Anticipating patients that are moving towards a health transition because of emerging health issues.
In Moray we monitor daily the number of patients that are over 65yrs, who attend A&E and are subsequently discharged. We used the Change Fund to second a senior nurse practitioner to work alongside a Consultant Geriatrician to follow up the patients who were discharged. Case studies suggest that early intervention of this type has prevented further deterioration or enabled planned interventions removing the unpredictability of an unscheduled admission.
To implement ‘Living & Dying Well’ across all settings in Aberdeenshire. A dedicated Project Manager was appointed to facilitate implementation of Living & Dying Well in Aberdeenshire. Previous work had focused on Aberdeenshire Care Homes which had been very successful in raising awareness of the identification, assessment and ongoing review of palliative patients using a facilitative, rather than an instructional approach. This had demonstrated that cross boundary working is possible and positive. There was a need to extend this approach to other primary care, social care, voluntary and independent care settings in order to provide all staff with the confidence they need to carry out effective, person centered palliative care for older people.
Client accommodation was unsuited for older person safe independent living (first floor, no lift, many steps, poor layout)
Person was frightened by thought of moving; family has pressed to ‘go into a home’ – clearly not older person’s preference.
GP confirmed suitable ground floor accommodation meant no need for move to care home or similar
Greatest barrier was older persons fears – how could I manage to move, how can I afford to move, how do I deal with everyone (who?), how do I pack / unpack. Do I have to give up independence because I am too old to cope.
It was recognised that an increasing number of older people with dementia and/or mental health problems are admitted to acute hospital inpatient settings. These patients often require additional supports and hospital staff are less able to manage these patients within a busy ward environment. In addition to increasing staff skills through staff training, often individual patients will highlight specific issues which require a more specialist understanding or assessment. The project sought to provide this additional support and assessment.