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Home > For Health Professionals > Aged care > Aged Care Assessment Teams

Introduction to Aged Care Assessment Program Self-Directed Learning Package - Generic Section - Version 4.0

Accessing ACAT

ACATs cover all Australia and are located in hospitals or the local community. Any person can contact an ACAT. Clients can contact an ACAT direct or others can make contact on their behalf. ACATs are promoted through a range of government, health service and aged care publications, presentations and websites. Enquiries/referrals may come by telephone, mail or facsimile.

Intake

Each ACAT will have a documented process for handling enquiries and for clients to enter the ACAT system, known as intake. ACATs use a range of models for the management of intake. Your team may use a dedicated intake officer, a rotating role or no dedicated role. Some teams use administrative staff for intake, others clinicians and some teams use a combination of both.

The key to effective intake systems is ensuring the intake is efficient and client focussed. Each member of the team must know what their role is in the intake process. Good intake processes are essential in contributing to waiting time management by ensuring that only appropriate clients progress to an assessment and, those with urgent needs are seen in a timely manner.

Generically, an ACAT intake process will comprise of the following (see the flow chart on page 55):

Initial screening to determine appropriateness

Does the client fit the target group? Frail, older client, 70 years of age or over, 50 years of age or over if they are an Indigenous client.
If not, do they predominantly have an age related or complex problems that may require ACAT involvement – if so these cases should be referred to a senior clinician or manager to decide on further ACAT involvement.
Further screening to determine risk, actual needs and priority setting.
Use standard screening tool to determine the priority level for client (see table that follows).
Risk screening to establish any issues with visiting the client and for the client prior to a visit and the establishment of services.
If any risks are identified implement risk mitigation strategies – this may include referral back to their GP, hospital or emergency care provider. Risk mitigation strategies for the team may involve conducting the visit with a second team member.

Consent

ACATs must obtain consent from the client (or representative) prior to undertaking an assessment. The ACATs must ensure that people referred for an ACAT assessment understand the assessment process and their rights and responsibilities.

Verbal consent must be obtained and documented prior to:

the assessment visit
contacting the person's GP, other health professional, family members or carers to obtain relevant information prior to the assessment.

Written consent should also be obtained at the commencement of the assessment. Many ACATs have developed separate consent forms to comply with state or territory privacy legislation.

The application section of the Aged Care Client Record (ACCR) is an application for approval as a care recipient and is not a consent form for assessment. The ACCR also includes information on the use and disclosure of the client's personal information.

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File creation

Electronic data capture and medical record notes need to be commenced early in the intake process and continue throughout until the case is closed. If the client is known to the health service, a medical record will already exist and may need to be retrieved. If the client is new, a client record number and file will need to be created.

Allocation of the client to the most appropriate assessor

Teams have varying allocation processes which may be based on geography, workload, known to the client, clinical specialty or a combination of all factors.
Allocation should occur at regular intervals to ensure waiting times and workload is constantly managed. Some teams will have an allocation meeting whereby new clients can be discussed and allocated to the most appropriate assessor.

Assessment

Most assessments are conducted by a single assessor unless there is a clear indication of the need for a dual assessment.
A comprehensive, holistic, independent, multidisciplinary, multidimensional assessment is required.
Assessments may be conducted in the home, hospital or aged care setting. If possible the initial assessment should be made in the clients' usual accommodation setting.
In the more complex cases follow up assessments, referrals to specialists and obtaining other medical information may be required to complete the assessment.
Attendance at assessment of a carer or advocate is recommended and the clients agreement is sought as to who should attend
If an interpreter is required, identify specific language and arrange early.

Case conference

Most teams use a case conference where team members come together at set times and at which cases are presented and discussed. This allows multidisciplinary involvement to occur.
Not all cases need to be presented at a case conference and criteria should exist to determine which cases are appropriate for presentation.
Guidelines for the way cases are presented should also be used to ensure the meetings are efficient.
Case conferences are an ideal opportunity to have broader input into the decision making process surrounding an assessment and care planning.

Delegation

Any clients requiring approval for a Commonwealth Government subsidised aged care service will require an Aged Care Client Record to be signed by an ACAT Delegate.
The ACAT Delegate should, wherever possible, be a different person to the assessor.
Each team will have a process whereby ACAT Delegates receive and approve the assessor's recommendations. This process should ensure no unnecessary delay in the process.

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Care coordination

Care coordination is the process of follow up to the point where an alternative case coordinator is identified and assumes the responsibility for coordinating service provision on behalf of the client. Case coordination can occur at two levels.
All care coordination by ACATs is intended to be relatively short-term. It is meant to bridge the time between when the assessment finishes and when responsibility for the client is taken on by a carer or another service provider, or until the client enters residential care.
Level 1 care coordination is aimed at monitoring care plan implementation, and would typically be undertaken for clients who need help to access services. This may be because either the client or their carer would have difficulty negotiating the service system without the help of the ACAT. Normally, Level 1 care coordination would occur less than once a week.
Level 2 care coordination is about helping clients who have complex needs or who are in an unstable or dangerous situation and who require close monitoring or active assistance from an ACAT staff member. Level 2 care coordination would usually require some action from the ACAT staff member more than once a week.

Documented processes should exist for all of the above and be current in each team. This includes a screening tool to ensure there is consistency in the questions asked and the resultant actions, an allocation process, a process for delegation and case conference guidelines.

Client priority

The guidelines stipulate a priority rating system for ACAT clients and suggested timeframes in which each client should be seen. These are described in the table below.

Table 4: Priority levels for time to first face to face assessment

Priority	Timeframe	Description
Priority 1	Within 48 hours	Refers to a client who, based on information available at referral, requires an immediate response. An urgent assessment is required if the person's safety is at risk (e.g. high risk of falls or abuse), or there is a high likelihood that the person will be hospitalised or required to leave their current residence because they are unable to care for themselves, or their carer is unavailable. This may be due to a crisis in the home involving either the client or the carer or a sudden change in the client's or carer's medical, physical, cognitive or psychological status.
Priority 2	Between 3 and 14 days	Refers to clients whose information available at referral indicates that the client is not at immediate risk of harm. Referrals that indicate progressive deterioration in the client's physical, mental or functioning status, or that the level of care currently available to the client does not meet their needs or is not sustainable in the long-term, should be allocated to this priority category.
Priority 3	More than 14 days	Refers to cases where the referral information indicates that the client has sufficient support available at present, but that they require an assessment in anticipation of their future care requirements. Examples include circumstances where the carer is planning a holiday, which will result in the care recipient requiring the provision of substitute care or recognition that the person is having increased difficulty living independently and options for future care need to be discussed with the client and their carer or family. In deciding to use this code the ACAT is making a judgment that delaying an assessment for more than 14 days will not jeopardise the client's health and well-being.