Explore how Care Act 2014 principles, multidisciplinary partnerships, and holistic, person‑centred care reduce elderly hospital readmissions and improve outcomes in UK health and social care practice.
In current era; hospital readmission of elderly patient is at the forefront of healthcare challenges; the issue is persisting to greater extent and this has further gained the attention of National Health Services [NHS] UK. For students seeking help writing assignments, this healthcare challenge offers critical analysis opportunities. High readmission rate placing undue strain on healthcare resources and often highlighting challenges experienced by patients in managing their conditions in post-discharge phase. Greenfield District General Hospital facing persisting complexities regarding readmission of elderly patients. Consistent readmission has been developing pressure on the hospital resources and influencing patient outcomes in drastic manner. The present assignment will be based on determining the principles outlined in The Care Act 2014 for underscoring the importance of partnership working among health and social care professionals for preventing readmissions.
The hospital setting providing services to elderly population suffering from multifaceted chronic conditions. This demographic is highly prone to consistent and frequent readmission that are primarily due to inadequate follow-up, insufficient support services and lack of coordination among staff. Despite commitment towards patient-centred care; rates of readmission within 30 days of discharge exceeding and further indicating that there is need to take an immediate systematic change in this context. The major stakeholders who are getting impacted due to this issue are- patient and staff members; there is huge pressure developing on staff members as their work load has been increasing. Additionally, patient health is not stable as they require consistent readmission. This is also creating drastic impact on the wellbeing of patient. The Care Act 2014 articulates about integrated and person-centred care by promoting the wellbeing of individuals. In accordance with this policy, it is pivotal to develop collaboration across health and social care sectors so that consistent support can be ensured to patient (Ley, 2023). Thus, this legislative framework providing a robust framework upon which partnership initiative can be built.
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The literature has been underpinning several best practices that leads to minimise readmission among elderly patients while complying with effective discharge planning, patient education, medication reconciliation and follow up appointments (Phillips et al, 2024). Comprhensive discharge planning supports in decreasing readmission rates along with suggesting early assessment of patient requirement. Studies have shown that providing home visit to patients who are at high risk proves to be effective in reducing admission. The post discharge activities such as consistent follow-ups and community health support develops sense of belongingness in patient and decreases readmission incidence within hospitals. Therefore, it is important to undertake consistent follow up from patients so that their health outcomes could be enhanced to greater extent. Furthermore, focus needs to be implied on undertaking appropriate medication management that complies with evidence-based medicines; many elderly patient suffers from polypharmacy that complicates their adherence to the prescribed treatments (Burn et al, 2024). Medication reconciliation is important specifically during transition of care for preventing errors and adverse event that can result in readmissions.
Patient education is a crucial domain; in accordance with The Care Act 2014; patient should be empowered and they must be made aware about the actions that can develops drastic impact on their wellbeing (Carr, 2021). Further, patient education supports in creating awareness among elderly patient for undertaking healthy practices that enhances Quality of Life [QoL]. Therefore, significant focus requires to be implied on this area and accordingly patient should be educated during discharge procedure. Appropriate information related to medications, food and other aspects requires to be given. Healthcare professional should ensure that patient does not have any kind of confusion and open communication requires to be promoted (Carr, 2021). In case patient needs consistent support then, appointment requires to be set and telephone follow-up must be taken. This supports in providing supports to patient and improves their condition and subsequently, it reduces readmissions at hospital. Based on these insights evidence-based strategies should be implemented while implementing coordination with local partners such as GP, social care providers, community-based charities and pharmacies.
Partnership working is crucial for ensuring holistic care to elderly patient post-discharge. Local GP practices are important for proposing follow-up strategies along with coordinating care within inpatient setting. Primary care physician should be engaged in the discharge planning facilities so they can manage health risks before exacerbations (Krachler, Greer and Umney, 2022). Community-based charities and social care providers performing significant role in addressing non-clinical factors that influences patient outcomes. This involves social isolation, lack of access to resources and lack of support; these organisations provide services related to home visit, transpiration and support group for enhancing patient engagement and complies with care plan (Krachler, Greer and Umney, 2022). Thus, by developing partnership with social care providers sustained support to elderly patients can be provided along with improving their health outcomes.
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Pharmacies is also a critical element of partnership as it focuses on medication management while preventing readmissions. Pharmacist supports in conducting and monitoring medication reviews, providing consultation on medication adherence and facilitating communication among patient, caregivers and healthcare providers (Alderwick et al, 2021). Thus, it assures that appropriate information has been provided to patient regarding their medical regimens. Hence, collaborative framework results in promoting consistency in care model under which each partner would be aware regarding their role, patient health status and care plan (Alderwick et al, 2021). Therefore, this leads to reduce the risk related to miscommunication and decreases the extent of readmission within hospital. Multidisciplinary approach could be followed for developing effective partnership; this adheres with keeping patient at the forefront of services and holistic care assured to them (Alderwick et al, 2021). Furthermore, focus ensured on empowering and safeguarding patients. In this manner, effective partnership could be developed that supports in reducing readmission of elderly patient along with enhancing their health outcomes.
In order to successfully implementing these evidence-based practices it is essential to follow a structured approach which facilitates robust communication channels among stakeholders. The major stakeholders who are involved in the procedure are social care providers, local authorities’ pharmacist, physician, nurses, patient, community services, GP and healthcare professionals (Fishley et al, 2023). Principles of health and social care comprehends with dignity, respect, empowerment, safeguarding, confidentiality, responsive care, autonomy and person-centred care. In order to implement the practices; it is pivotal to include all of these principles as this lead to enhance patient outcomes. The Care Act 2014 emphasis on the requirement of protecting elderly patients while providing quality care to them. Section 42 of the act depicts that local authorities are accountable for looking upon the concerns of elderly people who have care and support needs (Hunt‐O'Connor et al, 2021). By adhering with this policy, it is essential to focus on providing quality services to elderly patients in their post-discharge phase. Local authorities must undertake consistent follow up and in case of emergency immediate contact should be implemented with multidisciplinary team.
Maslow needs of hierarchy comprised with essential five needs and those are- physiological, safety, social, esteem and self-actualization needs. During follow-up procedure social care provider looks upon these needs of patient and focuses on taking appropriate actions in this context. This results in enhancing patient outcomes to greater extent and supports in reducing hospital readmissions. In accordance with the social model this can be articulated that an individual behaviour is influenced due to social context. For example- if patient does not receive any kind of support after discharging from hospital, then, this develops negative impact on their mental health and behavioural pattern which significantly influence their physical health and creates an emergency for readmission. On the other hand, when consistent follow up has been taken and social support is provided then patient health gets positively influenced and this reduces readmission rates (Alderwick et al, 2021). Therefore, it is important to prioritise the needs of patient and this can be done via adopting person-centred approach; this focuses on prioritising the requirement of patient and based on this, further actions are taken. Hence, by complying with this approach consistent support could be assured patient and consequently, readmission rate would be reduced. As a result, patient health outcomes would be increased to greater extent and further the process leads to empower them.
It is crucial to evaluate the effectiveness of strategies which have been implemented for combating hospital readmissions. The Metrics will be used and this include readmission rates of elderly patient and this would be tracked against historical data. The 30 days readmission rate would be assessed for tracking the data and progress. This is pivotal to stratify data through demographic factors and underlying health complexities for ascertaining trends and areas of improvement (Meskó and deBronkart, 2022). Along with readmission rates, patient feedback will be taken via conducting surveys; both patient and caregiver experience would be analysed in transition from hospital to home. The evaluation must encompass different aspects that involves clarity in discharge instruction, care quality experience during and after hospitalisation, adequacy of follow-up and experience of patent.
Regular audits and team meeting supports in implementing collaboration which is crucial for gaining effective results. All the involved partners are accountable for presenting their opinion and consistent discussion on patient health status is essential. Continuous communication should be maintained for reducing the errors and ensuring progress. Hence, this systematic approach enables in undertaking consistent improvement and further supports in aligning practices along with ensuring patient-centred care. Thus, by following these measures progress can be assessed and evaluated; this supports in knowing whether the taken strategies supporting in reducing readmission rates or not (Afzal et al, 2021). By undertaking consistent monitoring error could be witnessed and timely actions can be taken. Based on the presented information this can be said that it is essential to undertake effective evaluation strategies which supports in identifying whether the taken actions are appropriate or not. Consistency in the practices requires to be assured so that continuous support to patient can be ensured and this further helps in determining the practices which are needed to be taken for assuring evidence-based practices.
By adopting patient centred approach sense of belongingness can be developed in patient and further their needs could be prioritised to greater extent. Furthermore, patient should be involved in decision making process as this leads to empower them and creates consistent support for them.
Conclusion And Recommendations
Conclusively; it can be articulated that reducing readmission rate within hospital is essential and further this proves to be a complex issue among elderly patient. A concerted partnership approach is essential for Greenfield District Hospital as it supports in enhancing patient outcomes while streamlining healthcare resources. The principles of Care Act 2014 have been considered in the analysis and accordingly, it was evident that collaborative strategy proves to be essential for prioritising the needs of elderly patient. Furthermore, holistic care is essential for enhancing patient outcomes while reducing readmission rates. Below mentioned are the following recommendations for Greenfield District Hospital-
Multidisciplinary working- It is recommended to hospital that they must adopt multidisciplinary working that involves different healthcare professionals, care workers and social workers. An effective partnership can be formulated and support to patient could be ensured (England, 2022
Aunger et al, 2021). This approach support in undertaking consistent follow-up of patient and further reduces the chances of readmission. Therefore, it is recommended to hospital that a multi-disciplinary approach for patient in post-discharge phase should be followed.
Holistic Care- There is need to focus on providing holistic care to patient during post-discharge phase. Consistent follow up should be taken and emphasis must be implied on providing mental, emotional and physical support to patient (Plamondon et al, 2021). In case, patient belongs from vulnerable group then appointment should be set and monitoring requires to be undertaken. This results in creating consistent support for patients and accordingly, holistic care can be provided to them.
Patient Education- Patient education is an essential component; it is the accountability of nursing staff that they must focus on creating awareness in patient regarding medication, diet and physical exercise (Plamondon et al, 2021). Patient should be motivated for adopting a healthy lifestyle; this results in reducing the chances of readmission.
References
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