Healthcare & Social Services Access to MCMOP Frail Elderly - - PowerPoint PPT Presentation

Healthcare & Social Services Access to MCMOP

MCMOP Geriatrician RANP CCM (CNS)

Frail Elderly At Home PHN Senior SW for OP Clinical & Social Care Other CCM Community RANP Diagnostics & Intervention CIT CRT Imaging Management Respite care Home care Package CSAR PCCT

• GP
• Social

worker Safe guarding

Acute Hospital Post dc follow up Non-attendance OPD ED

Frail elderly In NH CGA Acute, chronic illness End of life St Mary’s Hospital Day Hospital MDT Community Response

POA

Specialist Palliative Care

North Dublin Steering Group for OP

Emergency Attendance of Nursing Home residents: DNC

224 197 240 229 326 398 350 379 296 248 172 169 187 181 210 187 281 264 8 10 13 12 9 10 7 10 8 Yr2008 Yr2009 Yr2010 Yr2011 Yr2012 Yr2013 Yr2014 Yr2015 Yr2016

Outcome of Nursing Home residents at ED 2008 to 2016

Adm DC DID 0.43 0.35 0.37 0.35 0.38 0.45 0.40 0.48 0.40 0.21 0.18 0.21 0.19 0.24 0.29 0.26 0.27 0.21 Yr2008 Yr2009 Yr2010 Yr2011 Yr2012 Yr2013 Yr2014 Yr2015 Yr2016

ED Transfer and Admission rate per bed per year 2008 to 2016

Transfer rate Admit rate 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 Oct-06 Feb-08 Jul-09 Nov-10 Apr-12 Aug-13 Dec-14 May-16 Sep-17

Proportion of ED attendances requiring inpatient care (monthly vs yearly)

Proportion admit (mth) Proportion admit (yr)

MCMOP

Presenting Complaint at Triage Y2013 Y 2016 Unwell Adult 235 Unwell Adult 175 Fall 125 Fall 89 Shortness of Breath 91 Limb Problem 59 Limb Problem 72 Urinary Problem 53 Collapse 59 Shortness of Breath 47 Urinary Problem 42 Collapse 29

Integration in Action

MCMOP Geriatrician RANP *

CCM *

(CNS)

Frail Elderly At Home PHN * Senior SW for OP Clinical & Social Care Other CCM Community RANP Diagnostics & Intervention CIT* CRT Imaging Management Respite care * Home care Package * CSAR * PCCT

• GP *
• Social

worker Safe guarding

Acute Hospital Post dc follow up * Non-attendance OPD ED

Frail elderly In NH CGA Acute, chronic illness End of life * St Mary’s Hospital Day Hospital MDT Community Response *

1 2 3 4 5 6 7 8 9 “I want to stay home, sit in my chair to watch TV, look out the window”

He lived at home for 18 months

• 78 yo Man,

sheltered accommodation,

• Diabetes Mellitus,
• Insulin requiring

(PHN),

• heart failure,
• recurrent cellulitis
• bilateral forefoot

amputee,

• recurrent falls,
• mild vascular

cognitive impairment,

• dietary non-

compliance,

• medication non-

adherence

• NOT SAFE TO BE

AT HOME