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Older People Who are Frequent Users of Acute Care: A Symptom of Fragmented Care? A Case Series Report on Patients’ Pathways of Care

journal contribution
posted on 14.11.2018 by Joanne Dollard, Gillian Harvey, Elsa Dent, N. Williams, Laura Trotta, Justin Beilby, Elizabeth Hoon, Alison Kitson, C. Seiboth, Jonathan Karnon
Older frequent users of acute care can experience fragmented care. There is a need to understand the issues in a local context before attempting to address fragmented care. 0.5% (n=61) of the population in a defined local government area were identified as having ≥4 unplanned emergency department (ED) presentations/ admissions to an acute-care hospital over 13 months. A retrospective case-series study was conducted to examine detailed pathways of care for 17 patients within the identified population. The two dominant presentation reasons were clinical symptoms associated with a declining/significant loss of capacity in fundamental self-care activities and chronic cardiac/respiratory conditions. Of patients discharged home, 21% of discharge letters were delayed >7 days and only 19% received a written discharge plan. Half of community dwelling patients received home nursing and/or assistance. Frequent users of acute care can experience untimely hospital communication and may require more coordinated care provided in the community to assist self-care and manage chronic conditions.

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2018

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