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Acute medical care of older people - outside hospital Simon Conroy Head of Service/Senior Lecturer, Geriatric Medicine Cardiovascular Sciences University.

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Presentation on theme: "Acute medical care of older people - outside hospital Simon Conroy Head of Service/Senior Lecturer, Geriatric Medicine Cardiovascular Sciences University."— Presentation transcript:

1 Acute medical care of older people - outside hospital Simon Conroy Head of Service/Senior Lecturer, Geriatric Medicine Cardiovascular Sciences University of Leicester

2 Not an acute medical problem Inappropriate admissions What is intermediate care? Ageing population Lack of primary care Poor social services

3 Patients come out worse than went they went in Inappropriate admissions Inappropriate investigations Ageing population Too many specialists Black hole Patients come out worse than went they went in Too many specialists

4 What is the truth? Ageing population, increasingly complex care More attending emergency care –Despite intermediate care etc Lower threshold for admissions Coordinated care more challenging as ‘silo mentality’ sets in

5 Some definitions ‘Unscheduled care’, ‘unplanned care’, ‘emergency care’, ‘urgent care’ Department of Health: –‘Emergency Care is an immediate response to time critical health care need. Unscheduled care involves services that are available for the public to access without prior arrangement where there is an urgent actual or perceived need for intervention by a health or social care professional. Urgent care is the response before the next in–hours or routine (primary care) service is available.’

6 Scope Emergency care –999/ED –Not appropriate for community setting Urgent care –‘In the eye of the beholder’ –Most urgent care is sub-acute care

7 Urgent (sub-acute) care – who?

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9 Urgent care – what? Non-specific presentations –Falls, delirium Multiple comorbidities Polypharmacy –Also under-prescribing Differential challenge –Communication, discharge support

10 Urgent care - where? Where there is ready access to: –Skilled assessment –Diagnostics, if necessary –Safe environment –Rehabilitation –Coordinated care

11 Figure 3: Fixed-effects meta-analysis of individual patient data: mortality at 6 months. Shepperd S et al. CMAJ 2009;180: ©2009 by Canadian Medical Association

12 Urgent care - standards The Silver Book –http://www2.le.ac.uk/departments/cardiovascular-sciences/people/conroy/silver-bookhttp://www2.le.ac.uk/departments/cardiovascular-sciences/people/conroy/silver-book Membership –Age UK –National Ambulance Service Medical Directors –Association of Directors of Adult Social Services –British Geriatrics Society –Chartered Society of Physiotherapists –College of Emergency Medicine –College of Occupational Therapists –Society for Acute Medicine –Royal College of General Practitioners –Royal College of Nursing –Royal College of Physicians –Royal College of Psychiatrists –Community Hospitals Association

13 Underpinning principles All older people have a right to a health and social care assessment and should have access to treatments and care based on need, without an age- defined restriction to services A whole systems approach with integrated health and social care services strategically aligned within a joint regulatory and governance framework, delivered by interdisciplinary working with a patient centred approach provides the only means to achieve the best outcomes for frail older people with medical crises

14 Standards (some) All older people accessing urgent care should be routinely assessed for: –Pain –Depression –Skin integrity –Falls and mobility –Continence –Safeguarding issues –Delirium and dementia –Nutrition and hydration –Sensory loss –Activities of daily living –Vital signs –End of life care issues

15 Frailty syndromes & urgent care The presence of one or more frailty syndrome should trigger a more detailed comprehensive geriatric assessment, to start within 4 hours (14 hours overnight) Frailty syndromes –Falls & immobility –Functional decline –UTI & incontinence –Pressure sores – Delirium and dementia – Polypharmacy (>4 items) – Carer strain

16 Who needs referring to the MDT? Population: Younger, single system problem Older, single system problem Older, multiple problems, frailty makers Refer to: Relevant service, e.g. mental health, diabetes Relevant service, e.g. mental health, diabetes & screen for frailty syndromes Virtual ward/ community MDT

17 Operationalising good practice Delivering multidimensional assessment & multiagency management Home based multidisciplinary teams –General practitioners –Community nursing, physiotherapy, occupational therapy, mental health –Specialist nursing –Advanced nurse practitioners –Interface geriatricians –Social care –Voluntary services

18 Does it work in practice? National Evaluation of the Department of Health’s Integrated Care Pilots; RAND Europe, Ernst & Young; March 2012

19 Key findings Horizontal > vertical integration Process improvements – e.g. more care plans Professional > patient driven service change –Patients less enthusiastic No evidence of reduced emergency care use Reductions in elective care use (in and out-patient) –Case management –Reduced costs

20 Effective urgent community care for older people Vertically integrated, using strengths of both sectors Comprehensive geriatric assessment, including social care Coordinated and communicated

21 Frail older person in crisis Intermediate care Bed-based rehabilitation/ reablement Specialist care In-patient CGA Liaison SPA – clinical discussion MDT Triage Trajectory Transfer EFU/ AFU

22 Summary outcomes for ED Percentage change 2010 vs. 2012

23 Impact on bed days Despite large increase in older people attending, bed-days only modestly increased

24 Summary Urgent care = older people It can be in the community, but: –Needs to be vertically integrated –Holistic & interdisciplinary –Underpinned by robust communication and cooperation


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