Nice | Older people with social needs and multiple long-term conditions

This is a new guideline from NICE on caring for people with both social needs and long term conditions. It really needs to be read after their other recent publication on home care (or see my post for a summary).

There are a few bits that will impact on us.

Assessing social care needs

When it becomes clear that a patient is likely to need social care or support, refer them for a needs assessment.

Consider referral to an elderly care physician or old-age psychiatrist to guide social planning if:

  • the social needs are likely to increase to the point where they have a significant impact on wellbeing.
  • the patient is likely to need a care home placement.

Care Coordination

Each patient will have a single named care coordinator (normally a nurse, social worker or practitioner for a voluntary organisation).

This coordinator will have a lead role in assessment, liaising with the other various people involved and ensuring that referrals are made and actioned. They will also formulate the care plan.

I can see issues regarding confidentiality here, so we will need to ensure that the patient consents to release of their information to the care coordinator. My hope will be (and this isn't in the guideline) that these care coordinators will be very clearly named in the notes and that the consent to release information to them is clearly documented too.


Carers must be offered an assessment of their needs too.

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