Systems & processes are not always conducive to good communication, anticipatory planning and integrated working. This is particularly evident for people with complex needs requiring a multi agency, multi disciplinary approach who may not able to advocate for themselves.
When someone is affected by a significant illness/condition such as a stroke, it impacts upon the individual’s lifestyle, and may result in the individual becoming dependent on another person such as a spouse, daughter, son, friend or neighbour, in order to remain in their own home. Intervention from statutory/private/ voluntary services may be required in order to maintain the quality of life, and information and advice regarding the locally available services becomes essential for both the individual and their carer/family members. The individual and their carer are then able to make informed decisions regarding support services, based on the information they have been provided with, which allows them to maintain control during their transition from hospital into their own home.
Early interventions with carers in the hospital setting will enable carers to be informed of systems in place, their right to a Carers Assessment and the process of that assessment, and the eligibility criteria for health and social care provisions. It will also enable planning for support services such as, respite and support groups.
Support carers in the management of medicines to allow patients to have their medicines administered in a safe and informed manner and to allow older patients to remain in their home safely and to reduce unscheduled hospital admissions caused by inappropriate use of medicines
Responding to the National Dementia Strategy and the National Dementia Standards, the Dementia Support Service was set up to provide short term intervention for cases that had ordinarily ended up at crisis or in the residential care system.
The management of frail Angus patients was reliant on hospital admission and prolonged stay to assess and manage acute or often non-acute de compensation to a frail person’s health. This resulted in high occupancy rates in community hospitals and adverse outcomes for patients such as hospital acquired infection.