Integrated Care Programme for Older Persons in Community Healthcare

The Integrated Care Programme for Older Persons (ICPOP) aims to provide integrated services for older individuals with complex health and social care needs, focusing on community-based care for improved quality of life. The programme includes pioneer sites across the country, such as CHO6 Community Healthcare East, which offers multidisciplinary care with a focus on short-term rehabilitation. The Older Persons Integrated Care Team facilitates early discharge from hospitals, re-enablement post-illness or injury, and continuity of care to transition individuals to long-term health-promoting activities and services.

• Integrated Care
• Older Persons
• Community Healthcare
• ICPOP
• Rehabilitation

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1. Brief review Older Persons Integrated Care Team Community Healthcare East Emer Nolan Senior Physiotherapist September 2018 September 2018 1

2. What is integrated care? Integrated care programme for older people (ICPOP) developing since 2012 to develop and implement integrated services and pathways for older people with complex health and social care needs, shifting the delivery of care away from acute hospitals to community based, planned and coordinated care. to improve the quality of life for older people by providing access to integrated care and support that is planned around their needs and choices, supporting then to live will in their own homes and communities. September 2018 2

3. The patients perspective Over 65yo 12.7% population September 2018 3

4. Integrated Care Services Purpose Patient focused Integrated Care Community Hospital Seamless transition September 2018 4

5. September 2018 5

6. Pioneer sites 6 pioneer sites across the country CHO 1 Sligo CHO 4 CUH CHO 6 SVUH CHO 7 Tallaght CHO 8 OLOL CHO 9 Beaumont Overarching principles provided by ICPOP, but the ability to develop services based on local needs September 2018 6

7. CHO6Community Healthcare East / St Vincents University Hospital Older Persons Integrated Care Team Multidisciplinary team with a focus on short-term, community based rehabilitation (usually up to 6 weeks duration) Aims 1. To develop and implement integrated services and pathways for older people with complex health and social care needs. 2. To shift the delivery of care away from acute hospitals towards planned and coordinated care in the community and home. In addition: Re-enablement of older people following acute illness or injury. To facilitate early discharge from hospital when appropriate. To avoid hospital admissions and emergency department attendance where possible. To have a focus on continuity of care (with existing community services and activities. To transition older people to longer term services and activities which promote health and well-being. September 2018 7

8. Older Persons Integrated Care Team (OPICT) Referral Process any of the following may make a referral with the approval of the supervising consultant or General Practitioner General Practice Primary Care team PHN or community allied health Rehabilitation hospitals OPICT Emergency Department Acute hospitals Geriatric Outpatients 8 September 2018

9. Older Persons Integrated Care Team (OPICT) Inclusion criteria: Aged 65 years and older Any one of the following: A fall within the last 3 months Recent reduction in mobility Recent reduction in function Living in Blackrock, Stillorgan, Milltown, Dundrum, Ballaly and Ballinteer Exclusions: Patients under 65 years Patients who are medically unstable Residents in residential care units September 2018 9

10. Older Persons Integrated Care Team (OPICT) Team as of July 2018 at our full compliment of staff Geriatrician 0.5 WTE (with additional commitments to SVUH and RHD) November 2018 Care coordinator 0.8WTE March 2017 Physiotherapist 1.0WTE March 2017 Occupational Therapist 0.8WTE October 2017 Clinical Nurse Specialist 1.0WTE March 2018 Health Care Attendants contracted from home care providerDecember 2017 Administrative Support Team established in March 2017 First referral received on 8th May 2017 September 2018 10

11. Since May 8th 2017 to end of June 2018 Referrals: 211 Patients admitted to the service: 145 individuals Re-attendances: 14 Referrals received but not admitted to team: 51 (still probably an underestimate) Reasons included: medically unstable, outside catchment area, patients who do not meet criteria Continuing to capture informal referrals September 2018 11

12. Patient experience as a measure of success Case 1 AR 76 yo man Multiple hospital admissions 2017-18 1st >7 months 2nd 1 week 3rd 10 days Discharged to service 3 times, with reduced length of stay due to supported discharge Case 2 LB 78yo man Right hip fracture May 2017 Supported discharge without inpatient rehab Fracture Left hip January 2017 Supported discharge without inpatient rehab In hospital length of stay 6 days September 2018 12

13. Older Persons Integrated Care Team (OPICT) Sin a Bhfuil Go raibh maith agat. September 2018 13