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 aim was to support clinicians in making person centred decisions, to assess and balance the risks associated with Polypharmacy in the elderly. This evidenced improvements in terms of reduced numbers of repeat medications, high levels of staff and patient satisfaction and increased efficiency within the prescribing budgets.
Continue to increase the rate of diagnosis, agree a diagnosis pathway for dementia that complies with the Dementia Standards and enhance current provision of post diagnostic support to achieve the Post Diagnostic Heat Target.