Integrating health care services for older people

A review of inpatient and community services for older people in Liverpool revealed that although quality services were being provided, this was only to a limited number of patients. The tracker nurses' role at this stage was to determine the factors that resulted in the emergency readmission of patients aged over 65 and attempt to prevent this. Eight months later the team began to focus on extending its services to a wider patient group by screening all emergency admissions and inpatients at a local acute hospital. The team compiled action plans for patients with complex needs, enabling discharge planning to begin as soon as possible after admission and ensuring that the needs of patients requiring intermediate care were met quickly. The average number of transfers to intermediate care trebled as a result of this change in focus.