ABSTRACT
Mrs B is 84-years-old and had a stroke ten years ago with gradual deterioration in her functional ability ever since. This chapter outlines an approach to supporting older people (OP) like Mr and Mrs B who commonly have complex needs in the community. The elderly resource team is a multidisciplinary team working across the West of Newcastle upon Tyne. The National Service Framework for OP envisions a single assessment process (SAP). Subsequent guidance sets out that 'Local implementation of the SAP by health and social care systems will promote better care services and better outcomes for older people, and more effective use of professional resources. By co-ordinating input to clients the team can be sensitive with timing of visits, maintain effective communication, and minimise duplication through effective sharing of information. From the screening process the team can identify an action plan and individual professionals will agree specific goals with the patient and the carer.
