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
The complexity of people with care needs has increased over recent years. The service means that people with high level needs can be supported at home with care delivered overnight. Previously this was only possible in a residential or hospital setting. Prior to the investment from the Change Fund there were two Overnight teams. The investment from the Change Fund allowed another three teams to be established. This has allowed people to move home from hospital, or remain at home, whereas previously a move away from home would be the only feasible outcome for meeting their needs. In some cases the requirement for care overnight was the only stumbling block to meaning someone could be cared for in their own home.
Provide a workforce capable of meeting the demands of increased anticipatory care activity within homes or homely settings by addressing the key priorities of the workforce development agenda. These priorities are: