As a health and social care Consultant Practitioner specialising in hospital discharge planning . I would recommend that as part of the hospital discharge planning , information regarding the patients ability to be discharged should be gathered at point of contact, as this causes hospital delay and readmission, this includes information regarding the housing environment.
I have developed a carers hospital assessment tool for nurses in which this type of information can be easily gathered. Patients living alone who are confused or suffering from dementia may not have the capacity, family carers may be too embarrassed to disclose this form of neglect.
However this type of information can be gathered from the paramedics, as part of hospital admission, the ward can report this information to the hospital social worker/ Occupational Therapist. The information can then be included in the hospital discharge letter as an alert.
As some GP's are employing social workers, this could be monitored by a social worker/or by the integrated community team as part of assessment care review.
Often Government institutions who have no direct contact with frontline operational management make decisions without consulting those who are involved in the process and miss out on basic Solution Focused Approaches.
Please contact me on my email valma.james@ntlworld. com- if any GP's interested in finding out more.
The National Service Framework for Older People was an excellent mechanism and tool for addressing key aspects of older people;s health and developed a seamless approach. Not sure why it is not being used! My perception is that Gov policies go and come , the ones that have proven to make a difference are shelved. NSF for Older people ensured that there was an integrated and multidisciplinary approach to improving the quality of life of older people.
An alternative option could be for the appointment of a specific worker, who will support the patient with planning health and social care support, such as the community health prevention GP outreach workers. Or if the patient has a social worker, this aspect of planning care can be integrated as part of their community care plan. email@example.com
Another good idea, but GP's will require support, however there is no reason why GP's cannot get their local council to provide seconded community health outreach workers, who can run community based well being workshops and preventative health care. Whilst working with a local authority I was able to access funding to establish a community health promotion service to train local people to deliver health promotion and community exercise, once trained the health promotion community facilitators and community exercise facilitators delivered their activities at local community luncheon clubs for the elderly but were also employed by Watford Borough Council. If you would like to know more about this activity contact you may contact me on firstname.lastname@example.org
Such projects provide local volunteering opportunities, for the unemployed who may want to consider a career in community development, social and health care, but it opens opportunities for building social capita as well as building communities.
Unfortunately the concept is not new, social workers use to be based at GP practice, which is the most practical solution in providing a holistic welfare support. A social worker in practice can undertake community care assessment, carers assessment and identify local community resources to support the patient. I am a social worker and qualified nurse and know the benefit of a systematic and holistic approach. Currently health,social services and GP IT systems are not compatible, hence a lot of wasted time in the referral process. I would be interested in being contacted regarding further discussions on my point of view, on how such an approach can be implemented and integrated within health and social care practice . My email is email@example.com