Angela Goddard N W London Hospitals NHS Trust Margaret Magee Brent PCT CARE CO-ORDINATING SERVICE - A Multi Agency Solution to Attain a High Quality Lifestyle in Older Life Angela Goddard N W London Hospitals NHS Trust Margaret Magee Brent PCT

AIMS To improve the older person’s experience of care available e.g.. Single assessment, support if in A&E, knowledge of a variety of services to access – from acute care or social support at home, to transport to the local bingo hall To enable older people to access appropriate and timely patient – centred care before a crisis occurs Agree goals together, whatever the desire or need To reduce confusion and duplication by client held record unified across social services and health Virtual team working across boundaries – Social ,acute & community, to identify vulnerable, over 75 year olds.

WINNIE - A CASE STUDY Before CCS Presented in A&E 5 times over last 3 months with falls Medically stable. Prevention of admission with CCS & CCT Care package, mows, personal alarm in situ. At risk of recurrent falls, poor transfer technique Unable to access community transport or mobilise outdoors Oedema in both lower legs

WINNIE - A CASE STUDY After CCS Isolated, depressed and lonely - “I tell people what I need but they don’t hear me” Ensured receiving correct benefits Arranged for mobile hairdresser and for ears to be pierced Put air into tyres of old wheelchair OT (CCT) reassessed and applied for new wheelchair to enhance outdoor mobility and activity - gave functional exercises Arranged for holiday by the sea Contacted GP and DN to review medications and incontinence Community transport - a ‘PDSA’

OUTCOMES Reduce delayed discharges - Prevention of admission – 13% in 1st quarter to 16% in 2nd quarter (CCT figs) + 6 months - 1 year audit Reduce number of GP visits – 1 year audit Readmission rates – over 6 months/1 year Patient satisfaction – quality of life questionnaires Public health Issues e.g. – - prevention of acute crisis - effective management of chronic disease (3-5 year trends)

REDUCTION IN BED DAYS WITH CCS AUGUST 2002

AWARENESS & ACCESS Awareness Access CCS presence in A&E & 2 GP Surgeries working in collaboration Presentation with lunch in acute unit for ward staff - launched by Chief Executive Stall and information pack to be given at GP flu clinics for patient and carers and GP’s Collaboration with HAZ groups such as - Afro Caribbean , Asian, Irish and other ethnic minority groups Access Single point of access for patient and professionals ”my own personal advisor” regarding health, social issues (GP’s, SS, DN’s, CRT etc) e.g Podiatry Training programme across agencies and Easy-Care prompts

SUSTAINABILITY NATIONAL - London Older People’s Services Development Programme (LOPSDP) - Changing Workforce Programme (CWP) - NSF for Older People - NHS Modernisation Plan - Department of Health Publications - Case Management -Role Re-design programmes LOCAL - Local health & social economy working together - Emphasis on local needs and high population of ethnic minority groups - Voluntary sector involved – Brent Carers, Age Concern, Brent Pensioners, Black Cancer Centre etc - Links with housing & homeless organisations - Intermediate care support