Gerald Okpara was readmitted twice in eighteen months, both times inside three weeks of going home, both times for reasons that were visible in advance.
The list grows because every appointment can add and almost none are structured to remove. Nobody is at fault; the mechanism simply only runs one way.
Home assessment finds things clinic assessment cannot: the rug, the third step, the light switch at the wrong end of the hall, the chair that is four inches too low.
Nothing about this is clever. It’s a phone call. We just weren’t making it.
Illustrative composite
The fortnight after discharge is where things come apart, and the interventions that help are unglamorous: a phone call, a medicines check, one visit.
No readmissions in fourteen months. “Somebody rang,” he says. “That’s the entire intervention.”
