Sarah Shanahan and Lucy Fergus Hawkes Bay DHB

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

eng. AGE 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% > 85 yrs • Approx. half of referrals from GPs. • A representative number of Māori in older age groups but over representation in younger age groups.

eng. AGE 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. Outcomes 5% Discharged home 15% Permanently into care 5% Died 55% 20% Admitted to hospital Moved out of area 159 patients, 2551 bed days over 16 months Average LOS 16 days

eng. AGE ORBIT Team • Rapid Response Allied Health Team in ED/AAU/Community outreach • OT/ PT/ SW Interprofessional approach and skill sharing • 7 day service, 7. 00 am- 7. 00 pm, 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. Over 85 yrs 1 287 Under 65 yrs 1 144 65 -85 yrs 2 336

Feedback Consumer Stakeholder “ It’s great to know that you are… not just a number that has been forgotten about” “Not only by way of putting faces to names, but understanding each other’s roles better and the services available” “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” “A very useful forum for case discussion and planning” “The knowledge sharing, particularly from those more experienced, has been wonderful and very much appreciated”. “eng. AGE has been absolutely invaluable to our patients and our General Practice”.

Outcomes Measure: ED use and acute bed days for over 65 s, adjusted for population increase 2015 adjusted 2016 actual Improvement 65+ 10883 10625 2. 4% 85+ 2442 2283 5. 8% 65+ 33269 31463 5. 4% 85+ 9236 8766 5. 1% ED Presentations Acute Bed Days