Hospital at Home. Frailty and Hospital at Home. 17 th March Pam Livingstone and Gwyneth Thom

Transcription

1 Hospital at Home Frailty and Hospital at Home 17 th March 2016 Pam Livingstone and Gwyneth Thom

2 National Definition of Hospital at Home December 2013 An episode of specialist care delivered at home as an alternative to acute hospital care and where the care is overseen by a consultant/equivalent specialist. An equivalent specialist would include Associate Specialist, GP with an interest in this type of care, Consultant Nurse or AHP or Specialist Practitioner who must be case load holding practitioners. The locus of care is usually at home but could be in a care home if the individual is usually resident there or is stepped up there by the team. Stepped up care in this context is when a more intensive response is required, but the individual does not require admission to hospital and could go to a temporary place of residence to get that care, for example a care home.

3 Referrals to Hospital at Home and Intermediate Care Single Point Of Access in each area Community Hospital beds Hospital at home Day Assessment, Treatment and Rehabilitation Intermediate Care

4 Hospital at Home in Fife A service set up as an alternative to hospital admission for frail elderly people living at home in Fife. OR A service which supports patients being discharged from hospital in a timely manner for completion of treatments and frailty pathways. Less need for long term institutional care as result of above. Work within Health and Social Care Partnership to facilitate above. Bed 1.1 Bed 2.3 Bed 4.2

5 Where are we? There are 3 Hospital at Home teams across the whole of Fife co-located with our Intermediate Care Services. Adamson Hospital, Cupar Whytemans Brae Kirkcaldy Queen Margaret Hospital Dunfermine

6 The Team Consultant Geriatrician GP with Special Interest sessions Specialist Nurse Practitioners Community staff Nurses Healthcare Support Workers Pharmacy / AHP Admin support

7 Service Parameters Predominantly for elderly people > 65 years or younger people with recognised frailties Health needs must be able to be met safely at home Meet criteria for referral to

8 Referral Guidelines Problems Included Delirium (chest infection, UTI) Dehydration Reduced mobility (chest infection, UTI or muscular) Chronic disease exacerbations (COPD, AF, PD, CCF) Cellulitis / Leg ulcers Diabetic foot infection Falls (no #s) Pain management Palliative care (acute) Problems Excluded Stroke Cardiac chest pain Lower leg fracture GI bleed / acute abdomen Head injury (loss of consciousness) Need for high level care eg. Need for MHDU care Acute abdomen Functional decline / unmet care needs in community

9 The Virtual Ward Daily nurse review Daily ward round Review progress / obs Medication review Results reviewed Management plan Comprehensive Geriatric Assessment - follow frailty pathways such as delirium, cognitive impairment, falls Rapid access to: Treatments -IV Abx / Scut fluids / IVI / O2 / nebs Investigations -ECG / bloods / Xray / USS / CT AHP intervention & Equipment providing the same level of care that would be expected in hospital for that condition If need hospital care they are admitted

10 Outcomes Quicker response than being admitted to hospital rapid medical assessment with CGA early Geriatrician input Care tailored to the individual maintain a patient s independence continuity of care seamless transfer of care within ICASS As little disruption to normal lifestyle as possible Familiar environment Continue with usual social contacts Shorter length of stay don t have the delays OR morbidity associated with hospital stay Family and carers involved all the way through

11 THE PATIENT EXPERIENCE 'thank you team for all you did for mum in her final days -you treated her with dignity and listened to what she wanted as if she were your own mother. I cannot thank you enough' it gave me such self confidence and assurance when the nurses came in to check on me. They are a magnificent team that couldn t have been more helpful and highly professional

12 For further information