Reducing levels of delayed discharge from hospital by providing specialist care at home or in care homes in the community; avoiding unnecessary admissions to hospital by supporting community-based alternatives to hospital admission; expanding and promoting choices for older people in anticipatory care planning; ensuring staff have the right skills to be able to appropriately and effectively support people at home.
The need for training that was merged and developed, if you will, to find the right balance between the needs of our clients and the needs of our volunteers. Existing training for befrienders was felt too ‘cold’ and failed to take into account the range of needs and aspirations of older people themselves – and the relationships which develop from such initiatives.
Older people and volunteers were unimpressed with existing training, and had viewed several packages; this was a truly co-productive approach.
The issue which had been evidenced through analysis of referrals was that in the Wishaw / Shotts area there were significant numbers of older people who were experiencing some degree of isolation and were seeking support to connect to social activity in their communities. It was recognised that the experience of loneliness and isolation, if not addressed, carried risk of precipitating detriment to medium to longer term health and wellbeing. The issue encompassed the need to work with older people to ascertain directly what would for them constitute meaningful social activity.
Inverclyde CHCP recognised that we had to develop our partnership working with the Care Home Sector in order that they could deliver care in line with the emerging RCOP agenda, supporting change initiatives in areas such as; Anticipatory Care Planning, Dementia Care and End of Life Care.
All parts of the patient’s support system (the carer, acute and community care services etc) should work together to achieve the best outcome for both the cared for person and the carer. Despite the policy and good practice advice which has been developed to guide us across this pathway, carers often report that they feel ill-informed and that policy is often not reflected in practice.
Establishing Carer Support as a key component of the hospital discharge process addresses the need to identify carers at an early stage and ensure that they are well informed and supported. It also addresses the need to support carers at key times of transition, eg where the admission meant the carer was no longer able to continue care at home and the person they cared for was being admitted to long term care.