Publications from ODSW Social Insights: Letters by DSW (Vol 2) | Page 60

Working with Various Client Groups
being involved in the follow up process with community services. This allows
more complex cases to be managed closer to home. Wherever possible, it
should adopt a multidisciplinary approach with access to secondary care
support and advice. The role of GPs/ family medicine in such an environment
will become more crucial and thus, the training of GPs must be done with
this growing role in mind.
There are further instances where acute admissions can perhaps be
minimised. This can happen if there is a way where adult social care services
can work with immediate care by a local team that has the capacity to
provide a rapid (two-hour) response to a frailty crisis with an older person.
Both the older person, the care givers and the community service providers
will be more confident of playing a larger role when they know that such a
crisis response is available.

Acute care by specialists familiar with geriatrics
Some have suggested that with the growing number of older people, it
will be helpful to have “old age specialist teams” that are available at the
medical admissions unit. This may reduce admissions and long term stay if
what some call, “consultant-led old-age specialist assessment” is available
at the pre-admissions stage or even at the community level. This could
also mean that some early assessments would have to be made before an
older person is moved into and “drift” in the system. This could result in
improved productivity with less down time in terms of transfers of wards and
a better patient experience. In the case of admissions, it could mean earlier
discharge to community-based care.

Community services that have clients at the centre
The design of services to meet the needs of older people can be complex.
More integrated care is correctly seen as the right general approach. What
is challenging though is the difficult discussions about risks for older people
and the ownership of the approach towards supporting older people
living in the community. For such integration and approach to work, it is
essential to build relationships and trust through inter-agency work on
strategy, operations, care plan and sharing of information. It is about multidisciplinary, if not trans-disciplinary work that requires sustained leadership
from all parties. What will motivate us to work to focus on good outcomes
for older people is the productivity gains for our agencies and the better
deployment of expertise and manpower. It is about an environment that
aligns, and over time integrates, health and social care provision to assure
better outcomes at lower cost.
59