Better Sooner More Convenient Primary Care - New Zealand Doctor
Better Sooner More Convenient Primary Care - New Zealand Doctor
Better Sooner More Convenient Primary Care - New Zealand Doctor
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Appendix Eleven: Frail older people<br />
1. Aspirational statement:<br />
Frail older people and others with long term disabling conditions will be able to access support<br />
services that are timely, flexible and appropriate to their individual needs and those of their<br />
carers.<br />
The pathway of care among primary, secondary and community based services for older people<br />
and those with long term disabling conditions will operate smoothly with excellent informationsharing<br />
among all services and with people and their families.<br />
All health and support service workers will be proactive in helping the person and their carers<br />
maintain and regain their functional abilities and prevent further illness or injury.<br />
2 Problem definition<br />
<br />
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<br />
Lack of clarity/agreement on appropriate pathway of care for frail older people, within<br />
Grey Hospital as well as between hospital and primary health services and home based<br />
and residential care services.<br />
Stroke patients not transferred to specialist care soon enough and sometimes not at all,<br />
and national stroke guidelines have not yet been adopted.<br />
Opportunities missed for keeping frail older people fit and well and preventing admission<br />
to the acute hospital and to long term residential care – lack of a pro-active approach to<br />
reducing the risks of avoidable hospital admission or rest home entry.<br />
Frail older patients admitted to the acute medical and surgical wards or presenting at<br />
ED are not always appropriately referred to specialist Health of Older Peoples services.<br />
Lack of a shared client information system even among DHB services, let alone primary<br />
care, home support or residential care.<br />
Lack of step down beds for convalescence and slow stream rehabilitation, and continued<br />
inappropriate use of long term respite care and carer support budgets for this purpose.<br />
Over use of long term residential care (particularly rest home level) due to under<br />
development of home based alternatives, (eg. flexible homecare packages, planned<br />
respite, dementia day care, support for carers).<br />
Under development of home support services – most carers are untrained and casual,<br />
with limited supervision or linkage to district nursing, community allied health, <strong>Care</strong> Link<br />
or primary health services. Home support agencies cannot always provide staff for<br />
high/complex packages<br />
Business case appendices V12 AC 25Feb2010 Page 101