This service was developed in response to the fact that older people can often be unnecessarily admitted to hospital, due to there being a lack of readily available transport to take them home, and the risk that the 4hr A&E target may be breached for them. It was recognised that patients may also be more likely to be admitted especially if they have arrived at A&E later in the day, and there is a lack of family/care support to ensure a safe return home.
In addition to this, a service that would support individuals into their own home, ensuring their safety and comfort, was seen to be beneficial both in terms of direct support to the patient, and potentially picking up on issues which might prevent further deterioration or a potential readmission to hospital.
To improve the experience of carers of older people through the journey of hospital discharge from beginning to end. Carers expressed views that they felt excluded from the process of hospital discharge and needed to access relevant information and support.
Very few patients had an anticipatory care plan in place should they become unwell and none had a plan should their informal carer become unwell or unavailable. There were often separate plans in both Health and Social Care and sometimes access to the required information out of hours was difficult or the information just unknown, potentially resulting in short term care home admissions and avoidable hospital admissions.