The Integrated Care of Older People ( iCOP) service is a fully integrated Multidisciplinary team that supports older people living with frailty. The demographic characteristics of this population commands a model of care tailored to the needs of people living with frailty attending Swansea's Singleton Hospital Assessment Unit (SAU). The original model did not deliver the high quality, integrated, person centred care that older people require.
There are guidelines for the identification and management of frailty in the acute setting. These are set out in the British Geriatric Society (BGS) “Fit for Frailty” document. Comprehensive geriatric assessment is identified as the gold standard for assessing older people living with frailty and leads to better outcomes for patients.
Following a successful pilot within SAU Singleton Delivery Unit during 2017, a business case was prepared and delivered to the Executive team of ABMU. Funding was granted, allowing the service to become embedded as a sustainable acute frailty service.
The iCOP team will deliver Comprehensive Geriatric Assessment (CGA) for 40% of the medical intake aged >75, to include people with frailty syndromes, such as, falls, confusion, dementia and immobility.
The aim is to increase the percentage of discharges directly from SAU, thus facilitating admission avoidance, and reduced length of stay.
Based within the Singleton Assessment Unit (SAU) in Singleton Hospital the iCOP team identify people aged >75 admitted with a frailty syndrome. A CGA is commenced by the team and early intervention, discharge planning and support with the transition of care to wards.
The iCOP team consists of:
- Consultant Geriatrician
- Physicians Associate
- Nurse Practitioners
- Pharmacy technician
- Occupational Therapists
- Therapy technician
- Community Reablement Nurse
- Social Worker
- Administrative Support
A key component of the iCOP model is the close relationship that has been nurtured with local community based services. This enables people to be managed in their own homes whilst continuing to address non-acute problems such as a reduced level of functional independence which may have contributed to their admission.
iCOP are assessing 40% of people aged >75 in SAU.
48% of people discharged directly from SAU compared to previous level of 28%.
55% of iCOP patients with a length of stay of 0-1 days in SAU.
57% of iCOP patients requiring hospital admission successfully transferred to ward 3 (care of the elderly) to receive ongoing specialist care.
Better clinical outcomes via:
- Earlier decision making and implementation of medical, social and therapeutic intervention.
- Admission avoidance and community outreach
- Excellent links established with community medical and Therapy teams
- Improved transitions of care, reducing length of stay.
Front door access to a specialist frailty MDT should become standard practice across the UK to improve patient care and outcomes.
Funding was via the Invest to Save Board of ABMU UHB
This work was presented at Physiotherapy UK 2019