1. Angela Goddard N W London Hospitals NHS Trust Margaret Magee Brent PCT
CARE CO-ORDINATING SERVICE - A Multi Agency Solution to Attain a High Quality Lifestyle in Older Life
Angela Goddard
N W London Hospitals NHS Trust
Margaret Magee
Brent PCT

2. AIMS
To improve the older person’s experience of care available e.g.. Single assessment, support if in A&E, knowledge of a variety of services to access – from acute care or social support at home, to transport to the local bingo hall
To enable older people to access appropriate and timely patient – centred care before a crisis occurs
Agree goals together, whatever the desire or need
To reduce confusion and duplication by client held record unified across social services and health
Virtual team working across boundaries – Social ,acute & community, to identify vulnerable, over 75 year olds.

3. WINNIE - A CASE STUDY Before CCS
Presented in A&E 5 times over last 3 months with falls
Medically stable. Prevention of admission with CCS & CCT
Care package, mows, personal alarm in situ.
At risk of recurrent falls, poor transfer technique
Unable to access community transport or mobilise outdoors
Oedema in both lower legs

4. WINNIE - A CASE STUDY After CCS
Isolated, depressed and lonely - “I tell people what I need but they don’t hear me”
Ensured receiving correct benefits
Arranged for mobile hairdresser and for ears to be pierced
Put air into tyres of old wheelchair
OT (CCT) reassessed and applied for new wheelchair to enhance outdoor mobility and activity - gave functional exercises
Arranged for holiday by the sea
Contacted GP and DN to review medications and incontinence
Community transport - a ‘PDSA’

5. OUTCOMES Reduce delayed discharges -
Prevention of admission – 13% in 1st quarter to 16% in 2nd quarter (CCT figs) + 6 months - 1 year audit
Reduce number of GP visits – 1 year audit
Readmission rates – over 6 months/1 year
Patient satisfaction – quality of life questionnaires
Public health Issues e.g. –
- prevention of acute crisis
- effective management of chronic disease
(3-5 year trends)

6. REDUCTION IN BED DAYS WITH CCS AUGUST 2002

7. AWARENESS & ACCESS Awareness Access
CCS presence in A&E & 2 GP Surgeries working in collaboration
Presentation with lunch in acute unit for ward staff - launched by Chief Executive
Stall and information pack to be given at GP flu clinics for patient and carers and GP’s
Collaboration with HAZ groups such as - Afro Caribbean , Asian, Irish and other ethnic minority groups
Access
Single point of access for patient and professionals ”my own personal advisor” regarding health, social issues (GP’s, SS, DN’s, CRT etc) e.g Podiatry
Training programme across agencies and Easy-Care prompts

8. SUSTAINABILITY
NATIONAL
- London Older People’s Services Development Programme (LOPSDP)
- Changing Workforce Programme (CWP)
- NSF for Older People
- NHS Modernisation Plan
- Department of Health Publications - Case Management
-Role Re-design programmes
LOCAL
- Local health & social economy working together
- Emphasis on local needs and high population of ethnic minority groups
- Voluntary sector involved – Brent Carers, Age Concern, Brent Pensioners, Black Cancer Centre etc
- Links with housing & homeless organisations
- Intermediate care support