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

2. 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

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

4. 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

5. September 2018

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Patient experience as a measure of success
Case 1 – AR
76 yo man
Multiple hospital admissions
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

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