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

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 1 st 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?