Integrated Care Programme, Older Persons

ICM frailty webinar

Jan 17th 2019

• ICP OP story to date (outline of ‘Lessons Learned’)

• Impact and insights

• Recommended next steps

• www.icpop.org

Overview

ICP OP

Challenges

• Complex concept (polymorphous)

• Working across professional and organisational boundaries

• Required new roles

• Required simultaneous implementation of multiple co-dependant strands (workforce, ICT)

• Lack of policy support

• Lots of silos (practice, strategic, budgetary, planning, data)

ICP OP

Opportunity

• Latent professional capacity and appetite for change

• New policy framework (Slaintecare)

• User support and opportunity to go beyond ‘medical’ model.

• Richness of community assets (citizen engagement) not fully realised

• Insights into implementation

• Test Technology

• Support and develop emerging roles (CM, HSCP, SP, cANPs)

ICP OP

We are (usually)

talking about the same people!

Integrated Care Pathway Status (2011 v 2014) (Ref: NCP OP Audit 2014)

ICP OP

0 2 4 6 8 10 12 14 16 18

Specialist Geriatric Wards (9-30 beds)

Rehabilitation Ward (on site)

Rehabilitation Ward (off site)

Day Hospital (on site)

Day Hospital (off site)

Community MDT

Older person pathways (2011 v 2014)

2014 2011

0

10

20

30

40

50

60

70

80

90

100

Dedicated Older Person staff (2011 v2014)- acute in-patient

2011 2014

ICP OP 10 Step Framework

Programme implementation

July 2015

De

c 2

01

5

Jun

e 2

01

6

Jun

e 2

01

7

Dec 2018Jan

20

16

Jan

20

17

De

c 2

01

7

Programme PID agreed

ICP OP Team recruited

ICP OP networking day• Data collection • User engagement

ICP OP networking day• Dashboard • Research results

Programme Manager/Clinical Lead commenced

Initial 6 pioneer sites initiated 35 wte. clinical staff funded

ICP OP Networking Day• Framework lunched

6 further pioneer sites funded

Jun

e 2

01

8

ICP OP networking dayinitiated; • Site info exchange

Jan

20

18

6sites

13Sites

?21

Sites

ICP OP role

ICP OP

Co-Production

Home Primary Care Ambulatory Care Acute Hospital

Key elements of integrated care pathways

RehabDomiciliary careResidential care

Living well at home with supports

Health Promotion , Maintaining health, wellbeing & nutrition

GP/PCT management Out of hours GP care Medication

management with local pharmacist

Carer support Home Care/ Home help Reducing Social isolation Information on local

services Local day service Social

opportunities 3rd sector Community

support Telehealth Supported self

management

Domicillary follow up by MDT

Early Supported DischargeEarly review in Day hospital post dischargeSupport via Case manager post discharge.

Community intervention team, increased home care via primary care team.

Home care package/home help.Links with voluntary sector

Rehab

Access to inpatient and outpatient rehabilitation with supported assessment,

therapies and clinical support.

Governance & Training to support ICP implementation and sustain

Inpatient

Specialist Wards for Older People with Frailty (SGW) staffed by

multidisciplinary teams and gerontologically trained nursing,

medical and HSCP staff.Comprehensive Geriatric Assessment.

Early Supported Discharge for admitted patients.

ED frailty at the front door

Timely access at crisis point. Divert/reduce requirement for acute hospital admission. Case manager as point of access at times of crises for Person in community. Community

hospital admission if required. Front door response to frailty in Ed, FiTT team, CGA(SAT). Early engagement with

integrated care team.

Ambulatory Care

Integrated Care Hub (MDT/Day Hospital). Single Point of access.

Case manager who links with community services, mental health team, palliative care services and Acute hospital. Rapid access clinics. Early Diagnosis, CGA (SAT). Post

diagnostic supports

Primary Care Team (PCT)

HH with knowledge and education re Frailty.

PHN who can identify frailty, can support family with care

and can link with GP/case manager/ANP/community

intervention teams

GP who can manage above with PCT and support patient

and family

Supports for Person in long term care. Links with Acute hospital team, (ANP,CNS,

Geriatrician). Integrated care team Single Point of contact for Nursing home

Residential Care

Patient Unwell/falls

Primary CareTherapy

In-PatientTherapy

ICP OP

ICP OP

Primary / Community Care Ambulatory Care

ED Inpatient

Ref: Tallaght Integrated Care Team Ref: Waterford Integrated Care Older People Ref: St Lukes Hospital Kilkenny Ref: Sligo Univeristy Hospital

Acute Hospital Care

VIP screen completed at triage by triage

nurse

Patient treated by

members of GEMS team as

needed

GEMS team huddle at 9am and 12 MD and

liaison with primary teams

VIP Positive

Comprehensive

Geriatric Assessment completed

VIP Negative

GEMS team plan

community contacts and follow

up required

Medical/Surgical

/ED treatment continues as per

patients

presenting complaint

Non-GEMS

patients requiring Physiotherapy /

Occupational

Therapy are referred as per usual pathways

Requires

Admission?

CNS informs

the shift leader in ED if patient meets

the criteria for transfer to the

GEMS Unit, otherwise

transfer to the other wards. All referrals

generated by the GEMS

team follow

the patient to the ward with their clinical

record

Community

referrals made as outlined in Referral

Pathways

Yes

No

Does patient meet the criteria for frail

elderly ward

Criteria for admission to frail elderly

wardPatient 70 years or over

Identified as Frail use the local ED/AAU

Frailty Tool Seen and assessed by the Frailty

CNS/c/ANP Rockwood Score 3 - 6

Would benefit from MDT input / CGA

CCU

Medical

North

Medical

South

Short Stay

WardMedical 7

Yes No

Gerontology

CNS to liaisewith:

Social Worker

PhysiotherapyHomecare

Bedmanagement

Community/OPD Age related medicine

inpatient/OPD/DH

Screening Tallaght Hospital

Integrated Care Team

Russell Building

Community: PHN,

Community HSCPs family

Tallaght: PIMs

hospital test results, recent admissions

Build database

CGATuesday clinic visit

Tallaght Hospital

Home visit

Treatment Physiotherapist

Occupational

Therapist

Social Worker

Case Manager

Geriatrician

Discharge

Community GP/PCT

Day Hospital

Day Centre

HCP

PLL

Rapid

Multi-disciplinary “Hub”

Specialist Assessment Channels

Frailty Memory FallsParkinson’s General

DiagnosisIndividualised Treatment Plan

Primary Care Therapy

In-patient Therapy

Hospital Referral

Nursing Home admission

Home with revised support arrangements

Crisis patients Pre-frail &frail patients

Social Engagement Day Care/Home visits

Integrated Care, Older Person Ecosystem

The HUB

Nursing Home

Voluntary

Sector

Private

Sector

Local Authority

Services

Case Management

GP/PCT Management

Acute Floor Frailty Pathway(FITT Team) CGA

Specialist Geriatric Ward

Early Supported Discharge

Rapid Access/Outpatients

Clinics, CGA

• PHN• ANP• Pharmacist• CIT• MH Team• Palliative Care Team

• Community Hospitals• Rehab• Respite • Convalescence

Self MangementTelehealth

Health & Social Care

Services

Cavan

Monaghan

Mullingar

Galway

Kerry

Wexford

Naas

Wicklow

Outcomes

National Support

Local Credibility

Research

Education

WICOP Hub

Relations

MFTE

Cost-neutral changeGovernance

ICPOP acknowledgement of relationshipscANP CampaignNew ways of working (Right person, right place, right time)Electronic database & CareFolk

National Frailty Education ProgrammeRoadshows; GPs, PHNs, HospitalPatient education (Cognitive Rehab, Dementia Café)

reMIND, DE-FRAIL, Frailty biomarkers, Carotenoids, CONVINCE3 PhD students, 1 MD student1 Research Nurse

Pine Ward – SGWSpace for WICOP HubFIT teamCHO-5 as exemplar

Annual investment (e.g. “Orphan” dietetic service)WICOP Stage II – need programmatic support

ICP OP- Local ripple effect (WICOP)

Ref: Cooke, J (2018) IFIC Forum

ED Attendances & Admissions: Month & YTD, (Ages: 75+)

19

ATTENDANCES at ED (Ages: 75+)

2018 2017 Change

Hospital Group Hospital October YTD October YTD October YTD

South/South West Hospital Group CUH796 7,638 695 7,005 14.5% 9.0%

Kerry464 4,294 433 3,942 7.2% 8.9%

Mercy325 3,280 358 3,053 -9.2% 7.4%

South Tipp.388 3,654 371 3,524 4.6% 3.7%

Waterford 600 6,178 596 5,801 0.7% 6.5%

South/South West Hospital Group 2,573 25,044 2,453 23,325 4.9% 7.4%

ADMITTED from ED (Ages: 75+)

2018 2017 Change

Hospital Group Hospital October YTD October YTD October YTD

South/South West Hospital Group CUH404 3,906 396 3,880 2.0% 0.7%

Kerry244 2,318 250 2,212 -2.4% 4.8%

Mercy175 1,799 198 1,788 -11.6% 0.6%

South Tipp.231 2,144 204 2,100 13.2% 2.1%

Waterford 255 2,627 276 2,695 -7.6% -2.5%

South/South West Hospital Group 1,309 12,794 1,324 12,675 -1.1% 0.9%

Impact

CHO 5/UHW

(2017-2018)

Intermediate Outcomes

Admission avoidance1,082 bed days saved

with crisis intervention (Hub)

:

€3.347m return on investment of €0.380m

Reduced Length of Stay5-day reduction AvLOS

for hip fractures

BDUs (medical) >64 Oct ‘17 – Apr ‘18 reduced by 3,938 compared to

previous year

CHO 2/SUH

(2016-2017)Intermediate outcome Reduced LoS by 2.6 day

for > 70yrs

€3.2m return on investment of €0.450m

CHO 5/St Lukes

(2017-2018)Intermediate outcome

Reduced LoS >85 by 34% €1.2m return on investment of

€0.230m

Reduced Los > 75 by 24%

ICP OP

ICP OP

Strategic decisions required

In summary

• Governance is fundamental

• User engagement enriches vision and generates potential

• Engaged workforce

• Care pathways

• Efficiency and effectiveness

Thank You

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