Your Care Record guidance: Appendix 1: SAP Coordination Principles

Single Assessment Process Coordinator: Basic Principles

What is the role of the Single Assessment Process (SAP) Coordinator?

• ensuring that the person/ carer is aware who the SAP Coordinator is
• coordinating the outcomes of person centred SAP assessments, care planning and appropriate information sharing
• ensuring that any other relevant parties/ professionals are informed of their role e.g. Service Providers
• leading the integration of care across agencies/professional groups
• ensuring that there is an effective handover if responsibility for SAP Coordination needs to be transferred
• taking a lead role in ensuring that the person/carers needs continue to be appropriately met
• facilitating access to an advocate if appropriate
• identifying when the care planning and coordination process has concluded. The SAP Coordinator will ensure that all parties (including the person/service user/carer and other agencies) are informed and that the SAP documentation reflects this.

• an appropriate SAP Coordinator is identified
• appropriate assessments are undertaken
• full participation of service user/ carer
• the assessment results in a Summary of Assessed Needs and a service specific Care Plan (if appropriate)
• oversight of the planning and delivery of care and act as a focal point for contact issues. Being SAP Co-ordinator does not mean they are responsible for the completion of all tasks, but can request other professional’s involvement.

How do we identify who is appropriate for the SAP Coordinator role?

• If there is a sole assessor, they are the SAP Coordinator.
• The initial assessor may or may not remain the SAP Coordinator.
• The decision should take into account the following principles:
  • agency with the longest history of involvement
  • agency with the longest potential involvement e.g. Health, Social Care, Housing and Mental Health (such as CPA)
  • agency with responsibility for meeting the greatest areas of need
  • identification of future potential problems
  • emerging short-term requirements vs. long-term involvement
  • resource or funding responsibilities
  • where the person/ carer is physically based. This may change with episodes of care e.g. Rehabilitation Centre / Care Home
  • the preference of the individual person/ carer.

At what level is a SAP Coordinator introduced into the assessment?

At the start of the Single Assessment Process

• The SAP Coordinator may change along the person/carers care pathway.
• There should only ever be one SAP Coordinator for the Single Assessment Process (SAP) identified at any one-time.
• Each agency has the responsibility to record who the SAP Coordinator is in either paper or electronic records. This should also include a list of other professionals/ organisations currently involved with the person/ carer.
• It is recognised that the role of the SAP Coordinator maybe encompassed within the multi-faceted role of Community Matron, Discharge Care Coordinator (Hospital), Assessment & Integrated Care Team (AICS) or Care Programme Approach (C.P.A.) Care coordinator.

What is the role of the SAP Coordinator in the hospital setting?

• identifying who the lead person for discharge is e.g. Discharge Liaison Nurse
• liaising with the identified lead person for discharge with regards to assessments, care planning and discharge.
• planning for discharge is the joint responsibility of the SAP Coordinator and if appropriate the identified lead person for discharge e.g. Discharge Liaison Nurse, Community Liaison Nurse. The same professional may undertake both roles in some circumstances.