This series takes a detailed look at the domains of the Decision Support Tool. This week we examine the first three descriptors in the Mobility domain, to help you assess your or your relative’s “level of need” in this important domain.
Don’t miss parts one, two, three, four, five, six, seven and eight of this series!
Following the 2018 revisions of the DST, Mobility kept its original position at domain number five. However, it now follows Skin and precedes Communication. As we discussed in our previous blog on the domains of the DST, the new proximity of the Skin and Mobility domains emphasises the common interaction between them. Any interrelation between domains (complexity), and its potential impact on the delivery of care (intensity/unpredictability), should be considered in the analysis of the four Key Characteristics.
The assessed levels of need in the Mobility domain range from ‘No Needs’ to ‘Severe’. There is no descriptor for a ‘Priority’ level of need in this domain, indicating that an issue with mobility is unlikely to present an immediate risk to life. That being said, a ‘Severe’ level of need in this domain is likely to result in significant intensity and complexity, in and of itself. In our experience, very few individuals meet the stringent criteria for a ‘Severe’ level of need in this domain, which far exceed an inability to weight bear or mobilise independently.
The following clinical factors are relevant to the assessment of ‘No’, ‘Low’ and ‘Moderate’ needs in this domain:
- Can the person move around independently?
- Do they use any mobility aids? (Walking stick, Zimmer frame etc.)
- Is there any history of falls?
- Have there been any recent falls?
- Were any injuries sustained?
- What is the person’s score on the Falls Risk Assessment?
- Can the person bear their own weight?
- If not, do they need a hoist to transfer?
- If so, is this a standing hoist (Stand-Aid) or full hoist (sling)?
- Can the person alter their own position in bed or chair?
- How many members of staff are required to assist with moving & handling?
- Is the person able to assist with moving & handling procedures?
- Does the person cooperate with moving & handling procedures?
The DST provides the following advice to those assessing needs in the Mobility domain:
This section considers individuals with impaired mobility. Please take other mobility issues such as wandering into account in the behaviour domain where relevant. Where mobility problems are indicated, an up-to-date Moving and Handling and Falls Risk Assessment should exist or have been undertaken and the impact and likelihood of any risk factors considered. It is important to note that the use of the word ‘high’ in any particular falls risk assessment tool does not necessarily equate to a high level need in this domain.
This underlines the crucial importance of verifiable, written evidence to support the assessment of needs in this domain. For example, in the case of a person who is at risk of falling, the MDT will expect to see a recent Falls Risk Assessment confirming the level of risk and steps taken to mitigate this; in the case of a person who is immobile and unable to weight bear, the MDT will expect to see a Moving & Handling assessment confirming this. A lack of appropriate documentation may result in a lower level of need being applied, regardless of the verbal testimony of family and/or staff.
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 ‘No’, ‘Low’ and ‘Moderate’ levels of need. For each level of need, we provide a case study to give you a better understanding of how the descriptors of need might be applied at your or your relative’s assessment.
Moves around independently, without aids.
No identified risk of falling or recent falls history.
CASE STUDY – NO NEEDS
Mrs. X is independently mobile and walks around the care home freely. She is able to stand without assistance and does not require any walking aids. Mrs. X has not suffered any falls since her admission to the home six months ago. She does not require any moving or handling interventions by staff and is able to alter her own position in bed or chair, which she does at frequent intervals without prompts.
Mrs. X presents with ‘No Needs’ as she is independently mobile.
|Able to weight bear but needs some assistance and/or requires mobility equipment for daily living.
Mobilises with some assistance.
May require the use of mobility aids (walking stick, Zimmer frame etc.).
No identified risk of falling or recent falls history.
CASE STUDY – LOW
Mr. X is independently mobile and walks with a Zimmer frame. He has not suffered any falls since his admission to the home and does not have a history of falls pre-admission. Mr. X can change his position in bed and chair and does so regularly without prompting. As his dementia progresses, Mr. X may need some gentle reminders from staff to use his Zimmer frame when he is moving around the home. To date, he has not attempted to mobilise without his Zimmer, but staff keep a close eye to ensure his safety.
Mr. X presents with a ‘Low’ level of need as he is able to weight bear but needs some assistance and/or requires mobility equipment for daily living.
|Not able to consistently weight bear.
Completely unable to weight bear but is able to assist or cooperate with transfers and/or repositioning.
In one position (bed or chair) for the majority of time but is able to cooperate and assist carers or care workers.
At moderate risk of falls (as evidenced in a falls history or risk assessment)
Ability to weight bear is inconsistent.
Cannot bear their weight, but can help carers to change position or transfer.
Chair- or bed-bound, but can help carers to change position or transfer.
At a “moderate” risk of falls and has suffered some recent falls.
CASE STUDY 1 – MODERATE
Mr. X is unable to weight bear and completely dependent on two members of staff for all transfers and movement in bed. He is able to co-operate with staff and follow instructions but is unable to stand for even short periods sufficient to transfer. A full hoist is required to assist him to transfer from bed to chair etc. Mr. X is diagnosed with osteoarthritis and osteoporosis and staff report that he can be stiff at times, especially in the morning. He is prescribed PRN Paracetamol for pain if required.
Mr. X does not have any contractures, but staff report that it can be difficult to manage his catheter at times as his hips are restricted due to stiffness which eases after a short time.
Mr. X has previously suffered with falls which have resulted in significant fractures. He continues to be assessed as being at a high risk of falling and, on one occasion shortly after admission, he was noted to have tried to sit on the side of his bed without assistance. Staff moved him to a quieter room as they noted that noisy areas increased his anxiety, since the change of room he has not attempted to get up. He suffers with periods of anxiety, but even when agitated he does not try to get out of bed or chair, and staff report that bed rails are not required when in bed as he does not move.
Mr. X presents with a ‘Moderate’ level of need as he is completely unable to weight bear but is able to assist or cooperate with transfers and/or repositioning.
NOTE – Mr. X’s Falls Risk Assessment indicates a high degree of risk. However, this does not equate to a high level of need in this domain as he has suffered only one fall since his admission and no longer attempts to stand and walk unaided.
CASE STUDY 2 – MODERATE
Mrs. X is able to mobilise with a Zimmer frame and the assistance of one carer. However, she is unsteady and has poor balance and will sometimes push herself back when mobilising and the staff have to catch her and allow her to lower herself to the floor.
Sometimes a wheelchair is used to transport Mrs. X when she is feeling tired or is particularly unsteady.
Mrs. X has suffered one fall since admission to the care home, which was not witnessed by the staff. No injuries were sustained.
Mrs. X has an alarm mat at the side of her bed and when the alarm goes off, she will sit on the side of the bed and wait for staff to attend to her. Mrs. X is able to use the nurse call system to alert staff if she needs their help.
Falls Risk Assessments indicate a moderate risk of falling.
Mrs. X presents with a ‘Moderate’ level of need as she is at moderate risk of falls (as evidenced in a falls history or risk assessment).
We hope this has helped you to understand the first three descriptors in the Mobility domain. Don’t miss the next part of this series, Mobility part 2, coming very soon!
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