Assessment of Older People's Health and Social Care Needs and ...

general healthvision and hearingFor each sub-scale, the WDRS has five response op(ions, compared to the Barthel which has justthree response options. This means that the data gathered is more specific and useful to the PHN.Implementation of the ProjectThe project commenced in November 1999 and was completed in February 2000. During this time, allclients aged 75 years and over, with medical cards, were visited and assessed using the WDRS. Theynumbered 3,871 clients in all. Those with scores of 33 or more were identified as being at risk and nursingcare plans were put in place. The project was subsequently audited using a set of questions put toparticipating PHNs and recommendations arising from the audit were implemented. Community RGNs andhome care assistants were employed in January 2001 and have continued to work on the project to date.Intermediate OutcomesThe intermediate outcomes of the project were as follows:a total of 3,871 medical card holders were visited and assessed• of those, 6.4 per cent (274) were found to have a WDRS score of 33 or more. Femalesoutnumbered males by two to onethe most common risk factors were a medical condition combined with living alonewe found that WDRS wcs useful as a measure of disabilityit identified actual as opposed to potential problemsin an audit of care plans, we found thirty-one nursing problemsone of the issues arising was the non-availability of services; specifically home helps and homecare assistants in the numbers required. As a result of identifying this as an issue, we were givenfunding to proVide these services, thus developing the skill mix team in our area• the project represents value for money: 583 maximum dependency patients were provided with apackage of care and maintained at home in 2001; of 989 discharges from Waterford RegionalHospital for the same period, 512 patients were provided with a package of care followingassessment by the area PHN; the total cost of the service for 2001 was £31,525._1---------------------------------Through the WDRS pilot project, we have operationalised an 'at risk' register for older people in ourCommunity Care area. This register is updated monthly by PHNs and helps us to identify older peoplewho will need packages of care.Information from the 'at risk' register is currently being shared with the Accident and EmergencyDepartment of Waterford Regional Hospital on a pilot basis. A directory of PHN's, with their contact details,has been supplied to each ward at Waterford Regional Hospital to facilitate early discharge planning.There are now data available to assist anticipatory service planning, and packages of care providinghome support, have been developed for patients, as outlined earlier.Conference Proceedings