This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the descriptors in the Communication domain, to help you assess your or your relative’s “level of need” in this important domain.
Don’t miss parts one to ten of this series!
Following the 2018 revisions of the DST, Communication moved from domain number four to domain number six. It now follows Mobility and precedes Psychological & Emotional Needs. The assessed levels of need in the Communication domain range from ‘No Needs’ to ‘High’ needs. There is no descriptor for ‘Severe’ or ‘Priority’ needs in this domain, indicating that an inability to communicate is unlikely to present an immediate risk to life, or amount to a primary health need in and of itself. Needs in the Communication domain are important because of their impact on the delivery of care and on other domains of the DST, particularly pain. This interrelation should always be carefully considered in the analysis of the four Key Characteristics.
In our experience, Communication is one of the most hotly contested domains in the DST, largely because the descriptors for ‘Moderate’ and ‘High’ need are so similar:
‘Moderate’ Needs – Communication about needs is difficult to understand or interpret or the individual is sometimes unable to reliably communicate, even when assisted. Carers or care workers may be able to anticipate needs through non-verbal signs due to familiarity with the individual.
‘High’ Needs – Unable to reliably communicate their needs at any time and in any way, even when all practicable steps to assist them have been taken. The individual has to have most of their needs anticipated because of their inability to communicate them.
Discerning between the ‘Moderate’ and ‘High’ needs descriptors is made even more difficult in a residential care setting, where the person’s needs will often be anticipated and met via routine care planning, regardless of their communicative ability.
The following clinical factors are relevant to the assessment of needs in this domain:
- Can the person communicate their needs or wishes verbally?
- Is English their first language?
- Is their speech clear? Do they use words in context?
- Can the person communicate their needs non-verbally?
- Is this difficult to interpret?
- Do they use sign language?
- Is the person’s communication reliable?
- Is the person under the care of a Speech & Language Therapist?
- Does the person use any communication aids (picture cards, Eye-Blink etc.)?
- Does the person have any degree of cognitive impairment?
- Are they diagnosed with aphasia and/or dysphasia?
- Do they require assistance to make their needs known?
- Can they understand and follow instructions?
- Can they call for help, either verbally or using the Call Bell?
- Does the person suffer pain?
- Are they able to communicate pain symptoms, either verbally or non-verbally?
The DST provides the following advice to those assessing needs in the Communication domain:
This section relates to difficulties with expression and understanding, in particular with regard to communicating needs. An individual’s ability or otherwise to communicate their needs may well have an impact both on the overall assessment and on the provision of care. Consideration should always be given to whether the individual requires assistance with communication, for example through an interpreter, use of pictures, sign language, use of Braille, hearing aids, or other communication technology.
REMEMBER – an inability to communicate verbally, or even to speak at all, does not necessarily equate to ‘High’ needs in this domain. Where CHC assessment is concerned, Communication is all about the ability to make needs known, regardless of how this is achieved.
Now that we’ve outlined the type of things the MDT will be considering in this domain, let’s take a look at the descriptors for the respective levels of need. For each level of need, we provide a case study to give you a better understanding of how the descriptors might be applied at your or your relative’s assessment.
|Able to communicate clearly, verbally or non-verbally. Has a good understanding of their primary language. May require translation if English is not their first language.|
No communication deficits.
Is able to make needs known clearly, either verbally or non-verbally.
Communication is reliable.
CASE STUDY – NO NEEDS
Mrs. X. can communicate her needs to staff clearly and effectively. She does not experience any slurred speech or word-finding difficulties. She wears hearing aids and can struggle to hear if the environment is noisy; however, this does not impact her ability to let staff know when she wants or needs something. Mrs. X will ask staff for meals, drinks and assistance spontaneously; she does not require any anticipation although most of her needs are met routinely due to the setting of care. Mrs. X is able to use the Nurse Call system.
Mrs. X presents with ‘No needs’ as she is able to communicate clearly, verbally or non-verbally.
|Needs assistance to communicate their needs. Special effort may be needed to ensure accurate interpretation of needs or additional support may be needed either visually, through touch or with hearing.|
Able to communicate verbally or non-verbally
Needs assistance to ensure effective communication
CASE STUDY – LOW
Mr. X gets confused and sometimes mixes up his words. He is unable to join in a conversation and he needs assistance to help him understand what is being said to him. However, he is able to express his needs clearly, often by using one or two words; e.g., he will tell staff when he wants to go to the toilet, go to bed, get up in the morning, walk around, and when he is hungry or thirsty. Mr. X wears glasses and his hearing is good.
Mr. X presents with a ‘Low’ level of need as he needs assistance to communicate his needs. Special effort may be needed to ensure accurate interpretation of needs or additional support may be needed either visually, through touch or with hearing.
|Communication about needs is difficult to understand or interpret or the individual is sometimes unable to reliably communicate, even when assisted. Carers or care workers may be able to anticipate needs through non-verbal signs due to familiarity with the individual.|
Able to communicate verbally or non-verbally
Communication is sometimes difficult to understand, and/or unreliable
Even with assistance, the person is sometimes unable to communicate their needs
Non-verbal cues are used to anticipate needs
CASE STUDY – MODERATE
Mr. X has dysarthria and, although he can communicate verbally, his speech is not always clear or coherent. Mr. X does not recognise that he speaks quickly or that others can’t understand him, and this can frustrate him at times. Often, Mr. X is encouraged to repeat what he has said slowly so staff can understand and with some time and patience they are usually able to do so.
Care Plan confirms he uses pictures to indicate basic needs, such as hunger, thirst, too cold/hot. Reponses to closed questions are usually reliable. Mr. X has been assessed by the Speech and Language Therapist who has recommended the use of picture cards and advised staff regarding effective communication strategies. Mr. X has now been discharged by Speech and Language.
Care records indicate that staff can usually interpret needs by monitoring body language, at times when verbal communication is unclear.
Hearing appears intact and he wears glasses.
Mr. X presents with a ‘Moderate’ level of need as his communication about needs is difficult to understand or interpret or the individual is sometimes unable to reliably communicate, even when assisted. Carers or care workers may be able to anticipate needs through non-verbal signs due to familiarity with the individual.
|Unable to reliably communicate their needs at any time and in any way, even when all practicable steps to assist them have been taken. The individual has to have most of their needs anticipated because of their inability to communicate them.|
Unable to communicate verbally or non-verbally
Any communication is unreliable and/or incomprehensible
Even with maximum assistance, cannot make needs known
Most or all needs are anticipated by staff due to inability to communicate
Non-verbal cues are unreliable
CASE STUDY – HIGH
Mrs. X is severely cognitively impaired and completely non-verbal. She is unable to indicate any of her needs at any time. She is unable to indicate pain, although she has no previous history of pain.
Unable to reliably communicate her needs at any time/in any way.
Staff anticipate all her needs for her.
Mrs. X is severely cognitively impaired and is unable to reliably communicate her needs in any way at any time. Staff are required to anticipate her needs at all times and to provide regular checks and interventions in order to ascertain and meet needs promptly.
Mrs. X presents with a ‘High’ level of need as she is unable to reliably communicate their needs at any time and in any way, even when all practicable steps to assist her have been taken. The individual has to have most of their needs anticipated because of their inability to communicate them.
We hope this has helped you to understand the descriptors in the Communication domain. Don’t miss the next part of this series, Psychological & Emotional Needs, coming very soon!
If you need help assessing your relative’s level of need in any domain on the DST, don’t hesitate to contact one of our specialist Advice Lines to discuss your case today.
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