Development of the National Integrated Care Pathway for Older Persons
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1 Development of the National Integrated Care Pathway for Older Persons 2 nd November, 2017 Cork University Hospital Dr Patrick Barry, MB,MD, FRCPI Acting Lead for Integrated Care, CUH 1
2 Context :Integrated Care Programme for Older Persons (ICPOP) Collaboration between Clinical Care Programmes Division and Social Care Division Emergency Medicine Programme Acute Medicine Programme Older Persons Programme Overall aim: to ensure a joined up approach to service delivery and in doing so improve the quality and continuity of care for older persons. High level objectives: Supporting Older Persons to live well Enabling Older Persons to live in their place of residence by providing secondary community care in the community Provide integrated Intermediate care( Hospital/Community care) Supporting Older Persons in Residential Care Supporting an integrated approach to end of life care
3 Context :Integrated Care Programme for Older Persons (ICPOP) Collaboration between Clinical Care Programmes Division and Social Care Division Emergency Medicine Programme Acute Medicine Programme Older Persons Programme Overall aim: to ensure a joined up approach to service delivery and in doing so improve the quality and continuity of care for older persons. High level objectives: Supporting Older Persons to live well Enabling Older Persons to live in their place of residence by providing secondary community care in the community Provide integrated Intermediate care (Hospital/Community care) Supporting Older Persons in Residential Care Supporting an integrated approach to end of life care
4 Introduction and Context Successful model of Integrated care team for Falls Community screening in FRAC clinic Therapy and Nursing led services High level Medical review 200 assessments to 1200 assessments in 18 months 2015 commenced Why not frailty? September 2015 EM and PB wrote up proposal and submitted to Social Care Division pioneer site for ICT Unlocking existing potential from services and workstreams involved in CHO4, Cork University Hospital and Mercy University Hospital Letter of understanding signed in 3/2016 4
5 4 Integrated Care Programmes
6 Context :Integrated Care Programme for Older Persons (ICPOP) Collaboration between Clinical Care Programmes Division and Social Care Division Overall aim: to ensure a joined up approach to service delivery and in doing so improve the quality and continuity of care for older persons. High level objectives: Supporting Older Persons to live well Enabling Older Persons to live in their place of residence by providing secondary community care in the community Provide integrated Intermediate care( Hospital/Community care) Supporting Older Persons in Residential Care Supporting an integrated approach to end of life care
7 Aims of the Cork Pilot The overall aim is to develop, support, test and embed a model of integrated working The new Community based integrated care team to work jointly with CUH & MUH To improve the ACCESS of frail older people to acute care, by providing alternatives to attending the Emergency Dept, where appropriate To improve the PROCESS of acute care when frail older people do attend the Emergency Dept, by, where appropriate, expediting their early assessment. To improve the EGRESS of frail older people from hospital to the community with appropriate identified community supports.
8 Governance structure Joint Project Sponsors Ger Reaney, Chief Officer Cork & Kerry CHO, Tony McNamara, CEO CUH, Sandra Daly, CEO MUH Project Implementation Group Gabrielle O Keeffe & Dr Mike O Connor (joint chairs), Dr. Pat Barry, Dr Liam Healy, Dr Paul Gallagher, Dr Kieran O Connor, Catherine O Mahony, Eileen Moriarty, Valerie Walshe (Economist), Judith Purkiss ADPHN, Deirdre Cullen (AHP rep), Natasha Lewis (ATC rep), Mike O Regan (IT), Dr Dan Crowley (ICGP rep), Betty Hickey (SSWHG rep), Dr Patricia Kearney (UCC), Carmel Walsh (MUH) Models of care workstream (Care pathways, Care Processes and Clinical roles) Lead: Catherine O Mahony, Liam Healy, Pat Barry, Kieran O Connor, Paul Gallagher, Judith Purkiss, Natasha Lewis, Dr Dan Crowley, Mary J. Foley, Deirdre Cullen, Eileen Moriarty Technology/ Information Sharing Work-stream Lead: Mike O Regan Evaluation Work-stream (Population planning, Value, Quality and Outcomes. Lead: Valerie Walshe
9 Inclusion Criteria. Age > 75 years Frail, Medically Unwell, Scrrening Under clinical governance of a Geriatrician after Comprehensive Geriatric Assessment Those who can be managed without an acute admission or with an abbreviated admission and early supported discharge Within a Geographic area 9
10 Screening - why 20% increase in over 75 year olds attending CUH in 1 year Admission/Conversion rate at least twice those of < 65 years old Universal frailty screen If positive (40%) CGA delivered by FITT team and Geriatrician If negative Usual care Early streaming to Home with ICT, CIT, Falls team Admission to Acute Frailty Unit and service Acute Medicine Unit Both above to lead to early supported discharge Specialist Geriatric Medicine Unit Rehabilitation
11 Integrated Care Team SHORT-TERM (up to 12 days) Implement Geriatricians agreed Care Plan. Domiciliary Nursing & Rehabilitation. Additional Home Care Support if required. Arrange urgent Geriatrician assessment in AMU. Timely communication of care plan, progress and discharge to GP and PHN. Arrange access to Voluntary Group support where acceptable. Adjust Care plan as agreed and required. 11
12 12
13 Access GP Emergency Department Acute Medical Unit Case Manager Assessment & Treatment Centre PHN Geriatric Medicine Outpatient Clinic 13
14 Process AMU Assessments ED Assessments Geriatric Medicine and Acute Medicine Frailty Pathway Suitable GIM patients 14
15 Egress ED patients Domiciliary Visits AMU patients Case Manager ATC Therapy Interventions Ward patients CIT & CREST Virtual Ward
16 Development locally Significant internal re-organisation Internal resource requirements CHO4 Capital Integrated Care Team Mercy Hospital 0.5 WTE of Consultant Geriatrician Cork University Hospital 6 th AMU post to support weekend opening and lead out on Frailty pathway ED/AMU based therapy resource currently 1.0 WTE Physiotherapist; need FITT team to meaningfully screen and push to community resource Capital no dedicated space -? Unblock AMAU for ideal location Acute Frailty Unit 10 beds within existing 35 bed cohort in Specialist Geriatric Medicine Ward Ensuring appropriate care by appropriate people in the appropriate place 16
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