Are community care pathways & resources available?
The fundamental problem lies in the lack of community based care resources and pathways to enable older people to be cared for in their own home.
It is recognised that that any person is more comfortable being looked after in their own home, after all the necessary (critical) procedures have been completed in the hospital. Quoting from the article, Caroline Abrahams, director of Age UK, said:
““These figures show that year on year, older people are being trapped in hospital in ever greater numbers because of a delayed assessment, care home place, home care package or home adaptation.
If the appropriate community or home based care pathways are not in place, then the older person's rehabilitation can be lengthened and also the probability of re-admittance to hospital can be increased. All of this consequences highlight the importance of an integrated discharge pathway - enabling a seamless transfer from hospital to community/home based care.
The contribution from Assesspatients
- A detailed multidisciplinary care assessment incorporating different set of care needs such as frailty, falls, dementia, stroke , quality of living etc
- A current set of care outcomes including what has been achieved and what is in progress
- Detailed dashboards providing advanced notice on numbers of people due for discharge and their care needs
- An ability to securely provide all of this information to the community care team and an ability for both the hospital and community teams to share and plan specific discharges.
Best practice in older care in different countries now regards the home as a primary centre of care for older people and Assesspatients can support this practice with its focus on integrated care pathways. We were interviewed on the use of Assesspatients in a discharge planning scenario at a recent DHI Scotland's exploratory event on Outpatient services.