Care planning for older people: the approach in Stafford
We have developed a new system of advanced care planning that you might want to consider.
Families and patients love it: we ask them to fill out forms on patient reported outcome measures about each element of our service. And good care is also efficient: we have found it reduces hospital length of stay, promote independence, avoid hospital admissions and make enormous health economy efficiencies: click here to read more.
How do we do it? First we identify those at risk of frailty. To do this we send out a birthday card to local people around their 75th birthday. This includes an assessment form which is easy to fill out. We get a good response to this: in our area, 85% of the patients hand these back to the practice.
Meanwhile we have recruited a new team called “eldercare facilitators" to score the assessments and pick out those that need a follow up visit. A history of memory loss or falls would automatically prompt a visit. The eldercare facilitator visits the patient at home and does a detailed assessment. This takes on board social and carer needs. The facilitator takes on a befriending role and becomes the single point of contact.
The patients are asked to come to the GP surgery where a trained senior GP performs a comprehensive geriatric assessment. This includes a discussion with both the person and family about the care inputs they value and what the outcomes would look like. We set out triggers for accessing urgent care.
All this is recorded as a paper care plan that the person can attach to their fridge. There is also a web-based electronic version which is owned by the patient: this can be seen here. The eldercare facilitator helps the family to take the care plan forward and we also offer 24/365 telephone support to the carers.
What did it take to achieve this? We developed a system of primary care federations to get commissioning resources to fund the advanced care planning. We joined forces with the social and community partnership trust. The resulting joint workforce capacity look and feels real.
The upshot is that we find out about frail patients before they hit the medical buffers: it is an important stitch in time. The fact that it is low cost means we think it could be replicated in many areas. We would be interested to see you have taken a similar approach or have experiences that others could learn from.