The needs for care assessment a longitudinal approach

schedule recommends specific care interventions and these were implemented where appropriate. The problem status of the patients was reassessed using the needs for care schedule after the interventions had been offered and tried. The recommended care items were within the compass of our rehabilitation service, were rarely refused by the patients and there was an improvement in symptom and social function. These findings provide some validation for the concept of unmet need.


Patients
Eighteen patients referred to a high support hostel from a Dublin district psychiatric sector (population 89 000) were assessed.Their median age was age 43 (range 21-64 years).Fourteen met DSM-III-R criteria for schizophrenia and four had affective disorders.The sample included ten males.The median length of psychiatric illness was 17 (2^10) years.Nine were in-patients (due to lack of adequate hostel facilities).The remaining nine resided at home with regular service contact.

Assessment and assessors
Three pairs of staff assessed six patients each using the NFCA and the Social Behaviour Schedule (SBS; Wykes & Sturt, 1986).To facil itate repeat assessments using the NFCA, we designed a semi-structured interview schedule.Another pair rated all patients using the Present State Examination (PSE; Wing et al, 1974).
Level of functioning in 20 social and clinical areas was assessed by questioning the patient or relatives/staff in close contact with them.The NFCA rates problems as 'current' if the level of function fell below a standard threshold within the previous month.If the level of function is above the threshold required for the previous month, yet has fallen below it in the previous two years, or is likely to in the future, the problem is rated as 'recent'.Staff were then interviewed to assess the items of care in place for dealing with these problems.
Primary need status was rated as unmet when a problem was identified and when the care item was considered appropriate, yet had not been given a recent and/or adequate trial.
Following assessment, the clinical teams re sponsible for each patient were notified of the results.Items of care were offered and provided on a one to one level by the clinical teams or where appropriate, in groups.
Needs status were re-assessed 3-6 months after the initial assessment by the same pairs of workers interviewing the same informants as before.To avoid bias, interviewers did not assess patients from their own clinical team and in formants were selected as far as possible who had minimal direct involvement in implementing the items of care.Statistical analysis was by Wilcoxon matched-pairs signed-ranks test.

Initial assessment
On first assessment, 109 current and 29 recent problems were identified from a possible 360 (18 patients x 20 functional areas).The range of current and recent problems per patient was 1-15 (median=6) and 0-5 (median=1.0)respec tively.For one patient who died prior to the second assessment, details (4 current/1 recent problem) were excluded from further analysis.
A total of 51 unmet needs for treatment were identified (51/133=38%).The related problems in the clinical area included psychotic symptoms (3), underactivity (3), physical illness (3), embar rassing behaviour (4), psychosocial distress (7) and other (3).In the social area, problems were with personal hygiene (4), household shopping (4), occupation (4), communication skills (5), money management (7) and other (4).More than half of the care items recommended in the clinical areas related to suppport/reassurance or coping advice to the subject (13/23=57%).In the social domain, 28 care items were recommended, with remedial training for personal hygiene, household shopping and money management being the most common.All these care items were within the capacity of the service to provide.Of the remain ing problems, 52 were rated as met need, six as unmet need for assessment, and 24 as no meetable need.

Repeat assessment
The problem, item of care and resultant needs status after 3-6 months are presented in Table 1.By this time one patient had been discharged from in-patient care and four out-patients had been placed in group homes.
Thirty-three items of care were actually offered to patients.One patient refused the offered care item.In two instances the care items were judged as unsuccessful in improving functional level.In 17 instances (51%) the care items care were judged successful, including a subgroup of six in which the intervention was continued to prevent recurrence.In a further 13 instances (40%), although functional level did improve, but not to the required threshold, the items were considered appropriate and worthy of continuation.Eighteen items of care were not offered.These included eleven instances where intervention was judged in danger of overloading two patients suffering schizophrenic relapses.Four were not implemented as the patient involved had left the catchment area and three were overlooked (all seven yielded unmet need status at follow-up).The reduction in the median number of unmet needs per patient was significant (P<0.001).

Comment
Both in conception and use the NFCA aims to set minimum standards of care.These minimum standards are defined by experts (normative) as are the care items proposed as necessary in maintaining such a minimum standard.Although the care items are listed whether or not the service can provide them, we found that all those required in the present report were within the compass of our service.This finding, together with the fact that only one care item was refused by a patient, indicate that the care items were at least above the minimum threshold of acceptability to our service and to the patients it served.
Inherent in the concept of unmet need status is that sub-standard levels of function are remedi able by listed care items.Given the thresholds for level of function as proposed by the NFCA we found support for this contention.Thirty-three care items were offered and of these 17 (51%) resulted in improvement above the threshold level.In a further 13 (40%), although the improvement was not sufficient to break the The needs for care assessment-a longitudinal approach

Table 1 .
Level of function, item of care and need status at the second assessment