1. Frail Elderly Pathway Walsall Healthcare NHS Trust

2. The Vision Integrating (or coordinating) care around the needs of patients Avoiding unnecessary admissions to Hospital; Finding alternatives to Acute Admissions Supporting Older People in their own environment; Maintaining Independence & Function Multidisciplinary Team Working; supporting Primary care Continuity of Care; Generalist approach; Specialist input when needed

3. The Team- in the Hospital FEP GP Based mainly in A&E; Visits and support to Community Teams; Community Ward Medical Cover FEP Nurses Assisting with assessments in A&E; supporting care co-ordination; facilitating a FEP approach within the Acute Trust FEP Social Worker and Older Adults’ Mental Health Worker Swift Ward (Community Ward within the Acute Trust) Step-Up from A&E/Community/GP Access to OT/Physiotherapists/Reablement Officers/Social Workers Generalist approach; Continuity; ‘Specialists’ brought to the Ward

4. The Team-in the Community Integrated Care Team/Rapid Response Specialist Nursing Team/OT/Physiotherapists Supporting assessments, therapies, and reviews ‘Hospital at Home’ Accepting direct referrals via GP/999/DN/A&E FEP Medical support via FEP GP and Specialist Geriatrician Joint visits when needed with FEP GP/Nurses

5. Some Numbers

6. Step-up Data: Phase 1 April-September 2012 N= 39 24F : 15M Average Age 84.7yrs Length of Stay Mean 4.8 days Median 2 days Mode 1 day Readmissions within 30 days of Discharge Zero

7. Step-up Data: Phase 2 October 2012-January 2013 N= 74 47F : 27M Average Age 86.4yrs Length of Stay Mean 6.7 days Median 4 days Mode 1 day Readmissions 9/74 directly from Ward to Acute Trust 14/65 (21.5%) within 30 days of discharge from Hospital

9. Further Information Simon.harlin@walsallhealthcare.nhs.uk GP Medical Lead, Frail Elderly Pathway Miriam.mcgurry@walsallhealthcare.nhs.uk Lead Nurse, Frail Elderly Pathway Margaret.williams@walsallhealthcare.nhs.uk Deputy Divisional Director, Speciality Medicine & Long-Term Conditions