Abstract
This project converted an on-demand, crisis intervention service into a doctor-initiated, anticipatory, preventive programme to improve management, based on home visiting and ‘activities of daily living’ screening by state enrolled nurse, with serial medical assessment and regular surveillance by the general practitioner. Opportunistic and domiciliary organised, standardised, serial, numerically scored, medical, social and functional assessment of list patients over 75 years, allowed comparison over time and identification of high need/risk patients — Focus for anticipatory service and aids provision. 24% healthy, 41% moderately impaired and 35% high risk patients were contacted or visited annually, six-monthly and quarterly respectively. Patient-initated calls decreased by 41% but additional surveillance input increased work load by 9% per annum. Improved standards of care helped patients live longer at home however. The nurse proved effective and economical in this role.
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