What was the issue you were addressing or working on?
East Ayrshire Community Health Partnership have been working collaboratively with Council , Health Board, private and voluntary sectors colleagues over a number of years to reduce admissions and readmissions to hospital, encourage independence and support older people to remain at home. At the same time older people are telling us that they wish to stay in their own homes whenever it is safe and practical to do so, to be helped to be more independent; and to have choice and control over how they manage their lives. Intermediate Care and Enablement Services is recognised as a key approach to meet the challenge to re-shape health, care and support services for older people.
What you did?
A 91 year old lady who was previously independent with all activities of daily living had become confused and had reduced mobility; she had taken to her bed. At this time her family were staying with her at all times as she was unable to mobilise without assistance. Her family request for a GP visit. Antibiotics were prescribed at this time and a MSSU taken for a suspected UTI. The GP made the referral to IC&ES as an alternative to hospital admission. The care manager from IC&ES visited on the same day and completed a multi factorial assessment and Homecare was requested initially 4 visits daily via the Home Care Manager IC&ES.
- A commode was issued and positioned in bedroom to make transfer easier. Advice given about transfer technique.
- Overnight Home care to allow the anti biotic to take effect and to offer some respite to the family.
- A walking aid was provided at time of assessment. Advice given re use.
- A physiotherapist assessed mobility, and gave instruction to technical instructor to progress same.
- The Occupational therapist assessed functioning, and progressed same in conjunction with the technical instructor/Rehabilitation Worker
- The pharmacist reviewed medication.
- Confidence building regarding independence and less reliance on family and homecare
What were the outcomes - benefits or otherwise?
Outcomes for the lady:
- Homecare was gradually cut back with ongoing practice in all areas of daily living.
- Patient/Service Users was mobilising independently.
- Homecare visits had reduced to a morning visit.
- Family were confident that overnight care was no longer required by then or carers
- The Service /users/patient had returned to previous levels of functioning with some support from carers once daily for personal care.
The service user/patient was discharged.
A single point of contact for referrals reduces admissions and readmissions to hospital, maximises older people’s ability to self manage at home and maintain their independence and at the same time reduces reliance on services. The community service will contribute to national targets on delayed discharge from hospital, number of emergency bed days saved in acute specialities and a reduction in the number of people (65+) admitted as an emergency to acute specialities.