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Frail Elderly Pathway

Frail Elderly Pathway. Walsall Healthcare NHS Trust. The Vision. Integrating (or coordinating) care around the needs of patients Avoiding unnecessary admissions to Hospital; Finding alternatives to Acute Admissions

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Frail Elderly Pathway

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  1. Frail Elderly Pathway Walsall Healthcare NHS Trust

  2. The Vision • Integrating (or coordinating) care around the needs of patients • Avoiding unnecessary admissions to Hospital; Finding alternatives to Acute Admissions • Supporting Older People in their own environment; Maintaining Independence & Function • Multidisciplinary Team Working; supporting Primary care • Continuity of Care; Generalist approach; Specialist input when needed

  3. The Team- in the Hospital • FEP GP • Based mainly in A&E; Visits and support to Community Teams; Community Ward Medical Cover • FEP Nurses • Assisting with assessments in A&E; supporting care co-ordination; facilitating a FEP approach within the Acute Trust • FEP Social Worker and Older Adults’ Mental Health Worker • Swift Ward (Community Ward within the Acute Trust) • Step-Up from A&E/Community/GP • Access to OT/Physiotherapists/Reablement Officers/Social Workers • Generalist approach; Continuity; ‘Specialists’ brought to the Ward

  4. The Team-in the Community • Integrated Care Team/Rapid Response • Specialist Nursing Team/OT/Physiotherapists • Supporting assessments, therapies, and reviews • ‘Hospital at Home’ • Accepting direct referrals via GP/999/DN/A&E FEP • Medical support via FEP GP and Specialist Geriatrician • Joint visits when needed with FEP GP/Nurses

  5. Some Numbers

  6. Step-up Data: Phase 1 • April-September 2012 • N= 39 • 24F : 15M • Average Age 84.7yrs • Length of Stay • Mean 4.8 days • Median 2 days • Mode 1 day • Readmissions within 30 days of Discharge • Zero

  7. Step-up Data: Phase 2 • October 2012-January 2013 • N= 74 • 47F : 27M • Average Age 86.4yrs • Length of Stay • Mean 6.7 days • Median 4 days • Mode 1 day • Readmissions • 9/74 directly from Ward to Acute Trust • 14/65 (21.5%) within 30 days of discharge from Hospital

  8. Further Information • Simon.harlin@walsallhealthcare.nhs.uk • GP Medical Lead, Frail Elderly Pathway • Miriam.mcgurry@walsallhealthcare.nhs.uk • Lead Nurse, Frail Elderly Pathway • Margaret.williams@walsallhealthcare.nhs.uk • Deputy Divisional Director, Speciality Medicine & Long-Term Conditions

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