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 WMAS NHS 111 GP Out of Hours Virtual Ward Single Point of Access for Advanced Nurse Practitioner Calls Triaged (1) Refer to ANP for priority assessment (2) Health/Social Care assistants undertake a preliminary assessment Care Passport Assessment By ANP or Care Home Practitioner Admit to EAU - 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 Palliative Care Nurse MacMillan Nurse Respiratory EOL Nurse Care Home Palliative Nurses Discharge to: (1) Step down to care of VW/Community Nursing/GP (2) Respite (3) Community Geriatrician 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?