title: The role of a specialist team in implementing continuing health care guidelines in hospitalized patients.
abstract: BACKGROUND
  Assessment of continuing health care needs is unstandardized and often undertaken by professionals not trained in the management of complex disability.
  
  
  METHODS
  A 6 month prospective study to evaluate the role of a specialist team in implementing continuing care guidelines in hospitalized patients. The team was responsible for assessment and facilitation of access to continuing health care throughout the hospital between hospital and community on a non-age-related basis. It had access to six inpatient beds and a budget to purchase health care after discharge for 7 days. Patients with complex disability were referred to the team if their continuing health care needs could not be assessed, improved or provided within routine practice.
  
  
  RESULTS
  Of the 93 patients included in the study, 34 (37%) were from geriatric wards and 59 (63%) from other specialties. Twenty-six (44%) of the patients from other specialties had been inappropriately referred (no continuing health care needs) and 24 (41%) appropriate patients had not been referred because of inadequate assessments. It was possible to facilitate discharge and continuing care provision in 26 patients without transfer to dedicated beds. Thirty-two patients were transferred for further management (median length of stay 17 days). Three (9%) patients died, 20 (63%) were discharged home and six (19%) were discharged to institutional care. Three patients had to be transferred to acute care. A high level of satisfaction with support and post-discharge arrangements was reported by 26 (81%) patients, 25 (78%) carers and 26 (81%) general practitioners for patients transferred to specialist beds.
  
  
  CONCLUSIONS
  Specialist intervention, using a team approach, facilitates effective implementation of continuing care guidelines in hospitalized patients.
authors.affiliation: Department of Medicine for Elderly People, Bromley Hospitals NHS Trust, Kent, UK.
authors.forename: A
authors.initials: A
authors.lastname: Cockram
authors.forename: R
authors.initials: R
authors.lastname: Gibb
authors.forename: L
authors.initials: L
authors.lastname: Kalra
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D003266:Continuity of Patient Care; D004739:England; D005260:Female; D015577:Geriatric Assessment; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D010343:Patient Admission; D010348:Patient Care Team; D017410:Practice Guidelines as Topic