Identifying older people at risk of admission/ readmission to hospital. High rates of multi-morbidity in older population. Evidence suggests that ‘anticipatory’ discussions with older people with long term conditions regarding their future care choices can reduce avoidable admissions
During October and November 2012, a total of 55 older people were referred from hospital for a Social Work assessment, more than double the number in the same period in 2011. This coincided with an upswing in the number of bed days lost to delayed discharge.
Users of the previous traditional home care service received a service that operated in a culture of ‘doing things for’ people that reinforced deficits and increased dependency. This ‘locked in’ resources with people who had the potential to improve their confidence, self esteem and independence while demand for the service was increasing because of the growing numbers of older people. In addition, there were financial pressures on the local authority.
East Dunbartonshire has the highest ratio of older people in Scotland. The percentage of population with dementia in the area is also greater than the national average and is expected to increase even further.
The clinic model contributes to a more efficient use of existing services through enhanced co-ordination of the existing resources of all of the partner organisations. They deliver flexibly and sensitively the type of advice and support that people with dementia have told us they need.