1. OPAL: Older Person’s Assessment and Liaison Team

2. Jim’s Story: Jim 86, lives alone with dog. STML, previous TIAs
Carer 3 x Week; son in Oxford
6 admissions to SDH since April, 2016
154 days in hospital
72 MFFD & awaiting POC
All admissions due to falls +/- increased confusion
Last admission; 5 wards
Gradual increase in care needs
Gradual increase in medications
Worsening mobility
Worsening confusion
Last fall-Pubic Ramus and rib #s
Discharged in January with 24 hour care,
No further admissions

3. Older Person’s Assessment and Liaison Service: OPAL
To identify frail patients presenting at the front door of the hospital, through ED, SSEU and MAU early in their pathway to:
Improve clinical outcomes
Prevent avoidable admission
Reduce length of stay
Reduce readmission
Provide a service which is patient centred and safe
To initiate a CGA and personalised care plan

4. OPAL Funding from Health Education Wessex £121,000
1 of 4 projects, £450,000 total
Pilot of a new frailty team at the front door of the hospital
Recruitment of Clinical Nurse Specialist ( Operational Resilience )
Physiotherapists, Occupational Therapists and Therapy Assistants
Initiate CGA on admission and PCP on discharge
Provision of short term re-ablement care
Liaison with GPs and community teams
Referral to specialist services, clinics (RACE and Falls) and 3rd sector
Ensure appropriate onward referral to downstream wards
Support form Wessex CLARHC and other projects

5. OPAL Pathway
Referral Criteria
to OPAL
Monday-Friday
8am – 4pm

6. Progress to date OPAL team now well established
Service and referral processes understood amongst other clinical areas
Developing competency framework
Developing IT and data systems to support clinical work and audit
1 clinical nurse specialist working alongside team
Limited Geriatrician input
PPI project

7. What has gone well? Effective and fully engaged clinical team
Willingness to learn from and support each other
Early discharge of frail patients at the front door (approximately 60%)
Emerging pathway for frail older people
Establishing relationships with GP localities and community teams

8. Next Steps: Continue to establish closer links with locality teams
Outreach frailty clinics, MDT meetings and Care home ward rounds
Explore options for direct referral to ring fenced ICBs and POC
End of life care
Recruitment in to substantive roles
7 day service
Development of data base and improvements to EDS
Support team through competency framework
Acute Frailty Unit opening on 7th December

9. Patient Story:

10. Outcomes of Service = 700 patients seen by OPAL in 1st 9/12
Average age = 83
Average LOS = 3 days ( Nationally = 9.4 days )
70% had LOS of 0-1 day
63% discharged directly from Majors, SSEU or AMU
91% had CGA initiated within 24 hours
11% readmission < 60 days ( SFT average =29% )
Improved streaming to Durrington and Winterslow wards
70 patients seen by OPAL have died (10%)