Clare Lewis1 Zena Moore 2 Tom O’Connor3 Declan Patton4 Linda E Nugent5 Examining the process and impact of risk stratification using a community virtual ward model to manage older persons’ complex care needs’ Clare Lewis1 Zena Moore 2 Tom O’Connor3 Declan Patton4 Linda E Nugent5 PhD student School of Nursing & Midwifery Royal College of Surgeons Ireland. Professor and Head of School of Nursing & Midwifery Royal College of Surgeons Ireland. Deputy Head & Programme Director School of Nursing & Midwifery Royal College of Surgeons Ireland Senior Lecturer & Director of Research School of Nursing & Midwifery Royal College of Surgeons Ireland. Lecturer & Programme Director School of Nursing and Midwifery Royal College of Surgeons Ireland.

In 20 years, 1 in 5 people walking down Grafton Street will be over 65 Older Population Growth Globally is predicted to at 140% by 2030 in Ireland since 2007 there has been a 32% increase in over 65 group

Frailty Clinical Condition Advancing Age Cognitive Decline Lethargy Nutritional deficits Deteriorating muscle strength Weight loss Greater risk hospital admission & institutionalisation Reduced physical activity Figure from Clegg A, Young J, Iliffe S, et al. (2013) Frailty in elderly people. Lancet;381:753  

The Problem: Hospitals have become the default solution 50% of bed days are for older persons An average length of stay for a frail older person is 70 days In 2016 11% increase in >75s presenting to ED in North Dublin 2015 21% increase in trolley waits (INMO 2015) 2016 29 % increase in trolley waits (INMO 2016) When healthcare system was designed – it wasn’t set-up to address ageing demography Hospitals are the default solution – because we don’t have Integrated Services between Hospitals & Community Care Hospitals are the stop-gap It’s a very expensive solution to the challenge of caring for older people An unsustainable model of care

Solution: Integrated Care Community Virtual Ward Model Home Care is Cheaper and its where people want to be cared for Reduces likelihood of infection Frees-up hospital beds for people who need them Etc – add your own notes €69-100 per day €485 per week €800 per day €5,600 per week Home care approx. 10% of Hospital Care costs

Studies CVWs CVW in UK, embedded within primary care, chronic disease, lead by a GP and overseen by a community matron. Predictive risk tool (who was at risk of an unplanned admission). No significant reduction in ED presentations or admissions (Lewis et al 2013, 2014). CVW in Canada, outreach approach, post discharge from hospital, dedicated team, chronic disease, had no impact on re-admissions at 30 days, 90 days and 12 months, LOS CVW 12 weeks.(Dhalla et al 2015). CVW in Hong Kong, patients selected as inpatients, chronic disease focused, integrated approach, dedicated team, 12 week interventions, reduction in ED presentations observed and unplanned admissions at 6 months (Lin et al 2015).

Patient & Family (Home) CVW Model Approach North Dublin Patient & Family (Home) GP Community Palliative Care Community Psychiatry Older Persons Primary Care Teams Community Intervention Team Specialist Gerontology Home Care Agencies Voluntary Organisations Clinical Case Manager Day Hosp/ Rehab Acute Care Specialists Chronic Disease

North Dublin: Community Virtual Ward Gerontology Services Clinical Case Manager Clinical Case Manager Assessment Virtual Ward Admission High Risk: Red Mod Risk: Amber Triage HOW …........ Green: Low Risk

CVW Impact unplanned admissions & ED presentations North Dublin Decrease in the number of bed days after interventions through the CVW (P=<0.001). The number of ED presentations were lower post CVW (P= <0.001). Median unscheduled admissions were reduced in comparison to the number of unplanned hospital admissions prior to CVW interventions (P=0.001).

Expanding on Previous Research The value of Frailty as a measurement of risk in a severely frail group. Risk prediction using risk scores- complex group older persons risk scores may remain high. Large focus of risk scores is unplanned hospital admissions and ED presentations. Do types of interventions and response determine level of risk. What determines reduced levels of risk in a high risk group. How are risks quantified and relate to those with poorer outcomes. Focus of CVWs has been on chronic disease rather than older persons care.

Study Aims To examine risk stratification through a CVW model and in older persons with complex health and social care needs. To identify the most common presentations of risk in the care of older persons with complex health and social care needs.

Research Questions Primary Research Questions Do risk scores or presenting event determine overall risk? How are lower levels of risk determined through this model of care? Secondary Research Questions Is Frailty measurement a reliable indicator of risk overtime in a high risk group? Do risk scores significantly change with service interventions in a sick older population? Are there key areas of risk that can be improved in this high risk group?

Research Design Methods Data Collection Sample Non-experimental longitudinal study Examining a population of older persons admitted to the CVW Retrospective & Prospective data Methods Descriptive statistics Regression analysis (multinomial & multivariate) Data Collection Baseline demographics Medical history Social history Medication Falls History Hospital activity (ED presentations, unplanned admissions) Risk Scores Events Service Interventions Responses overtime Collected on admission, transfer, re-admission and discharge Sample Convenience sample > 65 years Living in the community (residential care excluded) Admitted to the CVW

Study Variables Independent Clinical Predictors Dependent CVW Outcomes Age Gender Co-morbidities Pressure ulcer risk Falls Incontinence Frailty Cognition Nutrition Function Previous hospital admissions Previous ED presentations Informal supports   Type of events & severity Number of events Response overtime Hospital re-admissions ED presentations No. re-admissions red Complexity of interventions Psychological, Emotional status Medication

Conclusion CVW in North Dublin has shown to reduce unplanned hospital admissions and ED presentations. The PhD research will examine how patients are risk stratified, the relationship between risk scores, events, interventions and response overtime. Examine the impact of Frailty measurement in a high risk group as a predictor of risk. As the complexity of care in an aging population changes risk predictions using tools may not be sufficient in determining level of risk. Health care professionals may be guided by the types of events, interventions and responses overtime in determining lower levels of risk.

Acknowledgements Thank You School of Nursing & Midwifery Royal College of Surgeons Ireland Nursing & Midwifery Planning and Development Unit North Dublin Public Health Nursing Management Team North Dublin Specialist Gerontology Services Beaumont Hospital & Day Hospital Thank You