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Case study of home care for isolated and frail elderly patients by general practice nurses


Purpose
In a novel approach, two part-time “Link Nurses” within an NE Hampshire practice of 16,500 patients were funded by a local charity, to assess and manage unmet needs of isolated frail elderly patients at home. The paper aims to discuss these issues.


Design/methodology/approach
Patients in this vulnerable group with no recorded healthcare contact for a prolonged period were identified from practice computer records. One group was to be assessed at home, and appropriate interventions effected. Follow-up visits or telephone contacts also offered support to carers as well as isolated individuals. A matching quasi control group was identified but not visited, to assess the overall impact on the patients, GP and other healthcare contacts. Difficulties with the control group were encountered and addressed.


Findings
Important unmet healthcare needs were found amongst the visited patients, which the nurses were able to address themselves, or refer to the GPs or appropriate agencies. The control group demonstrated greater demand for out-of-hours, GP and district nurse contacts, and more unplanned hospital admissions.


Practical implications
Besides dealing with unmet needs at home, ongoing support by local GP nurses may reduce bed-blocking by moving away from “crisis management” of patients in this vulnerable group.


Originality/value
Few other trials have employed practice nurses to see and manage frail elderly patients in their homes.
