OPAL: Older Person’s Assessment and Liaison Team

Jim’s Story: Jim 86, lives alone with dog. STML, previous TIAs Carer 3 x Week; son in Oxford 6 admissions to SDH since April, 2016 154 days in hospital 72 MFFD & awaiting POC All admissions due to falls +/- increased confusion Last admission; 5 wards Gradual increase in care needs Gradual increase in medications Worsening mobility Worsening confusion Last fall-Pubic Ramus and rib #s Discharged in January with 24 hour care, No further admissions

Older Person’s Assessment and Liaison Service: OPAL To identify frail patients presenting at the front door of the hospital, through ED, SSEU and MAU early in their pathway to: Improve clinical outcomes Prevent avoidable admission Reduce length of stay Reduce readmission Provide a service which is patient centred and safe To initiate a CGA and personalised care plan

OPAL Funding from Health Education Wessex £121,000 1 of 4 projects, £450,000 total Pilot of a new frailty team at the front door of the hospital Recruitment of Clinical Nurse Specialist ( Operational Resilience ) Physiotherapists, Occupational Therapists and Therapy Assistants Initiate CGA on admission and PCP on discharge Provision of short term re-ablement care Liaison with GPs and community teams Referral to specialist services, clinics (RACE and Falls) and 3rd sector Ensure appropriate onward referral to downstream wards Support form Wessex CLARHC and other projects

OPAL Pathway Referral Criteria to OPAL Monday-Friday 8am – 4pm

Progress to date OPAL team now well established Service and referral processes understood amongst other clinical areas Developing competency framework Developing IT and data systems to support clinical work and audit 1 clinical nurse specialist working alongside team Limited Geriatrician input PPI project

What has gone well? Effective and fully engaged clinical team Willingness to learn from and support each other Early discharge of frail patients at the front door (approximately 60%) Emerging pathway for frail older people Establishing relationships with GP localities and community teams

Next Steps: Continue to establish closer links with locality teams Outreach frailty clinics, MDT meetings and Care home ward rounds Explore options for direct referral to ring fenced ICBs and POC End of life care Recruitment in to substantive roles 7 day service Development of data base and improvements to EDS Support team through competency framework Acute Frailty Unit opening on 7th December

Patient Story:

Outcomes of Service = 700 patients seen by OPAL in 1st 9/12 Average age = 83 Average LOS = 3 days ( Nationally = 9.4 days ) 70% had LOS of 0-1 day 63% discharged directly from Majors, SSEU or AMU 91% had CGA initiated within 24 hours 11% readmission < 60 days ( SFT average =29% ) Improved streaming to Durrington and Winterslow wards 70 patients seen by OPAL have died (10%)