As an Advanced Nurse Practitioner I usually work with high admitting care homes in the community of Cornwall to focus on complex patients at risk of admission and supporting the care/nursing staff to proactively manage long term condidions and frailty.
Following a successful four years reducing avoidable acute admissions it was agreed that I would test a similar model within the local acute hospital trust to assist with winter pressures.
My experience of care home patients suggests that the sooner they can be investigated, diagnosed and treated the less likely they are to decompensate or lose functional ability. Many care home patients are medically complex, comorbid, frail and have an element of dementia, they require and deserve consistent oversight to ensure their inpatient journey is productive, well informed and personalised.
My role within the acute trust is to proactively identify the individual and to drive a safe, supported and timely discharge, hopefully within 72 hrs if medically optimised.
We screen for acute care or re-ablement/therapy that can be delivered by our acute care team or therapy services in the community, for example certain IVAB therapy. We utilise our community matron and district nursing services and liase with the care/nursing homes themselves to support care delivery in the patients familiar enviornment, recovery, rehabilitation and re-ablement should wherever possible happen in the persons’ usual place of residence.
I measure discharge times and the outcomes since commencing the strategy has demonstrated the majority of discharges are within 72hrs many are turned around the same day and do not require admission.
A formal evaluation will be concluded in April 2016.
For more information contact Marie Prior Mob 07775227684 [email protected]