Integrated Care Programme, Older Persons ICM frailty webinar Jan 17 th 2019
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
...