278 Avoiding acute hospital admission through rapid access rehabilitation pathways for frail older patients through cross site integrated working

Abstract

Abstract Background Ireland’s population is ageing. Patients over 65 use over half of inpatient hospital beds. Prolonged Length of Stays (LoS) in ED and hospital increase risk of adverse outcomes. Barriers like complicated referral systems, ineffective communication across sites and reduced awareness of services contribute to delays in accessing timely rehabilitation. Aims include: (1) Establish alternative care pathways between ED, rehabilitation and community settings for frail older people; (2) To use a comprehensive geriatric assessment (CGA) as a single referral form. Methods Patients were identified in ED as suitable for direct transfer to rehabilitation, or discharge home with Community Specialist Team—Older People (CST-OP). The CGA was accepted as the handover document to all services. Patients in the community deemed to have increased rehabilitation needs could be admitted directly into inpatient rehabilitation. We analysed data from July to December 2022 for the ED, two rehabilitation sites, and the CST-OP. Results Patient were aged 66–101. The ED team saw 1,691 patients, 3.5% (n = 56) were transferred to offsite rehabilitation, and 3.7% (n = 63) discharged to the CST-OP. 69 patients were admitted across two rehabilitation units. 33% of patients seen in ED had evidence of a cognitive impairment, compared to 70% in rehabilitation. Approximately 80% of patients in rehabilitation had a Clinical Frailty Scale (CFS) of ≥5, compared to 60% ED patients. 16 patients represented to ED within seven days. On discharge from rehabilitation, 42% of patients required increased formal supports, compared to 3% from ED. Five patients discharged to the CST-OP required admission to inpatient rehabilitation. Average LOS for the rehabilitation units were 46 and 39 days. 9% of patients transitioned into nursing home care. Conclusion Shared clinical governance among geriatricians in different services facilitated integrated working of MDTs across sites. The teams have implemented end to end care pathways integrating front door frailty services, CST-OP and existing rehabilitation services.