Foundations Monthly Webinar, 21 June 2022
Assess a DFG
Assessing what adaptations someone needs is a key early stage in the DFG process. The aim should always be to work with the disabled person, their family and carers to come to a holistic view of their needs.
Some or all of that may be eligible for a DFG, but that should be a secondary consideration as other sources of funding – public or private – may be available.
Under the DFG legislation, the final decision on what is “necessary and appropriate” lies with the housing teams / grant officer – but an assessment by an OT or trusted assessor will be a key factor in making that decision.
Adaptations without delay
Across the UK there continue to be delays in the delivery of minor and major adaptations across all housing tenures. In recognition of this continuing issue, the Royal College of Occupational Therapy (RCOT) commissioned the Housing Learning and Improvement Network (Housing LIN) to conduct a UK wide review of Minor Adaptations without Delay (2006). Foundations were part of the Steering Group for this work.
The new Adaptations Without Delay guide sets out a better way of defining the assessment and delivery of adaptations based on complexity with an associated decision-making framework that guides the use of Trusted Assessors.
The overall aim of the guide is to reduce delays in the delivery of adaptations by providing tools that support a proportionate response. The guidance also ensures the specialist skills of occupational therapists can be used to work with the growing number of individuals whose circumstances are complex.
The guide and the framework are intended to be used at both a practitioner and a strategic level by personnel in occupational therapy services, Home Improvement Agencies, housing associations and other housing providers.
One of the outputs of the assessment will be a description of the required adaptations. It is important to record this information in a clear and consistent manner that others can follow.
Foundations Adaptations Triage Tool
Why have we developed a triage tool?
In health and social care, the demand for occupational therapy is increasing as their assessment and intervention skills are recognised as a critical element of ensuring people receive appropriate and effective care and support. At any one time, many assessment requests received by social care are for individuals who are seeking non-complex adaptations through the Disabled Facilities Grant (DFG).
The Royal College of Occupational Therapists’ publication Adaptations Without Delay identified how non-complex cases for adaptations could be effectively managed using trusted assessors if supported by appropriate operational and procedural mechanisms, such as a triage process. This approach then allows occupational therapists to focus on the complex cases where their skills and knowledge are most effective in assessing and supporting the design of the adaptation.
This triage tool has two aims. First, to improve the flow of referral through the DFG process by supporting the decision-making process as to when an occupational therapist is needed to be involved in assessing the necessary and appropriate element of the DFG application. Second, to make better use of the occupational therapy resource in social care by reducing the number of assessments for non-complex adaptations therapists are involved in.
Why are there only four questions?
Based on feedback during the tool’s design, we have kept the number of questions small. Although there are only four questions, they focus on the critical factors that make an assessment complex or straightforward. Detailed below is a brief explanation of what each question explores.
Question 1: Considers the complexity of the person’s current and future condition and the implications on the individual’s long term health & social care needs.
Question 2: Considers complexity of the activity(s) the person is struggling to perform and where those activities take place in the home environment.
Question 3: Considers the complexity of the care needs of the individual and any current or future equipment that may be required when using the adaptation.
Question 4: Considers the complexity of the impact the potential adaptation could have on others living and using the property
Why are there screening questions before the triage questions?
Screening questions have been included to ensure the person gives consent and can participate in the triage process. The screening questions also ensure that the person is put on the most appropriate assessment and intervention pathway. For example, it may be more appropriate for the individual to be assessed for reablement or rehabilitation. Where a local authority already has a robust screening process in place, these questions may not be necessary.
Assumptions for using the tool
- The tool is administered by a competent occupational therapist or trusted assessor.
- Where an occupational therapist is not directly involved in a case, competent assessors are involved in identifying what adaptations are necessary and appropriate.
- The person is aware that an assessment that identifies what is necessary and appropriate as part of a DFG application is not necessarily a Care Act assessment.
How the tool was developed
The tool developed through an iterative process that continues as we gather further user feedback. To date, the development of the tool has involved the following stages
- Stage 1: A desktop review of relevant legislation, good practice guidance, research, and other literature related to complexity and the occupational therapist’s role in the adaptation process.
- Stage 2: A stakeholder workshop, hosted by Foundations.
- Stage 3: Pilot of the triage tool at three sites, supported by occupational therapy students from the University of Salford.
- Stage 4: Formal launch of the triage tool.
- Stage 5: We will be continually refining the tool as we gather feedback from users.
Necessary and appropriate
In the DFG assessment, the housing authority must identify the needs of the disabled person and what ‘relevant works’ are necessary and appropriate to meet their needs. Below are some key principles to consider when identifying the adaptations needed.
- The primary purpose should be to modify a home environment to help restore or enable independent living, privacy, confidence and dignity for individuals and their families.
- The DFG can be used for a wide range of capital works to a home provided it meets the purposes set out in the Housing Grants, Construction and Regeneration Act 1996.
- Authorities should judge each request for adaptations on its merits in accordance with the legislation and not seek out reasons to refuse or delay approval.
- The starting point and continuing focus should be the needs experienced and identified by the disabled person and their carers. The process should be one of partnership in which the disabled person and their carers are the key partners.
- All partners should work to ensure that each adaptation is delivered sensitively, is fit for the purpose identified by the disabled person, their family, or their carers, and within a timeframe that is made explicit at the outset.
- Authorities should consider how best to achieve value for money, taking into account:
- how to design adaptations that will meet current and anticipated future needs; and
- projected costs of health and social care in the longer term.
- Value for money will not always be achieved by choosing the cheapest option. An adaptation should satisfy the present and anticipated needs of the disabled person even in large and complex adaptations costing above the maximum grant.
A collaborative model of assessment for complex cases
An integrated approach between the occupational therapist and technical officer is recommended to help determine the eligible works in complex cases.
In complex cases an occupational therapist may require the support of a technical officer to identify what adaptations are reasonable and practicable to install given structural limitations of the property. Only then can the occupational therapist recommend (in collaboration with the disabled person and their family), which solution is appropriate.
An integrated approach to assessment is illustrated below and demonstrates that the client is at the centre of the process:
- This begins with the assessment of need and with identifying if it is necessary to adapt the home environment.
- The next step involves considering the home environment and identifying the potential solutions for adapting the home environment and meeting the needs of the person.
- From the range of solutions, the occupational therapist collaborates with the person to identify the most appropriate solution.
- The final stage of the process considers whether it is reasonable to award a grant.
Adaptations should provide a sustainable and effective, individualised solution, including considering the role that assistive technology could play in meeting the identified needs. It is important that the assessment of need focuses on what is important to the disabled person, rather than solely on safety and function.
To reduce the risk of installing inappropriate adaptations, authorities should follow the nine guiding principles identified by Heywood (2004) in her research into the needs older and disabled people consider important when being assessed:
- Need to retain (or restore) dignity
- Need to have values recognised
- Need for relief from pain, discomfort, and danger
- Need to minimise barriers to independence
- Need for some element of choice
- Need for good communication as part of giving choice
- Need for light
- Particular needs of children: to provide for growth and change; and the need for space
- Needs of other family members and of the family as a whole
The above principles provide a framework to support decision-making and communication of what works are necessary and appropriate in each case.
Many local authorities have ‘funding panels’ to which occupational therapists have to present cases, in order to get agreement for the adaptation a person may need.
The use of panels in social care has been much criticized and the Care Act guidance is clear that they should not be used routinely for all cases. It’s also clear from the DFG guidance that DFG eligibility is a housing decision. Meetings to discuss complex cases can be helpful, but social care funding panels are unlikely to add value to the process.
Care Act Guidance
The statutory guidance acknowledges concerns about the use of panels and cautions against inappropriate use which may cause unnecessary delays or inadequate decision-making (para 10.85):
- Due regard should be taken to the use of approval panels in both the timeliness and bureaucracy of the planning and sign-off process. In some cases, panels may be an appropriate governance mechanism to sign-off large or unique personal budget allocations and/or plans. Where used, panels should be appropriately skilled and trained, and local authorities should refrain from creating or using panels that seek to amend planning decisions, micro-manage the planning process or are in place purely for financial reasons. Local authorities should consider how to delegate responsibility to their staff to ensure sign-off takes place at the most appropriate level. In cases or circumstances where a panel is to be used, and where an expert assessor has been involved in the care and support journey, the same person or another person with similar expertise should be part of the panel to ensure decisions take into account complex or specialist issues.
A Community Care magazine survey reported in March 2018 revealed a wide range of ‘decoy’ names for these funding panels – including:
- Risk/practice enablement group
- Advisory forums
- Community care boards
- Complex care forum
- Funding application discussion process
- Outcomes forum
- Peer review process
- Resource allocation meetings
- Validation boards
Using Independent/Private OTs
Content coming soon
Making a referral
In most DFG systems the assessment of need is carried out by an Occupational Therapist or Trusted Assessor. This should detail what is ‘necessary and appropriate’ to meet the needs of a disabled person.
This information should enable the housing team to confirm that the required adaptations are indeed ‘necessary and appropriate’ and then to decide whether they are ‘reasonable and practicable’ in the circumstances. Nottinghamshire have kindly shared the referral forms they use to document their assessments.
The forms focus on the specific needs of the disabled person rather than proposing a specific solution. The design and condition of the existing property are likely to influence what may be practicable to provide.
Speak to our Regional Advisors
Our team of Regional Advisors are at the heart of what we do – providing advice and support to Local Authorities and Home Improvement Agencies. And because we’re funded by the Department of Levelling Up, Housing and Communities our everyday support is free of charge.
Whether it’s a question about the DFG legislation, you need advice on how to commission a HIA or anything in between – we’re here to help.