Supporting Older People with frailty

Andrew Hindle: Commissioner for Integration

Dr Richard Bramble: Interim clinical lead for integration

Facts and figures for 2012/2013

19,500+ over 65 arrived at ED 14,500 admissions over 65 10,000+ over 75 85% arrived by ambulance

What are we doing?

Commissioning a new ‘Community Rapid Response Team’ for frail elderly

A team of eight Advanced Nurse Practitioners

Combined with social care professionals Improved interface with

primary/community and secondary care

Community Rapid Response Team for Older People with Frailty

Patient seen or contacted by

WMASNHS 111

GP Out of Hours Virtual Ward

Calls Triaged (1) Refer to ANP for priority assessment (2) Health/Social Care assistants undertake a preliminary assessment

Assessment By ANP or Care Home Practitioner

Discharge to: (1) Step down to care of VW/Community Nursing/GP (2) Respite (3) Community Geriatrician

Palliative Care NurseMacMillan NurseRespiratory EOL Nurse Care Home Palliative Nurses

Single Point of Access for Advanced Nurse Practitioner

Admit to EAU

Care Passport

- Initiate treatment → 48-72 hours (GP informed) - Initiate care package → up to 7 days (then review) - Rehab assessment → refer to OT if appropriate - Night sitting service (MBC Peripatetic) or GP respite- Refer if appropriate to MDT (specialist teams), CMHTOP, palliative care

A new integrated care approach

Teams working together in 5 localities Caring for the same group of patients Via a single point of access To start with health teams from April 1st

then later with social care Move to 7 day working Identifying people via risk stratification

A new integrated care approach

Integrated care group: involving older people’s experiences to be meaningful

Increase CCG support for carers CCG working with Age UK Dudley to identify

older people who are lonely and isolated and provide support services.

Increase support for palliative care advance care plans to avoid unwanted

admissions Risk stratification

A new model of care

Questions?

Discussion

What do you think of the changes we are taking forward?

What would you like to see to support older people with frailty?