National Screening and Assessment Form

This fact sheet provides information about the National Screening and Assessment Form (NSAF) that will be used by My Aged Care contact centre staff, the My Aged Care Regional Assessment Service (RAS) and Aged Care Assessment Teams (ACATs) when screening and assessing the aged care needs of clients.

Development of the National Screening and Assessment Form

The NSAF has been designed to support the collection of information for the screening and assessment processes conducted under My Aged Care. Ithas been developed by the Department of Social Services based on existing best practice assessment processes from around Australia, and through significant consultation with stakeholders, particularly the Assessor User Group (made up of representatives from Access Points, Home and Community Care assessors and service providers and ACATs).

The NSAF ensures that questions are appropriate to each level of assessment (screening, home support assessment or comprehensive assessment); that there is no duplication which would result in the client having to repeat their story; and that the appropriate client pathway can be facilitated through the completion of an action plan or support plan. The NSAF also includes a set of decision support rules that assists the screening and assessment workforce to make recommendations for the type of support a client requires.

Nationally consistent screening and assessment process

The national screening and assessment process, facilitated through using the NSAF, has three components:

  • Screening conducted over-the-phone by My Aged Care contact centre staff
  • Home support assessment conducted face-to-face by the RAS
  • Comprehensive assessment conducted face-to-face by ACATs.

Screening

My Aged Care contact centre staff will screen clients by asking a series of questions over the phone. Screening occurs after a person registers My Aged Care, and has a client record created. Using a conversational approach, screening addresses a client’s needs, circumstances andfunctional ability. Contact centre staff will develop an action plan with the client which identifies the pathway a client will take – to home support assessment, comprehensive assessment and/or direct to Commonwealth Home Support Programme services.Contact centre staff will also provide relevant information to clients, including in the instance where no further assessment or service provision is required.

The following areas may be addressed as part of screening:

Overview of questions
Reason for Contact / Key circumstances triggering contact
Current Support / Services and support currently being received
Carer Overview / Type of care provided/being provided, difficulties or concerns with the caring relationship, sustainability of the caring relationship, client as a carer
Health / Health conditions, recent hospital discharge, weight loss, oral health concerns, vision/hearing/speech, falls, pain
Function / Transport, shopping, meals preparation, housework, medicine management, money management, walking, showering, dressing, eating, transfers, toilet use – assistance received, assistance required
Cognitive / Memory problems or confusion, behavioural problems
Psychosocial / Being nervous, depressed or lonely
Home and Personal Safety / Risks, hazards and concerns in the home, concerns with living arrangements

Home Support Assessment
Home support assessments, undertaken by the RAS, build on the information collected at screening (if applicable), and areundertaken face-to-face generally in the client’s usual accommodation setting to determine a client’s eligibility to receiveCommonwealth Home Support Programmeservices.

During the assessment, the assessor will explore the client’s current level of support (including formal and informal forms of support), family and community engagement, health and lifestyle considerations, functional ability, cognitive or psychosocial considerations, and any issues relating to home and personal safety.

The assessor and the client will work together to establish a support plan that reflects the client’s strengths and abilities, areas of difficulty, and the support that will best meet their needs and goals.This will include the consideration of formal and informal services as well as reablement and/or restorative pathways.

The following areas may be addressed as part of a home support assessment:

Key:
  • Questions in black text are questions that may be asked as part of the screening process and are to be verified or completed as part of the home support assessment process.
  • Questions in green text are additional questions to be asked as part of a home support assessment.

Profile / Overview of questions
Reason for Contact / Key circumstances triggering contact
Current Support / Services and support currently being received
Carer Overview / Type of care provided/being provided, difficulties or concerns with the caring relationship, sustainability of the caring relationship, client as a carer
Family, Community Engagement and Support / Personal and family support networks, involvement in activities and client interests, engagement with family and social/community groups, recent changes to family/cultural/social situation
Health / Health conditions, recent hospital discharge, weight loss, oral health concerns, vision/hearing/speech, falls, pain
General observations, health and wellbeing challenges, allergies/sensitivities, skin conditions, continence issues, sleep difficulties, appetite concerns, fluid intake, alcohol consumption, physical activity, health literacy
Function / Transport, shopping, meals preparation, housework, medicine management, money management, walking, showering, dressing, eating, transfers, toilet use – assistance received, assistance required
Cognitive / Memory problems or confusion, behavioural problems
Changes in memory and thinking, changes in personality, psychological symptoms associated with memory loss
Psychosocial / Being nervous, depressed or lonely
Stressful events, change in mental state, social isolation
Home and Personal Safety / Risks, hazards and concerns in the home, concerns with living arrangements
Self-neglecting of care, equipment/modification required to maintain independence, personal and smoke alarms, personal emergency plan, driving ability, concerns with financial situation, safety concerns, legal issues
Complexity Indicators / Complexity indicators, risk of vulnerability, impact on ability to live independently
Support Plan / Client strengths and abilities, areas of difficulty, satisfaction with level of independence, hopes for change, areas of concern, goals, motivation, agreed action to be taken, referral information

Comprehensive Assessment

Comprehensive assessments, undertaken by ACATs, build on the information collected at screening and home support assessment (if applicable), areundertaken face-to-face generally in the client’s usual accommodation setting, to determine a client’s eligibility for care types under the Aged Care Act 1997.

During the assessment, the assessor will assess the client’s physical, medical, psychological, social and restorative needs. The assessor and client will work together to establish a support plan that reflects the client’s strengths and abilities, areas of difficulty, and the support that will best meet their needs and goals.This will include the consideration of formal and informal services as well as reablement and/or restorative pathways.

Where a care type under the Aged Care Act 1997 is identified as the most appropriate type of support to meet the client’s needs, and the client meets eligibility criteria,the assessor will make a recommendation for approval by a Delegate of the Secretary (i.e. ACAT Delegate). A client may be approved for a home care package, residential care, residential respite care or transition care. Clients may also be referred to Commonwealth Home Support Programme services where appropriate.

The following areas may be addressed as part of comprehensive assessment:

Key:
  • Questions in black text are questions that may be asked as part of the screening process and are to be verified or completed as part of the comprehensive assessment process.
  • Questions in orange text are additional questions to be asked as part of a comprehensive assessment.

Domain / Profile / Overview of questions
Reason for Contact / Key circumstances triggering contact
Current Support / Services and support currently being received
Current formal/informal support
Social Domain / Carer Overview / Type of care provided/being provided, difficulties or concerns with the caring relationship, sustainability of the caring relationship, client as a carer
Family, Community Engagement and Support / Personal and family support networks, involvement in activities and client interests, engagement with family and social/community groups, recent changes to family/cultural/social situation
Medical Domain / Health / Health conditions, recent hospital discharge, weight loss, oral health concerns, vision/hearing/speech, falls, pain
General observations, health and wellbeing challenges, clinical services, medical history, medication detailsallergies/sensitivities, mobility difficulties, skin conditions, continence issues, sleep difficulties, appetite concerns, fluid intake, alcohol consumption, physical activity, health literacy
Physical Domain / Function / Transport, shopping, meals preparation, housework, medicine management, money management, walking, showering, dressing, eating, transfers, toilet use – assistance received, assistance required
Cognitive / Memory problems or confusion, behavioural problems
Changes in memory and thinking, changes in personality, psychological symptoms associated with memory loss
Psychological Domain / Psychosocial / Being nervous, depressed or lonely
Stressful events, change in mental state, social isolation
Psychological / Memory problems, behavioural problems, mental health problems, disorientation
Home and Personal Safety / Risks, hazards and concerns in the home, concerns with living arrangements
Self-neglecting of care, equipment/modification required to maintain independence, personal and smoke alarms, personal emergency plan, driving ability, concerns with financial situation, safety concerns, legal issues
Complexity Indicators / Complexity indicators, risk of vulnerability, impact on ability to live independently
Support Plan / Client strengths and abilities, areas of difficulty, satisfaction with level of independence, hopes for change, areas of concern, goals, motivation, agreed action to be taken, referral information

Supplementary Assessment Tools

Supplementary Assessment Tools are included as part of the NSAF and may be used by an assessor to inform a holistic assessment of a client’s needs. The use of these clinically-validated assessment tools is not mandatory, but should be used if a need is identified that requires a greater level of assessment. An assessor may also choose to use other clinically-validated tools at their discretion, but should record within the NSAF the name of the assessment tool used, the result of the assessment and also attach a copy of the assessment to the client’s record.

The following supplementary assessment tools are available:

Assessment type / Supplementary Assessment Tools
Home Support Assessment /
  • Mini Nutritional Assessment
  • Older Americans Resources and Services Activities of Daily Living (OARS-ADL)
  • Barthel Index of Activities of Daily Living
  • Kimberley Indigenous Cognitive Assessment- Activities of Daily Living (KICA-ADL)
  • Kessler-10

Comprehensive Assessment /
  • Brief Pain Inventory (Short Form)
  • Residents Verbal Brief Pain Inventory
  • Abbey Pain Scale
  • Alcohol Use Disorders Identification Test (AUDIT)
  • South Australian Oral Health Referral Pad
  • Oral Health Assessment Tool (OHAT) for Non-Dental Professionals
  • Revised Urinary Incontinence Scale
  • Revised Faecal Incontinence Scale
  • Mini Nutritional Assessment
  • Older Americans Resources and Services Activities of Daily Living (OARS ADL)
  • Barthel Index of Activities of Daily Living
  • Kimberley Indigenous Cognitive Assessment- Activities of Daily Living (KICA- ADL)
  • Standardised Mini-Mental State Examination (SMMSE)
  • Rowland Universal Dementia Assessment Scale (RUDAS)
  • The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)
  • Kimberley Indigenous Cognitive Assessment (KICA-COG)
  • Geriatric Depression Scale

Decision support within the National Screening and Assessment Form

The NSAFincludes a set of decision support rules that assists the screening and assessment workforce to make recommendations for the type of support a client requires. There are five types of decision support rules:

  • Pathway and eligibility (e.g. this client should be referred for comprehensive assessment)
  • Priority (e.g. access to assessment or service is a high priority)
  • Recommended actions (e.g. the client should visit a GP)
  • Complexity indicators (e.g. the client is living in inadequate housing or with insecure housing or is already homeless)
  • Needs identification (e.g. behavioural concerns).

It is important to note that the NSAF is not a decision-making tool nor is it designed to recommend particular service types a client should access. This will be the role of the trained contact centre staff and assessors who, when developing the action plan or support plan with a client, considers their needs holistically, and recommends support most appropriate to their needs and circumstances.

Online and offline capability

Assessors will have several options for recording assessment information, including:

  • Online/real time – information is recorded during the assessment process via a mobile device (such as a laptop or tablet) connected to the internet
  • Offline – information is recorded on a mobile device that is not connected to the internet. Data is transferred when the device is connected to the internet at a later time
  • Manual – information is written on a paper form during the assessment and subsequently, when online, can be keyed into the NSAF via the Assessor Portal at the first available opportunity for the assessor.

For more information

Further information about the changes to My Aged Care in 2015, and support material to help assessors use the My Aged Care assessor portal, is available at

The Department would like to encourage assessors to review support materials and talk to colleagues to resolve any concerns or questions about using the My Aged Care assessor portal in the first instance. If this does not assist in resolving a question or concern, please contact the My Aged Care provider and assessor help line on 1800 836 799. The help line is available between 8am to 8pm Monday to Friday and 10am to 2pm Saturday, local time across Australia.