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
Prior to the establishment of the Duty and Response Team, there was no community rehabilitation team and social care and health elements of support operated independently, albeit collaboratively with one another. This still meant duplication of information sharing and assessment processes for older people requiring the service. The Change Fund enabled the addition of Physiotherapy and Occupational therapy professionals to join the Adult Wellbeing duty and response team to form a multidisciplinary duty, response and rehabilitation team.
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.
Falls are the most common call received by the Scottish Ambulance Service in Aberdeen, with a mid-morning peak. The purpose of this project was to maximise the number of Older People who can be supported to remain at home, following a fall. This is intended to significantly reduce the number of unnecessary hospital admissions for older people.
Very few patients had an anticipatory care plan in place should they become unwell and none had a plan should their informal carer become unwell or unavailable. There were often separate plans in both Health and Social Care and sometimes access to the required information out of hours was difficult or the information just unknown, potentially resulting in short term care home admissions and avoidable hospital admissions.