Coming up for Care: Assessing the post-hospital needs of older patients

Summary: How well does multidisciplinary care assessment work in practice? Which factors predict whether older patients receive post-hospital help, and what type of help? A stay in hospital can be a turning point in the lives of older people. Hospital staff must help them (and often their families) to decide whether short or longer term community services are needed upon return home, or whether residential or nursing home care may now be necessary. If older patients are to return home, hospital staff must assess what kind of help is needed: community health services (such as district nursing and day hospitals), and/or social care services (such as home help, personal care and delivered meals). Assessing these post-hospital needs can be a complex process that involves staff from different organisations and from different occupational groups. Such multidisciplinary assessment is regarded as desirable for patients since it brings together professionals with different skills and knowledge, offers an holistic view of a person’s needs, and reconciles different perspectives. Care assessment also includes deciding who is to pay for these services: patients and families, social services or the NHS. This study explores which staff are involved in assessing the post-hospital needs of older patients and the processes involved in that assessment. It looks at different multidisciplinary assessment team models, and analyses the factors that predict the post-hospital services likely to be received by older patients. This study has important practice implications for health and social services professionals, since it demonstrates that the post-hospital services received by older patients are influenced by the kinds of professionals who assess them and by the available services, as well as by the needs and circumstances of patients themselves