The Community Programme Better Together

4th December 2013

Comprehensive Geriatric Assessment in Nottinghamshire

The Community Programme Better Together2

The Community Programme Better Together

ISAR tool involves answering the following questions in yes/no manner: 1)            Does the patient have carers?2)            Have the carers found it more difficult to care?3)            Does the patient have any memory problems?4)            Does the patient have any visual problems?5)            Does the patient take more than 3 medications?6)            Has the patient been in hospital for more than 1 night in the past 6 months? Every ‘yes’ response equates to 1 mark.  The higher the score the higher the frailty of the patient/citizen.

Identifying Seniors at Risk (ISAR)

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The Community Programme Better Together4

Project 1 – Jackie Butterworth

Hospital Threshold CGA - Comprehensive Geriatric Assessment at the Front Door

Trial - Develop a multi-disciplinary team to provide CGA to Patients on Ward D57

Aim:• To improve service user, carer and staff experience• To reduce the likelihood of future crisis and readmission to the acute setting • To expedite transfer of care to a community setting (where appropriate) and reduce the time that frail older people, admitted as medical emergencies, spend in hospital unnecessarily

“Having the CGA team to focus onthe frail older people on our ward and help us to plan their care and assist with discharge planning is great.”Staff Nurse – Ward D57

The Community Programme Better Together

Strengthening our links for Dementia patients through CGA

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Project 1 During the initial trials links with the B47 team were made Attendance by Mental Health Nurse at Delivery Group meetings

During the trials links with the Liaison Psychiatry Team were made Referral process used for advise / assessment of D57 patients

Project 2 Links to Dementia Outreach Team when letters specify dementia

diagnoses Mental Health Specialist Nurse working on “Triage to CGA” as part of

the Integrated Health and Social Care Team Links to Mental Health Intermediate Care