Community Geriatrician

Examples of Practice

Avoiding unnecessary admissions to hospital by supporting community-based alternatives to hospital admission.

 

 

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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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Elderly Care Assessment Nurses

Examples of Practice

Many older people were being admitted to appropriate wards from an acute medical perspective but were missing the opportunity to benefit from a coordinated comprehensive geriatric assessment which would potentially ensure a better patient journey and reduce the hospital stay.

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Reducing Emergency Admissions to Hospital

Examples of Practice

We knew that more older people were being admitted to hospital as an emergency than was desirable and we wanted to identify how we could avoid these crises in people’s lives occuring.

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Access to Comprehensive Geriatric Assessment in the Community

Examples of Practice

Anticipating patients that are moving towards a health transition because of emerging health issues.

In Moray we monitor daily the number of patients that are over 65yrs, who attend A&E and are subsequently discharged. We used the Change Fund to second a senior nurse practitioner to work alongside a Consultant Geriatrician to follow up the patients who were discharged. Case studies suggest that early intervention of this type has prevented further deterioration or enabled planned interventions removing the unpredictability of an unscheduled admission.

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