211 A Novel Integrated Care Approach: Supporting Older Persons to Remain at Home

Background An Integrated Care Team (ICT) was established within our Day Hospital in September 2018 serving a catchment of older persons encompassing 3 Community Healthcare Organisations. The geographical spread of our patients poses challenges to the ICT in establishing an integrated network of services for patients. Provided here is a descriptive analysis of our patient cohort including basic demographics, co-morbidities, interventions and outcomes. Methods The team comprises of a Senior Physiotherapist, Occupational Therapist and Medical Social Worker supported by two Geriatricians. Referrals to the ICT are via the Day Hospital with a weekly multi-disciplinary team (MDT) meeting where they are discussed and prioritised. Interventions offered include domiciliary and day hospital based assessments. Following assessment appropriate targeted therapeutic intervention is provided which includes rapid access to enabling equipment, access to community supports and rapid access Geriatrician review. Additionally the ICT communicate with the acute and primary care services to identify existing or previous resource utilisation. Results In the inaugural 15 weeks of the service,132 referrals were received. This cohort had a mean age of 81,range (60-102) years; 58% female, 42%male. The Charlson Co-morbidity Index (CCI) score ranged from 2-9 with a mean score of 5. Of these, 50% had a Dementia diagnosis, 33% had a Falls history and 17% had a Stroke diagnosis. The mean Rockwood Clinical Frailty Scale score was 5; range ( 2-7). 62% of referrals were reviewed by both Physiotherapy and Occupational therapy, 58% by Medical Social Work. 34/132 required input from all 3 disciplines. Conclusion The ICT service has augmented the existing Day Hospital with timely multi-disciplinary assessment and treatment enabling older persons’ independence within their home in addition to forward planning if dependency levels increase. Additional benefits include reduction of primary care team waiting lists and forging links with our community and local rehab services. Future ambitions include recruitment of specialist nursing and direct referral pathways from our community colleagues.