1. Sarah Shanahan and Lucy Fergus Hawke’s Bay DHB APIC 1 November 2017

2. engAGE Community MDTs Weekly MDT Meetings in GP settings.
Teams include GPs, Practice nurses, Social Workers, Occupational Therapists, Physiotherapists, CNS Gerontology, Geriatricians, NASC Assessors, Older Persons Mental Health, District Nurses, Clinical Pharmacist Facilitators, Care Agency RNs.
Referrals from the team or hospital MDTs.
Team work collaboratively to support older people to remain independent at home.
Working with 20 out of 24 practices in Hastings and Napier.
1485 referrals since roll out, average 160 per quarter.
95% > 65 yrs, 40% > 85yrs
Approx. half of referrals from GPs.
A representative number of Māori in older age groups but over representation in younger age groups.

3. engAGE Intermediate Care
An alternative to hospital for older people requiring reablement.
“Step up” or “step down”- up to 6 weeks.
Older person is supported to set goals that are important to them and their family.
RN from ARRC facility attends MDT meetings and gives feedback on person’s progress to support discharge planning.
Home visits frequently carried out in preparation form discharge home.
Provide an alternative to hospitalisation for older people who require a period of reablement who cannot manage at home but do not need to be in hospital.
“Step up” from community or “step down” from hospital- up to 6 weeks.
159 patients, 2551 bed days over 16 months Average LOS 16 days

4. engAGE ORBIT Team
Rapid Response Allied Health Team in ED/AAU/Community outreach
OT/ PT/ SW Interprofessional approach and skill sharing
7 day service, 7.00am- 7.00pm, focussed on preventing admission to hospital for frail older people and supporting safe discharges
ORBIT saw an extra 1000 patients in first year of extended hours
St John Ambulance Frailty Pathway
Patient stats since Nov 2015 roll-out:
Total 4768 referrals, Average 670 per quarter
Half referrals from ED, half from AAU, small number from St John Ambulance.
Māori highly over represented in younger age groups.

5. Feedback Stakeholder Consumer
“ It’s great to know that you are… not just a number that has been forgotten about”
“If Mum had not gone into the bed and had the support she did to get back to her normal self and put weight on she wouldn’t have been able to cope (at home)”
“It gets a bit confusing with lots of them coming and going”
Stakeholder
“Not only by way of putting faces to names, but understanding each other’s roles better and the services available”
“A very useful forum for case discussion and planning”
“The knowledge sharing, particularly from those more experienced, has been wonderful and very much appreciated”.
“engAGE has been absolutely invaluable to our patients and our General Practice”.

6. Outcomes
Measure: ED use and acute bed days for over 65s, adjusted for population increase
2015 adjusted
2016 actual
Improvement
ED Presentations
65+
10883
10625
2.4%
85+
2442
2283
5.8%
Acute Bed Days
33269
31463
5.4%
9236
8766
5.1%
2015 column has been scaled up to account for population growth in ie it is the 2015 ED admission number multiplied by the population increase