Glasgow Integrated Care for Older People Intermediate Care

Glasgow Integrated Care for Older People – Intermediate Care

Comparison of Rates of Admission Rates per 100, 000 of Population – Council Area – 2004 – 14. Source ISD

Older people are not heterogeneous • • The fit and well Economically active Volunteers Carers • • The frail/ vulnerable Often women Usually over 80 Multi morbid

Frailty as an abnormal health state A state of vulnerability to poor resolution of homeostasis following a stressor event Clegg, Young, Iliffe, Olde-Rikkert, Rockwood. Frailty in elderly people. Lancet 2013; 381: 752 -762

Reshaping Care for Older People Population changes over time – 2015 – 2037 (22 Years!) Source – Census / General Registration Office Scotland 2014

Where did we come from? • High number of older people in Acute hospitals Ready for Discharge but ‘delayed’ • Older people going to long term care when some could potentially go home • Assessment for future care needs being carried out in crisis and in Acute hospital Environment • Older People being admitted to Acute Hospital Care due to ‘lack of alternatives’

What we had • Direct ordering of homecare by hospital staff in place since 2000 • Small step up unit in NE • Community Rehabilitation Teams with in-reach to A&E, early supported discharge, GP rapid response • Broken relationships/ lack of trust

Planning & Delivery • Small operational group – small quick cycles of change – PDSA- met weekly initially • Representation from Health, Social Work, Independent and Voluntary sector- key to building relationships • Developed based Intermediate Care Model • Introduced a BHAG – 72 hours • Changed practice to be more risk enabling • Involved service users and families and front line staff in service evaluation

Intermediate Care Principles • Professionals should not make decisions about an individuals future care needs while they are in crisis. • Older people should not be assessed for their future care needs in a hospital environment • We should afford an older person the greatest opportunity to remain in / return to their own home

Intermediate Care – Good Practice • We established dedicated units in all Sectors of Glasgow City. • Each unit has dedicated GP Sessions, Rehabilitation and Social Work Staff and access to Consultant Geriatrician Support • We provided training and support to staff in care homes in developing an enabling and rehabilitating ethos • Service focused and targeted with service user at the centrefocused on what we had to achieve- 48 hr goal planning , weekly reviews, outcome focused care planning.

Feedback – service users & family “Following her stay in intermediate care my mum is more improved than she was 6 months ago at home. We feel we have got our mum back “ “They ( hospital)said I’d need to go into care, the fact that I got home to my own bed meant the world to me “ They were great in the unit, I felt people were really interested in helping Mary to become more independent - Mary it’s your turn to make the tea”

Results- People aged 65 plus delayed over 72 Hours Excludes – AWI / Mental Health / Learning Disability from Weekly Report – 2 nd February 2015 to 8 th February 2016

Results Nov 2014 - Feb 2016 SOURCE: EDISON & GCC MONTHLY BALANCED SCORECARD 160 Average Monthly Delayed Discharges of Patients over 65 & Patients going home from Intermediate Care Glasgow City November 2014 - February 2016 140 120 100 80 60 45 40 15 20 1 0 ноя-14 дек-14 янв-15 фев-15 мар-15 >65 Patients Delayed апр-15 май-15 июн-15 июл-15 авг-15 сен-15 окт-15 Patients Going Home from Intermediate Care ноя-15 дек-15 янв-16 фев-16

Emerging Issues • • Relationships Language Readmissions Risk – perception

Continuous Improvement • Early identification of those ‘at risk’ • Need to look at the ‘front door’ to prevent Older People reaching crisis- step down beds • Provide creative and different solutions to allowing and support Older People to remain in their own homesaccommodation based strategy • All partners need to have different conversations with Older People, their families and Carers • On going evaluation and improvement