Information Services Division (ISD) was keen to further develop the Scottish Patients at Risk of Readmission and Admission (SPARRA) tool to identify patients who may benefit from a more anticipatory approach to their care; planning for events or exacerbations to reduce the risk of emergency hospital admission.
SPARRA is a tool which predicts a patient’s risk of emergency admission; a patient with a SPARRA score of 50% has a one in two chance of being admitted to hospital in the following year.
The number of people in the UK aged over 65 is growing and is forecast to reach 16.1 million by 2035. The burden of disease associated with aging will increase as will the demands on health services including end-of-life and palliative care. The National Confidential Enquiry into Patient Outcome and Death in 2008 found that rather than advanced care planning and palliation taking place, some patients were subjected to excessively active interventions in their last months of life.
The pilot study aimed to ascertain whether using primary and secondary care data to identify patients at risk of hospital admission and agreeing and implementing an Anticipatory Care Plan in this population could help to reduce hospital admission rates. Anticipatory care planning allows patients to express their wishes for care prior to a sudden deterioration in their health.
One example was a lady with Dementia who was referred in order to consolidate support available and identify any areas that might require assistance. However, during preparation it transpired that this elderly lady was also a victim of financial abuse. The family knew this was going on and wanted it stopped but did not know what to do about it. The Family Group Meeting brought these concerns into the open. Social work was informed of these allegations but they agreed to wait for the outcome of the Family Group Meeting before pursuing their own enquiries.
Older drinkers can be more vulnerable and their needs more complex than younger people with alcohol problems. This can be as a result of the potentially greater physical impact of alcohol misuse on older people, as a result of, for example, the interaction of alcohol and medications; higher blood alcohol concentrations caused by body water reducing with ageing; and reduced alcohol tolerance levels.
Many service users from Addactions over 50’s alcohol service also identified social isolation as an on-going issue for them. Once they have became alcohol free and their health and well-being improved, they often found it difficult to exit from the service, and still sought ongoing support. In response, 55 positive seeks to provide an additional care pathway that encompasses peer mentoring, befriending, and social and educational activities.