1. Interface Geriatric Service Description: Rapid access weekday acute comprehensive geriatric assessment (CGA) Monday to Friday 9-5 access to senior geriatric medical telephone advice (via existing number) or e-mail advice (via secure mailbox) and assessment in conjunction with clinical navigators. Geriatric Consultant interface sessions via weekly MDM’s to intermediate care beds (4-5 sessions in total). Geriatric Consultant interface to high risk nursing homes, attending weekly MDT etc. 1 session each per week. PROJECT SUMMARY KEY MILESTONES Date of Update: Dec 2014 RISKS AND ISSUES ACHIEVEMENTS/COMMENTARY OBJECTIVES: A joint approach to developing care pathways across primary and secondary care to ensure effective continuity of care Consultant Geriatrician leadership and input into community and social care environments and improve communications and signposting across the whole health and social care system Provide an opportunity to see and review patients before a crisis precipitates to an acute environment Avoid acute admissions where possible and reduce LoS for care home residents over 75 and intermediate care community hospitals Risk: uncertainty of outcome Issue: concerns or queries PreviousCurrentForecast AAG RAGRisk/IssueDescription / mitigation Dr Abdul Mallick did take up the post but will now not be working for a period of several weeks due to illness. The trust are offering a limited number of assessments carried out by a geriatric consultant already in post. Dr Wijayasiri will take over from w/c 8 Dec. Dr Mallick is expected to return to work in January, at which point assessments will be made available 5 days a week IG Team have been asked to provide Consultant input into the 10 additional beds commissioned at Pine Lodge Dr Rippingale fed back to John Watson that the Interface Geriatricians would not have capacity to provide this. The focus will be on delivering service and outcomes specified by the Interface Geriatric Pilot project. Dr Abdul Mallick, in post from September 14 Dr Susantha Wijayasiri in post from 1 Dec 14 Key Performance Indicators signed off and monitoring arrangements put in place. Referral Pathway and Referral Form / Clinic Letter template finalised and in use New service communicated via CCG Practice Bulletin on 26 Nov 14. Potential Care Homes to receive IG input from January 15 could be: o Guysfield Residential Home (Garden City Surgery) o Knebworth Care Home (Knebworth & Marymead Surgery) o Martins House (King George Surgery) Communications with care homes and practices will take place during Dec / early Jan to agree details of IG service. IG consultants will work with the lead GP for each care home to develop advanced care planning (PEACE model) Project ToR, Metrics and KPIs and referral pathway have been mapped, reviewed and agreed Assessment performa and clinic letter template finalised and shared with the project team. Reference information and bypass numbers have been made available to the IG team. Communications piece has gone out via CCG Practice Bulletin ENHT has been asked to provide a schedule of costs per month for the IG Project work, trust and CCG contracts teams are negotiating. Dr Abdul Mallick has been seeing patients and carrying out geriatric assessments from Sept 14 and Dr Wijayasiri from w/c 8 Dec. At this stage, referrals are coming mainly from the Emergency Department. Rapid access clinics will increase to 5 days a week (Mon to Fri) once both IG consultants are working in January Geriatric consultant input to nursing homes – details of this service are being agreed during Dec / early Jan. Service is expected to commence during January. Completed by: Martina Vogel-Matthews