Brief review Older Persons’ Integrated Care Team Community Healthcare East Emer Nolan Senior Physiotherapist September 2018 September 2018

What is integrated care? Integrated care programme for older people (ICPOP) developing since 2012 “to develop and implement integrated services and pathways for older people with complex health and social care needs, shifting the delivery of care away from acute hospitals to community based, planned and coordinated care.” “to improve the quality of life for older people by providing access to integrated care and support that is planned around their needs and choices, supporting then to live will in their own homes and communities.” September 2018

The patient’s perspective… Over 65yo 12.7% population >85 yo will increase by 15,200 39% increase in carers aged >75yo September 2018

Integrated Care Services Purpose Patient focused Community Integrated Care Hospital CHO6 was identified as a capacity building area in the HSE Service Plan 2016 for the development of integrated services. CHO6 and Stvincent’s hospital have a proven track record in the provision of innovative programmes for older people such as the Slan Abhaile programme. Any intervention should be patient focused and provide a seamless transition between hospital and the community. The aim is to provide care within the home as the preferred method of care, in those deemed suitable. Seamless transition September 2018

September 2018

Pioneer sites 6 pioneer sites across the country CHO 1 – Sligo CHO 4 – CUH CHO 6 – SVUH CHO 7 – Tallaght CHO 8 – OLOL CHO 9 – Beaumont Overarching principles provided by ICPOP, but the ability to develop services based on local needs September 2018

Older Persons’ Integrated Care Team CHO6 – Community Healthcare East / St Vincent’s University Hospital Older Persons’ Integrated Care Team Multidisciplinary team with a focus on short-term, community based rehabilitation (usually up to 6 weeks duration) Aims 1. To develop and implement integrated services and pathways for older people with complex health and social care needs. 2. To shift the delivery of care away from acute hospitals towards planned and coordinated care in the community and home. In addition: Re-enablement of older people following acute illness or injury. To facilitate early discharge from hospital when appropriate. To avoid hospital admissions and emergency department attendance where possible. To have a focus on continuity of care (with existing community services and activities. To transition older people to longer term services and activities which promote health and well-being. Written in this order as the order by which we have had our greatest impact to date September 2018

Older Persons’ Integrated Care Team (OPICT) Referral Process – any of the following may make a referral with the approval of the supervising consultant or General Practitioner General Practice Rehabilitation hospitals Primary Care team – PHN or community allied health Consultant Physician or Surgeon GP NUM / CNS / ANP Hospital or community based allied health PHN / CLPHN Rehabilitation allied health or medical staff OPICT Emergency Department Acute hospitals Geriatric Outpatients September 2018

Inclusion criteria: Exclusions: Older Persons’ Integrated Care Team (OPICT) Inclusion criteria: Aged 65 years and older Any one of the following: A fall within the last 3 months Recent reduction in mobility Recent reduction in function Living in Blackrock, Stillorgan, Milltown, Dundrum, Ballaly and Ballinteer Exclusions: Patients under 65 years Patients who are medically unstable Residents in residential care units Those with cognitive impairment may be unsuitable for the following reasons: Unable to follow instructions so have no rehab potential Unable to permit access to their home because of poor memory Increased agitation with multiple calls September 2018

Team – as of July 2018 at our full compliment of staff Older Persons’ Integrated Care Team (OPICT) Team – as of July 2018 at our full compliment of staff Geriatrician – 0.5 WTE (with additional commitments to SVUH and RHD) November 2018 Care coordinator 0.8WTE March 2017 Physiotherapist 1.0WTE March 2017 Occupational Therapist 0.8WTE October 2017 Clinical Nurse Specialist 1.0WTE March 2018 Health Care Attendants – contracted from home care provider December 2017 Administrative Support Team established in March 2017 First referral received on 8th May 2017 September 2018

Since May 8th 2017 to end of June 2018 Referrals: 211 Patients admitted to the service: 145 individuals Re-attendances: 14 Referrals received but not admitted to team: 51 (still probably an underestimate) Reasons included: medically unstable, outside catchment area, patients who do not meet criteria Continuing to capture informal referrals As of end of August 2018 – 161 individuals admitted September 2018

Patient experience as a measure of success Case 1 – AR 76 yo man Multiple hospital admissions 2017-18 1st >7 months 2nd 1 week 3rd 10 days Discharged to service 3 times, with reduced length of stay due to supported discharge Case 2 – LB 78yo man Right hip fracture May 2017 Supported discharge without inpatient rehab Fracture Left hip January 2017 In hospital length of stay 6 days Informally statistics show improved timed up and go, improved Tinetti score, patient satisfaction with programme September 2018

Older Persons’ Integrated Care Team (OPICT) Sin a Bhfuil Go raibh maith agat. September 2018