Challenges in Transitional Care highlighted to Minister.
Standard of care being ‘lost in transition’.
Challenges in transitional care including lack of rehabilitation therapies and people staying in step down care longer than intended – have been highlighted to the Minister of State for Older People and Housing Kieran O’Donnell.
In a dedicated meeting with Minister O’Donnell, Sage Advocacy set out the issues which its advocates see in practice including:
- People in step down facilities not being offered essential therapies for their recovery, and not having contact with a medical team.
- People being transferred to Transitional Care Units for a short stay, but remaining for several months – with some never returning home at all.
Transitional care means when patients are discharged from hospital but not recovered enough to go home – so either attend a step-down facility before returning home, or before being admitted for long term care in a nursing home.
Sage Advocacy is the National Advocacy Service for Older People and Survivors of Institutional Abuse, and said difficulties in transitional care arise regularly in its work.
CEO Bibiana Savin said there is an urgent need to develop and apply national standards in this area:
“Sometimes vital patient information is lost in transition, leaving people without what they need for recovery and well-being. Also, a lack of home care support, particularly in remote areas, leads to people staying in step-down facilities far longer than anticipated – and this results in unnecessary deterioration in mobility and overall deconditioning.”
A further issue is that people mount arrears in fees if discharged to nursing homes without a Nursing Home Support Scheme (NHSS) in place, and many are unaware of this. In some cases, NHSS applications are not progressed due to relatives obstructing them and major financial difficulties arise.
Sage said these problems are systematic across the country and the charity urged Minister O’Donnell to sanction a framework of standards for transitional care to include that, when a person goes to a step-down facility, the following be managed within 4-6 months:
- Provision of needed rehabilitation and treatment
- Documenting of the person’s will and preference on health, welfare and place of care
- Identification of decision-making capacity challenges and set up of arrangements
- Identification of safeguarding issues and taking of preventative steps
- Addressing Deprivation of Liberty issues if arising
- Support with financial, property or housing issues, including recoup of NHSS funding.
In its meeting Sage also reported to the Minister a need for broadening of State supported home care to include social supports – such as assistance with shopping, meal preparation and medication management.
A third issue presented to Minister O’Donnell was major shortfalls in availability, choice and options regarding housing for older people.
Sage Advocacy Chairperson Mark Mellett said: “We need housing policies that give older people real options to remain at home and in their communities, delaying, and where possible avoiding, moves that are unwanted or unnecessary.
“Evidence consistently shows social connection is a cornerstone of wellbeing in later life. That’s why housing and health supports must be planned together, not in silos. We need multi-purpose, intergenerational spaces for everyday living, a café, wellbeing or fitness facilities, and childcare, so communities stay connected and grandparents can help with grandchildren while parents are at work.”
A further housing issue raised with the Minister was housing supports proposed for survivors of institutional abuse, including the re-introduction of housing liaison officers in local authorities, and to apply priority status for survivors of industrial and reformatory schools.
In conclusion Bibiana Savin said Sage was pleased to have a constructive meeting with the Minister and looked forward to continued dialogue, and progress, on these issues.
Sage Advocacy can be contacted at 01 536 7330, or email info@sageadvocacy.ie. See www.sageadvocacy.ie.
Further information
Ronan Cavanagh, Cavanagh Communications: 086 317 9731 ronan@cavanaghcommunications.ie
Sage Advocacy is the National Advocacy Service for Older People and Survivors of Institutional Abuse. It works to ensure that people have easy access to information, support, independent advocacy and safeguarding services in all settings: homes, day centres, respite facilities, congregated care settings / nursing homes, hospitals, hostels, hospices and in the process of transition between them.
Sage Advocacy is fully funded from public sources, chiefly the HSE and the Department of Education, with additional funding from the Department of Justice.
