Anticipatory Care Planning

Examples of Practice

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

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Home Care Re-ablement

Examples of Practice

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.

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Carers Innovative Personalised Short Breaks

Examples of Practice

Carer burn-out or extreme fatigue has often been anecdotally cited by carers themselves as the lead cause for the cared-for being moved on to institutional hospital care, often viewed as an avoidable hospital admission.

This can often lead to poor personal outcomes for both the cared-for and the carer.  Tackling this in a preventative manner has allowed carers to retain their physical and mental well-being, supporting them in the longer term in their caring role.

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Hospital Discharge Liaison – Mrs W’s Story

Examples of Practice

A concerned neighbour contacted Services about Mrs W, aged 90 living in Eastwood Area. A visit was conducted, identifying Mrs W as being in an extremely fragile state, physically and cognitively.  Her house was found to be dirty and difficult to access due to clutter in rooms and passageways.  Kitchen flooring was a trip hazard; oven, microwave and washing machine were dirty and broken.  She presented as delusional and unable to convey appropriate self determination as to her presenting circumstances.  Her GP was called with regards to an emergency health assessment.  It was determined that she was at such a high level of risk that she was detained in Hospital.  Mrs W spent 16 weeks in Hospital.  Made good health progress, and was supported through good discharge planning to return home at the earliest appropriate time.

Mrs W was identified as having complex issues regarding her capacity.  Supporting her to return safely and within Hospital Discharge guidelines to her own home in community from Hospital was considered to be complex.

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