Single Point of Access for Frailty Kevin Pollard Clinical Lead, Rapid Access Services, CNWL Virginia Franklin Project Manager for Frail and Elderly Integration, Haverstock Healthcare Ltd

FE Single Point of Access (SPoA) Rapid Access Services FE Single Point of Access (SPoA) PACE REDS Rapid Response

Single Point of Access Frailty SPoA due to go live in October 2016 Monday to Friday, 9-5pm for non-urgent and urgent referrals Out of hours ‘urgent’ referrals diverted to Rapid Response – 24/7 cover Dedicated phone line direct to senior frailty nurse screener (in hours) ‘Clinician to clinician’ discussion and screening for the most appropriate pathway for the patient. Add un-met need – unsure referral.

Frailty SPoA SPoA Referral Pathway University College Hospital London Ambulance Service Royal Free GP REDS Team Rapid Response Team PACE Team District Nursing Refer In Long term conditions teams Self/carer/ relative MDT Locality or Hub Rapid Response District nursing Complex care nurses Long term conditions Social services Assessment by frailty nurse screener Refer Referrals into FE SPoA

Single Point of Access & MDT Referral into Frailty Nurse Screener for MDT assessment Screener can refer directly to an MDT, depending on need Three levels of assessment, mild moderate and severe

Non-urgent frailty referral Example Case Study “An 80 year old female with bilateral knee osteoarthritis and ischaemic heart disease. Has carers who support with domestic ADLs and provide some assistance with personal care, and is able to go out on a wheel chair/uses a frame to mobilise indoors. She is now beginning to develop increasing problems with indoor mobility, and has had two falls. Also developing some mild problems with memory and is finding it difficult to manage her bills/medication.” Screened and assessed as moderately frail. Referral made to locality MDT

Urgent frailty referral Example Case Study “An 87 year old gentleman referred by GP with a history of Alzheimer’s, heart failure. Presenting with an acute chest infection and functional decline. Lives with wife and daughter and has a 4x daily care package. Normally mobile short distances with a frame, however now bedbound.” Assessed by frailty nurse screener. Deemed as being at risk of hospital admission, requiring urgent intervention. Referred to Rapid Response.

Rapid Access Services REDS - Up to 6 week programme of therapy and Carelink re-enablement to facilitate early hospital discharge and reduce long term care burden. FE Single Point of Access – 5 day service for frailty and/or complex patients. Clinical assessment of referrals to agree appropriate pathway, which may be MDT. PACE – 5 days early supported discharge from the RFH for medically unwell and therapy patients. Includes 7 day PACE Step-down if needed. Rapid Response – 10 day service for admission prevention. MDT approach to supporting acutely unwell patients at home.

Future plans Frailty SPoA: Developing referral pathway to Over 75’s GP home visit service Reablement: integration of health and social is an ongoing project in Camden and the future SPoA may include all reablement services Informing commissioning intentions: Identifying ‘what we don’t know’ missing provision and pathways (the unmet needs)

Any questions?