Care options and Discharge planning Flashcards
What alternatives are there to hospital admission for geriatric patients?
Home treatment service - can take referrals from any healthcare professional including paramedics and GPs, consists of consultant geriatrician, speciality doctors and advanced health care assistants.
Or rapid response team - made of nurses and healthcare assistants that can provide short-term urgent care for 1 week
Bedded frailty units - run by the geriatric MDT, do an early CGA and can work closely with social services with the aim of avoiding length hospital admission
What can the home treatment service do?
venepuncture with same day results
CRP point of testing
venous blood gases machine
can loan out an oxygen sats monitor and nebuliser for COPD pts
ECG machine
Can administer IV antibiotics and IV fluids
follow up phone calls and review before discharge
can refer onto other services
What are the factors to consider when deciding whether it is suitable for a pt to be treated at home - ie what further information would you need?
FOREST
Function – Can they do basic ADLs with care available at home/ can additional support be found? can the pt stand with a minimum of two people assisting, allows staff to help with personal care and check pressure areas and transfer to a comode
Obs (ie vital signs)– are these within normal limits for them?
Reviewing – Can you ensure prompt reviews with appropriate HCP? how quickly does she need reviewing? If their situation is stable, them may be triaged as less important
Examination – Needs to be thorough - can the underlying cause be identified? will they need to go to the hospital anyway for radiology eg if there are injuries?
Safety - Of environment for incoming clinical teams and clinical condition
Timely - Initiation of action plan needs to be prompt and possible in the home.
What are the advantages of frail pts staying at home?
Less likely to be subject to adverse events:
- falls
- delirium
- infection
- reduction in mobility
- pressure ulcers
Patient may not want to go into hospital, so suits their wishes
Financial costs reduced
When assessing a pt in their own home, what should you do and discuss with them?
ABCDEFGH
Access – can we get into the property? Is there someone there who can let us in eg the husband or neighbour
Baseline obs– repeat obs and examine, can do ECG, finger prick CRP, can compare the blood results to previous ones, can also ring the GP surgery and ask information about the pt. Also repeat examination of patient and take any urine samples and examine pressure areas
Capacity – establish that they understand that they are unwell and would they be happy to have their treatment at home? Discussion about the benefits of staying at home and the harms of hospital eg pressure ulcers, muscle wasting ,reduced mobility, unfamiliar environment which can increase confusion, more likely to fall – this can reassure patients and relatives about home treatment
Discussion – supporting the husband and pt, do they need additional carers? Can provide night support for families looking after pts with delirium
Environment – is it safe enough for the staff to go in? Do we need adaptations eg pressure relieving equipment? Is there a space for a hospital bed downstairs in the house
Functional level – what is their normal functional level? This helps us understand what the baseline is – helps in consideration of physio to get back to baseline
Goals – what makes a good day for them? What would you not give up if you became unwell – just to understand what we are aiming for and what support to put in
Hope for the best, but plan for the worst – At what point would you want me to escalate your care and would you want me to? If I found her more unwell on the next home visit, would she want me to transfer her to hospital? Has she had any advance care planning that we should know about? DNACPR discussions
What are the consequences of poor patient flow?
- EDs becomes crowded, stressful and unsafe
- patients are admitted as outliers to wards that are not best suited to manage their care, which may mean they have worse clinical outcomes
- Ambulatory care services, clinical decision units, even catheter labs and endoscopy units may fill with patients waiting for ward admission
- Inpatients are shuffled between wards to make room for newcomers
- Clinical outcomes are worse, particularly for frail older people, who suffer more harm events and may decondition due to extended periods in hospital beds
- Patients’ and carers’ time is wasted due to delays and slow care processes, and their experience is adversely affected.
- Staff are overstretched and routine activities slow down dramatically
What are the consequences of lack of integration between health and social care?
- delays in discharge
- more pts going into care homes
- admissions occur that could have been prevented or managed in the community
- increased healthcare costs due to unplanned admissions
Why is the health and social care system fragmented?
Due to separate funding and government departments
What are the features of our health and social care system that show lack of integration?
- having services focussed to one condition, leads to polypharmacy
- no one having a generalist birds eye view of the pt’s care eg a care coordinator
- concentrating on pt’s physical health and not on mental health
- no joint access to health care records
- reactive rather than predictive services. Servies only step in when a patient needs help rather than preventing this in the first place
In what ways can we increase the coordination of care between health and social care?
- single point of contact for pt and family in the form of a care coordinator/keyworker
- pt having an integrated care plan which they can keep at home that outlines what happens when the pt or family are unwell and services the pt can access with contact details
- continuity of care
- advice and support for pts so they can manage their own conditions
- cross-disciplinary education and education about the roles of OTs, physios, social workers etc so that staff understand who to refer to
- greater use of the voluntary and third sector
- greater use of informal support network eg friends, family, support groups
- focus on prevention rather than cure
- shared electronic records
- colocation - put the health and social care staff together in one place with clinics under one roof
- regular meetings between health and social care teams
- joint assessment - both physical, mental and social assessments
- joint commissioning of services
can summarise as:
- information continuity (info about condition, services, health care records)
- management continuity (joint and collaborative care plans)
- relational continuity (care coordinator)
Define rehabilitation
a multidisciplinary set of evaluative, diagnostic, and therapeutic interventions whose purpose is to restore functional ability or enhance residual functional capability in elderly people with disabling impairments
So trying to find out what the problems are and seeing whether we can improve them
remember that functional capability is physical, mental and social
Define rehabilitation potential
The MDT’s perceived ability of the pt reaching a designated goal or potential to improve from their current state
Don’t just think about physical rehab, they may not be able to do more than a hoist transfer, but they could improve in their self-care
Are there certain individuals who may be unsuitable for rehabilitation and who are they?
- People who are at the end stage of their disease
- rapidly progressive illness
Can patients with dementia still get benefit from rehabilitation?
yes - all pts should be assumed to have rehab potential and studies have shown benefit of rehab in pts with dementia
Why might someone assume that pts with dementia have no rehab potential?
- Dementia can affect balance and gait
- Can affect planning, execution and interpreting information into action
- thought that they will not retain information into the next session - ie ‘carry over’ information (remember though that they may not remember doing it in the last session, but they may still be able to do it)
