Background

Providing cost-effective rehabilitation depends on being able to match staff provision to the care and rehabilitation needs of the client group treated. It is therefore pertinent to have valid and reliable measures of patient dependency in terms of their needs for nursing and therapy staff time. Ultimately, however, for rehabilitation to be cost-efficient, we have to be able to demonstrate that the initial investment in rehabilitation is offset by long-term savings in cost of care in the community. We therefore need a direct measure of care needs and costs in the community.

Widely used global disability scores such as the Barthel Index and the Functional Independence measure (FIM) have been shown to correlate with care needs, but cannot be used to assess them directly as they do not measure the number of people needed to provide help for tasks or the time taken to complete them. They have recognised floor and ceiling effects: for example, at the dependent end of the scale they do not differentiate between the need for one or two carers. Similarly, at the opposite end of the scale, they do not identify the need for constant supervision of a patient who functions automatically at a basic level but has poor safety awareness and tends to wander.

The Northwick Park Dependency Scale (NPDS) and Care Needs Assessment (NPCNA) have been developed to provide an assessment of care and nursing needs in rehabilitation setting, which translates directly into an assessment of care hours and costs of providing care in the community.

Brief outline of the NPDS

In development since the 1990s, the NPDS is an ordinal scale, designed to assess dependency of patients in a rehabilitation setting, in terms of impact on nursing staff time.

• It takes account of the increased time taken to stand back and supervise while a patient undertakes a task for themselves, rather than simply doing it for them.
• It also allows for the extra time needed to communicate with patients who may have language or cognitive difficulties.

The tool is divided into two sections: Basic Care Needs and Special Nursing Needs.

• The Basic Care Needs (BCN) section (range 0-65) includes 12 items associated with activities of daily living such as washing, dressing, eating and drinking - also safety awareness, behaviour and communication.
• Each item is rated on a scale of 0-5.
• The cut-off points between levels are determined by the number of nurses required to help and the time taken to complete each task. (See example in Table 1)
• The Special Nursing Needs (SNN) section (range 0-35) contains seven specific care items which would normally need to be undertaken by a qualified nurse, or a specially trained carer. These are rated on a dichotomous scale of 0 or 5.

Summation of the Basic Care Needs and Special Nursing Needs scores provides a total NPDS score ranging from 0 - 100. Lower total scores represent great independence.

Table 1: Example of an item in the NPDS
7. Dressing (includes putting on shores, socks, tying laces, putting on splint or prosthesis)

Use of the NPDS

The NPDS was first published in 1998 (1) together with evidence for its reliability. Since then it has been taken up quite widely in the UK (2) , and has been explored in other countries including Sweden and Australia.

• Individual ratings may be scored prior to admission to quantify needs in advance of a patient’s arrival on the ward.
• During admission, the NPDS may be recorded serially to monitor improvement in independence,
• NPDS scores for the whole ward may be summated to assess case mix in relation to staffing levels.

Computer programme

• A simple computer programme for data entry is available.
• This is written in Microsoft Excel and is available to anyone who has the Microsoft Office software on a PC.
• The programme facilitates data entry and automatically produces a single summary sheet for ease of reference / filing.
• It also computes the trabsliation to the NPCNA

Further information and copies

The NPDS and NPCNA are feely available for use without restriction.

 For copies of the insturments and computer programme please contact

Prof. Lynne Turner-Stokes DM FRCP.

Regional Rehabilitation Unit, Northwick Park Hospital , Watford Road

Harrow Middx HA1 3UJ

Tel +44 (0) -208-340-2464

E-mail: Lynne.turner-stokes@dial.pipex.com

Brief outline of the NPCNA

The Northwick Park Care Needs Assessment (NPCNA) provides an assessment of care needs in the community.

It is derived from the NPDS by applying an algorithm based on a set of validated `rules' or assumptions, together with a small additional set of 5 questions about the community setting {Turner-Stokes, 1999 #1229}

The rules are based on common habit, for example:

• If a person requires help from two people to dress and takes less then ½ hour, the NPCNA would allocate 1/2 from two carers in the morning (to get dressed) and in the evening ( to get undressed) ( See example in Table 2)

• If the person requires help from one person to eat their meals, and takes less than 1/2 hour, the NPCNA would allocated 1/2 from one carer in the morning (for breakfast), at Midday (lunch) and in the evening (supper).

In this way the NPCNA builds up into a timetable of care needs throughout the day

Table 2: example of algorithm for calulation of care needs for dressing

The NPCNA therefore provides an estimation of care needs in the community represented by:

1. An individualised care timetable detailing the times care would be required throughout the day and by how many carers (see page 4)
2. A calculation of the total approximate care hours required per week
3. The type of care package required to meet those care needs on the basis of the number of carers required at different times of the day or night.
4. An estimation of the weekly cost of care (see page 5)

The NPCNA was published together with evidence of reliability and validity in 1999 (3, 4) . Since then it has been used in several studies to demonstrate the lstability of long-term gains (5) and the cost-efficiency of rehabilitation (6)

NPCNA Timetable of care needs

The day is divided into six sections or `time slots' of 2-3 hours each (morning, mid-morning, midday , mid-afternoon, evening, bedtime) and the NPCNA algorithm assigns tasks to these sections. (See Table 2 for example)

Certain assumptions are made about the timing of tasks - for example:

• meals are timed in the `morning', ` midday ' and `evening' slots.
• bathing (if help is required) is allocated to the morning slot.

The NPCNA is therefore a generic scale designed to give comparable information about care needs, regardless of the level of care actually provided or any individualised pattern in the timing of tasks.

Total Care Hours (TCH) and Restricted Care Hours (RCH)

The daily and weekly care hours are recorded in two ways.

The total weekly care hours (TCH) represents the simple summation of the care times allocated for each task in each time slot of the day. It does not allow for the fact that, in real life, many care tasks are undertaken simultaneously and therefore the total time taken to deliver a morning care programme may be very much less than simple the sum of the individual care tasks.

The restricted weekly care hours (RCH) overcomes this by setting a minimum of 30 minutes and a maximum of 2 hours in any one time slot of the day. This is because 30 minutes is the minimum allocation of time that can be bought from most care agencies, and 2 hours is the maximum length of time within the time slot before it overlaps with the next section.

Field-testing of the NPCNA in a variety of community settings suggests that the RCH provides a more realistic prediction of actual care needs or care provided in the community, than does the TCH which tends to over-estimate care. Thus the RCH is currently used for most practical purposes.

Table 3:

Example of the NPCNA-estimated care costs from the Timetable illustrated in Table 2

References

1. Turner-Stokes L, Tonge P, Nyein K, Hunter M, Nielson S, Robinson I. The Northwick Park Dependency Score (NPDS): a measure of nursing dependency in rehabilitation. Clinical Rehabilitation. 1998;12(4):304-18.

2. Skinner A, Turner-Stokes L. The use of standardised outcome measures for rehabilitation in the UK. In press 2005.

3. Turner-Stokes L, Nyein K, Halliwell D. The Northwick Park Care Needs Assessment (NPCNA): a directly costable outcome measure in rehabilitation.[comment]. Clinical Rehabilitation. 1999;13(3):253-67.

4. Nyein K, Turner-Stokes L. Sensitivity and predictive value of the Northwick Park Care Needs Assessment (NPCNA) as a measure of Care Needs in the Community. In: Society for Research in Rehabilitation; 1999; Southampton: Clin Rehabil; 1999. p. 482-491.

5. Rusconi S, Turner-Stokes L. An evaluation of aftercare following discharge from a specialist in-patient rehabilitation service. Disability and Rehabilitation 2003;25(22):1281-1288.

6. Turner-Stokes L, Paul S, Williams H. The efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries. Journal of Neurology, Neurosurgery & Psychiatry 2005;In press.