Prevention of unnecessary admissions to hospital
This is to improve care for vulnerable patients who are at high risk of multiple admissions to hospital.
We will identify patients who are at high risk of unplanned admissions to hospital. Such patient s will have a package of care with patients and carers full involvement.
The care package includes:
Answering urgent queries the same with a dedicated telephone line for that purpose.
Ddedicated telephone number to accident and emergency clinicians, ambulance staff and care and nursing homes if they need to contact the practice about you. This is to support decisions relating to admissions and transfer to hospital.
Personalised care plan with details of your medical conditions, results of laboratory tests, medications and allergy. Where relevant, your wishes on care, like end of life care and allowing natural death to occur will be recorded. You will have the document with you so that out of hours care team, accident and emergency and other services will be aware of your medical history and care plan.
Your GP as the accountable GP will have overall responsibility of your care supported by a named care coordinator which can be your district nurses who already sees you regularly, community matron or manager of the care home.
The care co-ordinator will be responsible for ensuring that the agreed care plan is being delivered, that the patient or carer is informed of any changes made to the plan and keeping in contact with the patient or their carer at agreed intervals.
If you are admitted to hospital we will review your care to see if the admission was avoidable and also ensure you will have timely and coordinated care.
We will review your care every month.
For further details see our practice website.
Last updated on 10 May 2014.
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