The increased number of older people living at home with one or more long term condition means there is increased risk of errors with medication. This has been identified as a risk for emergency admission to hospital. These older people are not a group who would routinely receive a review. Post Hospital Discharge a ‘transition’ time for many older people was originally targeted with the service now being available for all Care at Home clients.
Additional support to vulnerable older people to manage their medications can avoid emergency admission to hospital.
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 the traditional model was outdated, no longer met the needs of the service users and was preventing the capacity of managers to provide the high quality of care services which we aim to provide.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.
transfer appropriate people to the HWCRS (e.g. those who meet the agreed criteria)
work with and encourage service users to regain their level of function with regards to mobility, personal care and kitchen tasks resulting in an increase in confidence and independent living for the service user
educate the informal care/family regarding the re-ablement approach to care
encourage socialisation and taking part in mainstream HWC activities
The management of frail Angus patients was reliant on hospital admission and prolonged stay to assess and manage acute or often non-acute de compensation to a frail person’s health. This resulted in high occupancy rates in community hospitals and adverse outcomes for patients such as hospital acquired infection.