Timely and effective hospital discharge for older people: a person centred approach

Authors: Greene, Jane; Caldwell, Geraldine; McVeigh, Angela; Rankin, M Gillian; Sheeran, Catherine

Source: The International Journal of Clinical Leadership, Volume 16, Number 1, March 2008 , pp. 49-57(9)

Publisher: Radcliffe Publishing Ltd.

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Abstract:

During the late 1990s, long term care for older people with complex needs was moving from hospital care to community settings: domiciliary, nursing home or residential home (DHSSPSNI, 1990). Needs assessment for these people was carried out within a framework of care management.

From November 2004, Craigavon and Banbridge Community Trust moved the care management assessment process out of hospital, allowing for better informed decision making in respect of long term care options.

This article tracks the development of a whole systems approach to hospital discharge for older people with complex needs. Using a person centred approach, multidisciplinary assessment and care planning aimed to offer older people an opportunity for further assessment and, if appropriate, rehabilitation, following hospital discharge. This would allow for meaningful, supported decision making with regard to long term care options.

Building on the existing intermediate care service, an enhanced intermediate care pathway was developed to facilitate earlier discharge for patients who previously stayed in hospital to undergo the care management assessment and discharge process.

The outcomes have demonstrated high levels of user satisfaction, saved hospital bed days and successful rehabilitation resulting in reduced levels of need and reduced service requirements. There is also evidence that some older people are returning to their own homes following a period of supported discharge, with a subsequent reduction in long term admissions to institutional care.

The strategic direction towards primary care led health and social services in Northern Ireland has fostered and supported this approach.

Following the success of this approach, trusts across the region are now expected to provide complex care assessment and provision for older people in this way.

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Keywords: CARE MANAGEMENT; INTERMEDIATE CARE; LONG TERM CARE OPTIONS; PERSON CENTRED CARE FOR OLDER PEOPLE; WHOLE SYSTEMS APPROACH

Document Type: Research article

Publication date: 2008-03-01

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