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
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.
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.