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Redesigning a Community Geriatric
Service to reduce readmissions and
avoidable presentations to the Modbury
and Lyell McEwin Hospitals:
Our story so far.
Anja Clark
Clinical Services Coordinator
Community Geriatric Service.
Northern Adelaide
Local Health Network
Community Geriatric Service
Who are we and what do we do?
Our service comprises of Geriatricians, Nurses, Social
Workers, Occupational Therapists, Physiotherapists and
Pharmacist
We provide comprehensive geriatric assessment, short term
interventions and case management to clients in the Northern
Adelaide Local Health Network
Community Geriatric Service
Who are we and what do we do?
The focus of the service is:
• Hospital avoidance through identifying clients residing
in the community who are at high risk of presenting to an
emergency department and working with these clients to
establish longer term support networks to address their
health concerns
• Supported discharge from hospital by working with
acute and subacute hospital teams to ensure
intermediate care is coordinated and seamless for the
client
Community Geriatric Service
Who do we see?
Older people aged 65+ years or 50+ years ATSI who:
• Have had recent multiple admissions to hospital or the
Emergency Department
• Are experiencing a recent decline in health, cognition
(especially memory) or ability to self-care which increases their
risk of being admitted to hospital
• Have health conditions that can be assessed or managed
safely in the home environment
Community Geriatric Service
Who do we see?
• Would benefit from establishing services and supports to
manage their health in the community
• Require a multidisciplinary home assessment to determine
their level of independence in the home and to support their
discharge from hospital
Community Geriatric Service
History
Western
ClinicCentral
Clinic
Falls
Northern
Community
Geriatric
Service
MAST CGEM Team
Northern
Area
Geriatric
Service
MAST - Mobile Assessment and Support Team
CGEM - Community Geriatric Evaluation and Management
(MAST and Falls Prevention)
North and North
Eastern Clinic
Community Geriatric Service
Service Planning: The Broader Context
Community Geriatric Service
Objectives for Reform
To enable early identification and assessment of
patients’ needs to maximise the period of time that older
persons can live independently and with dignity.
Promote patient independence through an enablement
model.
Coordinate assessment and care planning of patients to
create a more efficient flow of patients across the
continuum of care and between settings.
SA Health Priorities for the Older Person Service Delivery
Community Geriatric Service
Objectives for Reforms
Work with acute services to facilitate timely transfer from
an acute hospital to sub-acute or home.
Work with community based services to potentially avoid
hospitalisation.
Provide services closer to a patient’s home.
SA Health Priorities for the Older Person Service Delivery
Community Geriatric Service
Why the service was redesigned
Not fully aligned with SA Health service priorities for the
older person
Service fragmented with no significant evidence of
achieving decreased client presentations to ED or
readmissions to the hospitals within the Northern
Adelaide Local Health Network – Modbury Hospital and
Lyell McEwin Hospital
MAST service initially only accepted referrals solely from
the community and its relationships with hospitals and
emergency departments were poorly developed, with
hospitals having limited knowledge of the service
Community Geriatric Service
Why the service was redesigned
Limited engagement with the client’s GPs
No formal access or input by Geriatricians
Limited networks with ACAT and service providers -
Clients often required similar multiple assessments
across spectrum of service providers for services to be
implemented
Community Geriatric Service
How the service was redesigned
Geriatrician dedicated to the service for access to
specialised clinical support and formal links with NALHN
Geriatrician team established
Co location at Modbury Hospital with:
• Inpatient Geriatric Evaluation and Management Unit
• Aged Care Assessment Team
Working parties formed to develop strong relationships
and referral pathways with the GEM Unit and ACAT
Service Integration
Community Geriatric Service
How the service was redesigned
Stronger linking with client’s GPs to support ongoing
case management of client
Falls and MAST teams integrated to enable client’s to
access both services from the one referral
Formation of partnerships with external service providers
in particularly:
• Metropolitan Referral Unit
• Older People’s Mental Health
• Domicillary Care
• Community Aged Care Providers
• Chronic Disease Services
Community Geriatric Service
How the service was redesigned
Actively formulated relationships with Modbury Hospital
GEM unit and Lyell McEwin’s Acute Care of the Elderly
team through:
• Attendance at GEM Unit’s twice weekly Case Management
and Discharge Planning meetings
• Attendance at weekly inter hospital discharge meetings
• In person clinical handover of clients
Actively formulated relationships with both hospital ED
liaison teams through meeting with the team and
presenting education sessions regarding the service
Service Integration –
Modbury and Lyell McEwin Hospitals.
Community Geriatric Service
The results of the redesign
More than 700 referrals were received to the service last
year, with 353 of these referrals supporting client
discharge from hospital
Geriatrician advice was sought for 49% of the clients,
resolving health issues in the community which
otherwise may have required a hospital admission
ACAT commenced for 46% of clients with streamlining of
the assessment through integrated case discussion of
the client’s situation along with their service wants and
needs.
Community Geriatric Service
The results of the redesign
In the past 6 months, where hospital admission was
required for medical stabilisation, a direct admission to
the hospital was arranged on 16 occasions which
enabled:
• The client to bypass ED
• The admitting team to have information of the client’s health
status, medical issues, concerns regarding their ability to manage
living at home and recommendations regarding care requirements
for discharge
During this year to date, over 500 more episodes of care
have been provided by the service than during the
previous year
Community Geriatric Service
The results of the redesign
Allowing for sufficient time for post implementation data to
be available, analyses of 22 patients who utilised the
service last year was undertaken:
• In the 6mths prior to the program, the 22 patients used
283 bed days (average of 12.8 bed days per person)
• This reduced to 58 bed days in the 6mths following the
program (average of 2.6 bed days per person).
• A reduction of 10.2 bed days per person.
Audit of the service also revealed a four fold increase in
utilisation of non-hospital community services following the
service’s intervention to establish a long term support
network for the clients.
Community Geriatric Service
The Future
Community and inpatient teams to rotate to enable more
holistic client care, service knowledge and enhancement
of the ‘in reach/outreach’ service model
Formation of one assessment tool for both Community
and inpatient GEM Unit to utilise to further enhance
seamless and thorough care coordination
Community GEM Service team members to undertake
ACAT training to become associate assessors to enable
one comprehensive geriatric assessment to be
undertaken to address all client concerns and for team
members to work across the services
Community Geriatric Service
The Future Central referral and triage for the service to also incorporate
Geriatric Outpatients to best enable correct service response for
the client
Expansion of geriatric nursing specialties offered by the service -
Parkinson's and Movement Disorders, Behaviors and Physical
Symptoms of Dementia, Continence
Formation of relationships with providers of the new
Commonwealth Home Support Program and Regional
Assessment Service programs
Expansion of the service in alignment with the SA Health
Transforming Health directive
Community Geriatric Service
Thank You
Gill Bartley
Samara Zubrinich
CGEM and NALHN Geriatric Service