The number of frail older people needing to attend hospital in Staffordshire and Stoke-on-Trent is set to reduce, thanks to a new approach developed to identify people at risk of falling.
The new approach, or ‘pathway’ as it is sometimes called, is a result of joint work between local health, care, prevention and wellbeing services and is being made possible by the partnership transforming health and social care for the people of Staffordshire and Stoke-on-Trent, Together We’re Better.
The falls pathway will be fully embedded into the ‘frailty pathway’, trials of which will take place this summer in the south east of the County, with a view to rolling it out across Staffordshire and Stoke-on-Trent at the end of the year if successful.
More people will be assessed in the community; by a GP, a community health professional or other public sector professional.
Individuals, families and communities will be encouraged to take practical day to day steps to maintain personal mobility, physical and mental wellbeing
Anyone deemed to be at risk of falling will be encouraged to take up specific exercise programmes that will build up their strength and balance.
These simple practical steps can significantly reduce the number of people who fall and get taken to accident and emergency departments as a result.
As part of the improvements, frail older people living in and around Lichfield, will benefit from a new frailty hub. This will act as a single point of contact for local residents. Using resources already available to the local health and care organisations, the hub will include Community Connectors who can help signpost and connect individuals with local community activities and groups. It will also include vital staff, such as a Care Navigator and an Elderly Care Facilitator, to coordinate care for those referred to the service.
The new service will support more people to access the information, care and/or support that they need, as close to home as possible, as well as identifying and reducing levels of duplication and waste across organisations.
Dr Gulshan Kaul, a Lichfield GP, began developing these ideas along with Dr Bhaskar Mukherjee, Consultant Geriatrician at Queen’s Hospital, Burton, after seeing lots of his patients being admitted to hospital several times due to falls.
Dr Kaul, said: “It is vital that individuals are supported to live independently in their own surroundings for as long as possible. To this end we are promoting three things: Living Well, Staying Well, and Ageing Well.
“When people do become frail, we will wrap personalised care around them. We will do this by providing integrated health and care, in a co-ordinated and seamless manner. We will share records, with consent, so you only have to tell your story once. And when people do get into trouble, we will respond quickly, and do our best to help them recover speedily, and safely.’’
Simon Whitehouse, Together We’re Better Director, said: “We want to help our older people to live well for as long as possible and stay in their own home for as long as possible. The Together We’re Better team has worked with professionals to develop the most effective and efficient way to prevent people from falling and losing their independence. The development of the frailty hub is another example of how increased co-operation can better support our most vulnerable people. We have more to do but this is a good start.”