Unscheduled Care Forum September 4th, 2018 “The Benefits of FIT Teams Operating at the Front Door in Acute Hospitals” Population Ageing A success story, not a catastrophe I’m going to talk to you about the FIT Team Unscheduled Care Forum September 4th, 2018 Paul Maloney Occupational Therapy Manager Beaumont Hospital

Future Demographics in North Dublin 53% of over 75’s admitted By 2026 there will be a 44% increase in the population of North Dublin >65 years

FRAILTY & the Emergency Department Liew found that length of stay in the emergency department independently predicted inpatient length of stay ED stay 4-8 hours increases inpatient length of stay by 1.3 days ED stay >12 hours increases inpatient length of stay by 2.35 days LiewD, LiewD, Kennedy M. Emergency Department Length of Stay Independently Predicts Inpatient Length of Stay. MJA 2003; 179; 524-526 Thus the importance of our motto “every hour counts”

↑26% presentations (n=800) to ED ≥65 years Q1 2015 vs Q1 2018 This is the context in which Beaumont operates and continues to do so Beaumont choose to implement a therapy team Sept 21st 2015 Next few slides I’ll outline who the team is, what we do in ED and the impact that they’ve had on two fronts – avoiding unnecessary admissions to hospital but also to the patients that were admitted

What is FITT and what do we do? Next few slides I’ll outline who the team is, what we do in ED and the impact that they’ve had on two fronts – avoiding unnecessary admissions to hospital but also to the patients that were admitted

FIT Team Physiotherapy OT SLT Pharmacy Social Work Dietetics ED Doctor ‘Frailty Intervention Therapy Team’ ED Nurse On-take team We triage every patient over 75 in ED within core working hours Verbal referrals between HSCP was agreed to minimise delays Core working hours 8am-4pm Mon-Fri ‘Every Hour Counts’

Transforming Our Practice Dedicated ED HSCP service Identification of “FRAIL” Generating early referrals to HSCP’s Early assessment of physical, cognitive and functional ability Initiation of treatment on appropriate pathway Rehabilitation and collaborative discharge planning commences on day 1 Primary Care/ICT Services How do we screen for FRAILTY? Tool - multiple frailty tools ISAR not working, worked for us at the time Measures added from the Kings Fund Doesn’t matter what tool – identify frailty Interdisciplinary working – added approx 1 WTE back into the team

Core working hours of the team Most patients present during day, currently not 7/7 Shows huge productivity for the hours that we are there Axillary services are not 7/7

75% Frail Age range 75 to 97 yrs , Mean 84 YRS 35% live alone 52% have no formal community supports 17% had no informal support 5.6% are primary carer for other person

Impact on admitted patients Data Trends Admission avoidance Impact on admitted patients LTC Conversion What did we achieve

≥75 yrs.: ED Presentations ↑15.8%

≥ 75 years: % of ED patients remaining at home (1st Representation to ED)

≥ 75 years: Cumulative Days at Home April 2014 vs April 2018 2698 days spent at home for April ↑11.7% FITT Patients (April) : 13,479 days Include no of patients seen by FITT (Dc -195) Supported Dc is why patient s Culture 32,376 days

≥75 yrs.: ED Complexity (Manchester Triage System) April 2014 vs April 2018 (No.) April 2014: 42% admitted April 2018: 50% admitted Why such an increase in the admission ratio – significant increase in complexity Orange are acutely unwell – focus on orange

FITT beds/Specialist Geriatric Wards (SGW’s) Activity Jan-July (2016-2018) ↑ 31% Discharges 2016 vs 2018 ↓ 1.3 % Bed days 2016 vs 2018 SGW 70 beds, intensive MDT 31% increase in Dc 2016 vs 2018 1/3% decrease in bed days

≥75 years: LTC Conversion rate 55 Pt’s less listed for LTC Jan-July 2018 (-2.3%) LTC bed approx €1400/week Less patients are converting to LTC despite an increase of 31% in 75+ presentations If conversion rate remained as is in 2015 – extra 55 patients Jan-June (9 per month) More patients remaining at home and cost savings to the state Jan-June 2015 LTC conversion = 9.4% ↑31% presentations (n=1117) to ED ≥75 years Jan-June 2015 vs Q1 2018 Jan-June 2018 LTC conversion = 7.1%

Why has it worked? Adding a therapy resource to the existing medical and nursing ED team i.e. Dr can focus on medicine, nurse on nursing. Therapists are used to crossing boundaries between hospital and community – connecting patients to services Senior exec support – initially a novel team, took a risk! Right people is critical Invested in clinical specialists, extensive experience in COE and understand the system Therapy leaders who develop a culture of embracing risk! Work hard on relationships and connections You need to invest Making a real and sustained difference

What could have happened Patient story What happened PC: ↑Confusion Early Ax by OT,PT,SLT,Diet and MSW Medically cleared Discharge plan set Outreach visit Community supports Referral to Geriatrician Remained at home What could have happened Carer demands admission Patient admitted Becomes agitated (why am I here) Sedated ↑ Confusion No relatives at Ass. with DC Unable to manage at home Listed for LTC

Email details: paulmaloney@beaumont.ie @FITTBeaumont