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Specialist Care for Older People - What we currently deliver

This specialist care program aims to enhance the delivery of services for older people by integrating primary, secondary, and social care. It includes acute inpatient service, outpatient clinics, subspecialty services, stroke care, and geriatrician support.

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Specialist Care for Older People - What we currently deliver

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  1. Specialist Care for Older People - What we currently deliver • Acute inpatient service (65+) with lowest LOS nationally • Liaison teams working in acute medicine and A&E (OPAL) and surgery • Outpatient clinics to reduce or shorten admissions • Subspeciality services (e.g. falls, continence, heart failure, Parkinson’s) bridging secondary and community care • Stroke - acute service incl thrombolysis and rehabilitation • Explicit links with MHOA

  2. What geriatricians currently deliver for Lambeth PCT • Community clinics (Whittington, LCCC, Pulross) • Specialist ward rounds / MDMs in bed-based IC (Lambeth) • Specialist sessions with community IC teams • Specialist support to PCT strategy/ operations • Specialist input to NHS Care Home (Minnie Kidd House) • Clinical Governance • Only 10 PA’s of consultant time

  3. Specialist Care for Older People - What we would like to happen Chaos of multiple assessment: costly, non-integrated, non-responsive service • Shared clinical information with IT linking primary and secondary and social care and patient • Integrated working (secondary, primary, social and IC) to reduce hospital discharge delays (e.g. ward-based excess bed days worker) • Integrated working to reduce A&E reattendances and hospital admissions (e.g. rapid response from community and social care)

  4. Specialist Care for Older People - What we would like to happen • Early home discharge linked to effective monitoring and intervention in community • Rapid access (48/72h) comprehensive assessment with geriatrician support • Community case management by geriatricians for patients failing to thrive at home or at risk of long-term placement • Effective community case-finding (e.g. Southwark POPP model) • Integrated health and social services community-based intermediate care with more geriatrician input

  5. Specialist Care for Older People - What we would like to happen • Effective bed-based intermediate care for targeted patient groups (e.g. post-op, post-acute frail OP, # NOF, stroke) • Assessment and community case management for patients on threshold of needing continuing care • Multidisciplinary care home support teams to deliver quality care, and reduce hospital admissions More community geriatician time

  6. Specialist Care for Older People - What we would like to happen • Skilled domiciliary care workers (rehab, mental health, medicine supervision, ‘handyman’) • Carer support (Day Centres, sitting services etc.) • Accessible health promotion (e.g. fitness groups, handouts with opportunity to discuss, domiciliary dentistry and optician for homebound)

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