Reducing unplanned hospital admissions in Older people with high needs: a review of local practice in a small sample of primary care patients in an inner London borough.

Background: Older people with complex health and social care needs are a growing group of people with high use of NHS and social services. In particular, this group account for a large number of unplanned hospital admissions a year.Aims: To evaluate the evidence base for preventing unplanned hospital admissions in this group, to identify their characteristics and to undertake a focussed local review of their primary care management.Methods: A literature review, a review of the Southwark CCG data risk stratification tool and a review of high risk patients and their management at a Southwark GP practice.Results: High risk patients have multiple comorbidities and are frequent users of healthcare services. Although there was in general good involvement with social care services, there were certain areas that could be improved upon. For instance, the referral of frequent fallers to falls services and provision of an older person’s annual health check both offer opportunities for primary prevention.Conclusions: An older person’s annual health check would ensure holistic assessment of their health and social care needs and could then be acted upon to ensure that there is the required level of support in place, including a personalised anticipatory care plan and attention to key preventative measures such as falls prevention, exercise, smoking cessation, medicines optimisation and sensory impairment.