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.
All parts of the patient’s support system (the carer, acute and community care services etc) should work together to achieve the best outcome for both the cared for person and the carer. Despite the policy and good practice advice which has been developed to guide us across this pathway, carers often report that they feel ill-informed and that policy is often not reflected in practice.
Establishing Carer Support as a key component of the hospital discharge process addresses the need to identify carers at an early stage and ensure that they are well informed and supported. It also addresses the need to support carers at key times of transition, eg where the admission meant the carer was no longer able to continue care at home and the person they cared for was being admitted to long term care.
The increased number of older people living at home with one or more long term condition means there is increased risk of errors with medication. This has been identified as a risk for emergency admission to hospital. These older people are not a group who would routinely receive a review. Post Hospital Discharge a ‘transition’ time for many older people was originally targeted with the service now being available for all Care at Home clients.
Additional support to vulnerable older people to manage their medications can avoid emergency admission to hospital.