It is important to look for underlying reasons why people fall and if these are preventable. We know that falls record the highest total length of stay for all admissions and can result in a fracture with the associated loss of confidence and lengthy rehabilitation. Many older people have a ‘community alarm’ and use this to call for help when they have fallen with immediate support provided through the Social Care Response Service (SCRS). Information relating to the call out is gathered by the service and logged, however the information is not shared and other than GP/Emergency service referrals, there is no pathway from the service to falls clinics, etc.
Formal Anticipatory Care Planning and recording were not carried out within the Day Hospital (Medicine for the Elderly). Ensuring that anticipatory care and forward planning are introduced at the most appropriate time in an older person’s life is crucial to planning future care. The team agreed that patients who attended the Movement Disorder Clinic would be most appropriate due to their diagnosis of a degenerative long term condition and in addition these patients are well known to the team and are reviewed regularly.
The pro-active identification and assessment of people at a high risk of experiencing an adverse drug reaction leading to hospital admission / re-admission, otherwise known as a polypharmacy medication review.
Supported by improving communications and information transfer between hospitals and primary care with regards to medication.
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.
Falkirk Council Home Care Service provides care to approximately 1,600 in house service users and manages the care of approximately 300 + external agency only and in-house plus external agency and or voluntary provider service users.
The traditional model of management for this service had been to appoint home care managers on a geographical basis to manage the whole range of services to be provided. Whilst this was acceptable 15 years ago with the changes to care provision, increased volume of care at home services and the changing ethos of how we provide services, e.g. re-ablement, use of private providers etc. the traditional model was outdated, no longer met the needs of the service users and was preventing the capacity of managers to provide the high quality of care services which we aim to provide.
As part of our self evaluation exercise we highlighted the need to diversify our management arrangements and specifically aim to target the effective splitting of the patch home care manager’s role into three specialism’s. These will be long term service provision within a geographical patch, resource management of agency providers, shopping meals and laundry services and our 24/7 service providing specialist re-hab at home, crisis care and to move into a more involved relationship with facilitating more appropriate and timely discharge of patients as well as preventing hospital admission by extending the remit of our rapid response services and working closer with our colleagues in Reach.