cause life threatening harm or danger to client or others.

Substantial

• Harm or neglect has occurred or is strongly suspected
• Significant health problems which cause significant risks of harm or danger to client or others.

Moderate

• Adult at risk needs to raise their awareness to potential risks of harm
• Some health problems Indicating some risk to Independence and/or Intermittent distress – potential to maintain health with minimum interventions.

Low

• Preventative measures including reminders to minimise potential to risk of harm
• Few health problems indicating low risk to independence – potential to maintain health with minimum interventions.

Critical

• Unable to do vital or most aspects of personal care causing major harm or danger to customer or others or major risks to independence
• Unable to manage the most vital or most aspects of domestic routines causing major harm or danger to client or others or major risks to independence
• Extensive / complete loss of choice and control over vital aspects of home environment causing major harm or danger to customer or others or there are major risks to independence.

Substantial

• Unable to do many aspects of personal care causing significant risk of danger or harm to customer or others or there are significant risks to independence
• Unable to manage many aspects of domestic routines causing significant risk or harm or danger to client or others or significant risk to independence
• Substantial loss of choice and control managing home environment causing a significant risk of harm or danger to client or others or significant risk to independence.

Moderate

• Unable to do some aspects of personal care indicating some risk to independence
• Able to manage some aspects of domestic activities indicating some risk to independence
• Able to manage some aspects of home environment leaving some risk to independence.

Low

• Difficulty with one or two aspects of personal care, domestic routines and/or home environment indicating little risk to independence
• Able to manage most aspects of basic domestic activities
• Able to manage most basic aspects of home environment.

Critical

• Unable to sustain involvement in vital aspects of work/education/learning causing serious loss of independence
• Unable to sustain involvement in vital or most aspects of family/ social roles and responsibilities and social contact causing severe loss of independence.

Substantial

• Unable to sustain involvement in many aspects of work/education/learning causing a significant risk to losing independence
• Unable to sustain involvement in many aspects of family/social roles and responsibilities and social contact causing significant distress and/or risk to independence.

Moderate

• Unable to manage several aspects of involvement in work/education/learning and this will in the foreseeable future pose a risk to independence
• Able to manage some aspects of family/ social roles and responsibilities and social contact that poses some risk to independence.

Low

• Has difficulty undertaking one or two aspects of work/education/family and/or social networks indicating little risk to independence
• Able to manage most aspects of family/ social roles and responsibilities and social contact indicating little risk to independence.

The following information indicates the progression from initial referral to the provision of support. It indicates where the process of determining eligibility falls within the process and illustrates how the intensity of risk and access to support services is determined using the eligibility criteria.

1. Record referral and screen
2. Gather information to gauge risk and eligibility
3. Critical Risk, Substantial Risk, Moderate Risk, Low risk
4. Put in place immediate support required
5. Discretionary referral for short-term rehab, enablement or preventative
6. Offer advice, information and signpost to other support
7. Develop and agree full Assessment and Support Plan, confirming and recording eligibility, risk and prepare support / budget for approval with primary outcome to reduce risk to a moderate level
8. Monitor and review support plan at least annually with service-user, carer and relevant professionals
9. Reassess if required
10. Update support plan as required.