Alternative Care Pathways Research Articles

Effect of insurance type on Management of Vancouver B Periprosthetic Fractures: length of stay, discharge destination and cost implications.

To assess the effect of private versus public insurance on hospital length of stay, discharge destination, and costs in managing Vancouver B periprosthetic femoral fractures (PFF). A retrospective cohort study of PFF patients operatively managed at five public trauma centers. The primary outcome was hospital length of stay. Secondary outcomes included discharge destination and costs related to implants and hospital beds. The study included 195 PFF cases (133 public, 62 private). Private patients had lower ASA scores (2.8 versus 3.1, P = 0.006) and were more likely to come from independent residences (87% versus 74%, P = 0.045). Private patients spent 8 fewer days in the hospital (12 ± 8 versus 20 ± 19 days, P < 0.001) and were more often discharged to rehabilitation (74% versus 48%, P = 0.003). Public hospital costs were higher for public patients ($37 456 versus $25 324, P = 0.005), largely due to longer stays. Implant costs were similar between private and public patients, but patients that underwent revision surgeries increased costs significantly compared to patients that underwent open reduction and internal fixation alone ($6257 versus $3511, P < 0.001). Private insurance was linked to shorter hospital stays and increased discharge to rehabilitation. Public PPF patients incur an average cost of $37 456 for public hospitals, compared to $25 324 for private patients. Delays in public patient rehabilitation access may prolong hospital stays, suggesting a need for alternative care pathways, such as PPF tailored home-based rehabilitation and support programs.

Utilizing a Geriatric Emergency Multi-disciplinary Service (GEMS) To Improve Care For Nursing Home (NH) Residents In The Emergency Department (ED)

Abstract Background The GEMS team provides an age attuned service for older adults living with frailty who present to the ED. Under the governance of a Geriatrician older adults living with frailty receive a Comprehensive Geriatric Assessment (CGA) and a collaborative plan of care. NH residents are often the most frail cohort of patients. They can sometimes be referred to the ED with needs that could be managed in the community. Moreover, transfer is associated with a higher risk of mortality (Lemoyne et al. 2019). To address this, all NH residents are classified as priority one by the GEMS Team. Pathways have been developed to the Community Integrated Hub for the Older Person (ICPOP), General Practitioners and Community Palliative Care Teams. The goals is to provide the right care, in the right place and at the right time. Methods Plan, Do, Study, Act (PDSA) Quality Improvement Methodology was utilized. Data was collected on all NH patients presenting to ED and interrogated over a 3-month period. Results 27 patients presented to ED from a nursing home during the collection period. (n=16) 60% of patients were discharged. 89% were living with severe frailty. 100% received a CGA, Advanced Care Planning and family liaison. (n=5) referred to ICPOP. (n=6) referred to Palliative Care through the GP. Conclusion The majority of patients reviewed were living with severe frailty and likely beginning the final journey of their lives. A CGA on presentation to ED ensures the goals of care are aligned with the persons will and preference. Alternative care pathways in the community enabled patients to be discharged back to the nursing home with appropriate follow-up supports. Reference 1. Lemoyne SE, Herbots HH, De Blick D, Remmen R, Monsieurs KG, Van Bogaert P. Appropriateness of transferring nursing home residents to emergency departments: a systematic review. BMC geriatrics. 2019 Dec; 19:1-9.

“Pathfinder Filled The Gap And Linked In With The Necessary Services” Service User Perceptions Of The Pathfinder Service

Abstract Background Pathfinder is a service designed to keep older adults who phone 999 at home by utilising alternative care pathways, when it is safe to do so. Pathfinder responds to adults aged 65 and older who present with low acuity complaints. The service is delivered by Occupational Therapists, Physiotherapists and Advanced Paramedics and is embedded between acute and community care. The aim of this study is to capture how the service user found their interaction with this novel service. Methods As part of routine service evaluation, semi-structured brief telephone interviews with closed and open-ended questions were completed with a number of service users (the patient or their primary care giver). Interviews were completed at least one week after their discharge from the service, by a member of the team who had not been involved in their care. Interviews were then analysed using Microsoft Excel® for closed ended questions and thematic analysis for open ended questions. Results One hundred service users were contacted, of which 76 completed the brief telephone interviews. 99% of respondents felt Pathfinder treated them with respect and dignity, 100% felt Pathfinder communicated clearly and 97% rated the service as excellent. Five key themes were identified from open-ended questions (1) the prompt arrival of care, (2) the thorough examination and reassurance provided, (3) the benefit of follow-up after the initial 999 call, (4) the domino effect of onward referrals and (5) the holistic approach to care given. Conclusion There was universal positive feedback for the Pathfinder service reported by both older adults who engaged with the service and their primary care givers. Key elements of the service delivery were complimented including the assessment, the follow up service provided and the onward referral to acute and community services.

Answering an “SOS”: A 12-Month Review of An Urban Pathfinder Service

Abstract Background The Pathfinder service is a collaboration between the National Ambulance Service (NAS) and acute hospital Physiotherapists (PT) and Occupational Therapists (OT). The service aims to safely treat over-65s who have called 999 with low-acuity problems at home. It offers safe alternative care pathways to traditional Emergency Department (ED) attendance to older adults within our hospital catchment area (Bernard et al. 2021). Methods A retrospective review of the service database for 2023 was completed. A patient experience survey was conducted over a 4-week period in Quarter 4 of 2023. The survey consisted of both Likert scale and open-ended questions. Service statistics and Likert data were analysed in Microsoft Excel, while open-ended responses were analysed thematically. Results A total of 598 calls were received by our Pathfinder service in 2023: live 999 calls (n=407), and “Special Services” (SS) calls from Dublin Fire Brigade (n=191). 55% of live 999 call referrals attended by Pathfinder were safely kept at home. Of 191 SS referrals, 35% (n=66) had a review by the Pathfinder team. Of the 66 assessed, 94% (n=62) were safely kept at home. A total of 1,392 follow-up interventions (home visits, phone calls, onward referrals) were completed by PT and OT. Service user feedback was overwhelmingly positive, with 100% (n=20) of respondents stating they would be happy to see the Pathfinder team again if calling 999. General feedback highlighted the responsiveness, thorough assessment, and friendliness and professionalism of the team. Areas for development included increasing staffing and increasing to a 7-day service. Conclusion The Pathfinder service is effective in an urban setting. Over a 12-month period, 55% of patients assessed by Pathfinder were safely treated at home, with follow-up support from Pathfinder PT and OT. Service users report positive experiences and would be happy to see the team in the future when calling 999.

Community Specialist Teams: Are We Making an Impact? Insights from General Practitioners

Abstract Background Within our catchment area, General Practitioners (GPs) are the primary source of referral to community specialist teams (CSTs) for older adults and are key stakeholders in supporting the integrated care pathway. We sought to evaluate their experience to inform service development. Methods GPs across four healthcare networks were invited to complete an online questionnaire evaluating their experience of the CSTs for older adults. Results Twenty-eight GPs responded. Of these, 85.7% (24) found the referral criteria clear, and 89.3% (25) reported ease of access to the service. However, 50% (14) were uncertain about when to refer patients to primary care alone versus the CST. A significant majority, 96.5% (27), felt the service positively impacted the health and well-being of referred patients, and 92.9% (26) were satisfied with communication regarding patient care plans and progress. Identified strengths of the service included the multidisciplinary approach to providing comprehensive, patient-centered care and effective communication with both GPs and patients. Areas for improvement included enhancing access for specialist teams to community radiology and increasing staffing levels to ensure timely assessments. Regarding the impact on unscheduled and emergency care, 71.4% (20) reported a reduced need to refer to the acute medical unit, and 35.7% (10) reported a reduced need to refer to the emergency department due to the ability to refer to CSTs. Conclusion GPs value the CST service for the quality of assessment and intervention their patients receive. Targeted areas for operational and clinical improvement include provision of diagnostics and role distinction from primary care teams. This survey also suggests CSTs are providing an alternative care pathway and point of contact for older patients in crisis, resulting in a reduction in unscheduled and emergency care utilisation. The role of the CSTs should be supported and enhanced and warrants more detailed exploration.

The Development And Implementation Of A Multi-Factorial Falls Assessment Tool In A Pathfinder Service

Abstract Background Falls are a common complaint of older adults who present to the Pathfinder service. Pathfinder offers alternative care pathways to older adults when they phone 999 for low acuity concerns. As part of the service, Occupational Therapists and Physiotherapists provide home-based assessments and interventions. The aims of this project were firstly, to develop a falls assessment tool to assist therapists’ compliance with guidelines relating to older adults who have fallen and secondly, to ensure consistency of assessment and intervention among therapists on the team. Methods A falls assessment tool was created in line with the most recent world falls guidelines (Montero-Odasso et al., 2022). The initial roll out began on October 1st, 2024, when the tool was used to assess older adults who presented to the Pathfinder service following a fall. After three months, areas of poor compliance and barriers with usability of the tool were highlighted from a chart review and stakeholder engagement. The document was then revised based on this feedback. From February 1st, 2024, the tool was then used with all older adults who presented to the service. Compliance was re-audited at the end of April 2024 and therapists on the team were surveyed to gather user feedback. Results As a result of the falls assessment tool, compliance with the World Falls Guidelines increased initially from 54% to 86% but continued to improve when reviewed seven months post implementation. Qualitative data was universally positive when stakeholders were surveyed with benefits identified as: improving patient care, consistency across the therapy team and a useful means of communication. Conclusion The development and implementation of a falls assessment tool into the practice of a Pathfinder service increased compliance with the most recent world falls guidelines and received positive feedback from all key stakeholders.

Cost-effectiveness of monitoring ocular hypertension based on a risk prediction tool

Background/AimsTo assess the cost-effectiveness of making treatment decisions for patients with ocular hypertension (OHT) based on a risk prediction (RP) tool in the United Kingdom.MethodsA discrete event simulation model was...

Out-of-hospital paramedic interactions with people living with dementia: a scoping review.

Dementia encompasses neurodegenerative disorders that account for a global estimated healthcare expenditure of 1.3 trillion US dollars. In Australia, one in 12 people aged ≥65 has a diagnosis of dementia and it is the second leading cause of death. Paramedics play a crucial role in person-centred dementia care, particularly in the community. While consensus has been established on paramedicine's integration into interdisciplinary care teams, there remains a lack of clarity regarding the paramedic role in dementia care. This study aimed to examine and report paramedic interactions with people living with dementia in the out-of-hospital setting. This was a scoping review study of paramedics and people living with dementia within the out-of-hospital setting. This study was guided by the Joanna Briggs Institute (JBI) scoping review framework. Databases were searched without date limits, up to 4 April 2023. These encompassed OVID Medline, CINAHL, Scopus, APA PsycInfo and OVID Embase. Articles were included if they were primary, peer-reviewed studies in English and reporting on paramedic-specific interactions with people living with dementia in the out-of-hospital setting. Data extraction was performed based on study setting, design, population and key findings. Twenty-nine articles were included in the thematic analysis. Four themes emerged: need for training, patterns of attendances, patterns of documentation and the integrative potential of paramedicine. Paramedics reported feeling ill-equipped and unprepared in caring for patients living with dementia due to challenges in assessment and management of caregiver tensions. They were often called as a last resort due to poor service integration and a lack of alternative care pathways. Despite high conveyance rates, there was low incidence of paramedic interventions initiated. Underdocumentation of dementia and pain was found. Emergency ambulance conveyance of people living with dementia is a surface reaction compounded by a lack of direction for paramedics in the provision of out-of-hospital care. There is a pressing need for establishment of research and educational priorities to improve paramedic training in dementia-specific skillsets.

Service users' preferences and feasibility – which alternative care pathway for adult ambulance users achieves the optimal balance? Workshops for the COLLABORATE project

IntroductionAdults presenting to the ambulance service for diagnosed epilepsy are often transported to emergency departments (EDs) despite no clinical need. An alternative care pathway (CP) could allow paramedics to divert them from ED and instigate ambulatory care improvements. To identify the most promising CP configuration for subsequent testing, the COLLABORATE project surveyed people with epilepsy and family/friends who had recently used the English ambulance service to elicit preferences for 288 CP configurations for different seizures. This allowed CPs to be ranked according to alignment with service users’ preferences. However, as well as being acceptable to users, a CP must be feasible. We thus engaged with paramedics, epilepsy specialists and commissioners to identify the optimal configuration. MethodsThree Knowledge Exchange workshops completed. Participants considered COLLABORATE's evidence on service users’ preferences for the different configurations. Nominal group techniques elicited views on the feasibility of users’ preferences according to APEASE criteria. Workshop groups specified the configuration/s considered optimum. Qualitative data was analysed thematically. Utility to users of the specified CP configurations estimated using the COLLABORATE preference survey data. ResultsTwenty-seven participants found service users' preferences broadly feasible and outlined delivery recommendations. They identified enough commonality in preferences for different seizures to propose a single CP. Its configuration comprised: 1) patients staying where they were; 2) paramedics having access to medical records; 3) care episodes lasting <6 h; 4) paramedics receiving specialist advice on the day; 5) patient's GP being notified; and 6) a follow-up appointment being arranged with an epilepsy specialist. Preference data indicated higher utility for this configuration compared to current care. DiscussionStakeholders are of the view that the CP configuration favoured by service users could be NHS feasible. It should be developed and evaluated.

Developing an alternative care pathway for emergency ambulance responses for adults with epilepsy: A Discrete Choice Experiment to understand which configuration service users prefer. Part of the COLLABORATE project

IntroductionTo identify service users’ preferences for an alternative care pathway for adults with epilepsy presenting to the ambulance service. MethodsExtensive formative work (qualitative, survey and knowledge exchange) informed the design of a stated preference discrete choice experiment (DCE). This hypothetical survey was hosted online and consisted of 12 binary choices of alternative care pathways described in terms of: the paramedic's access to medical records/ ‘care plan’, what happens next (described in terms of conveyance), time, availability of epilepsy specialists today, general practitioner (GP) notification and future contact with epilepsy specialists. DCE scenarios were described as: (i) typical seizure at home. (ii) typical seizure in public, (iii) atypical seizure. Respondents were recruited by a regional English ambulance service and by national public adverts. Participants were randomised to complete 2 of the 3 DCEs. ResultsPeople with epilepsy (PWE; n = 427) and friends/family (n = 167) who completed the survey were representative of the target population. PWE preferred paramedics to have access to medical records, non-conveyance, to avoid lengthy episodes of care, availability of epilepsy specialists today, GP notification, and contact with epilepsy specialists within 2–3 weeks. Significant others (close family members or friends) preferred PWE experiencing an atypical seizure to be conveyed to an Urgent Treatment Centre and preferred shorter times. Optimal configuration of services from service users’ perspective far out ranked current practice (rank 230/288 possible configurations). DiscussionPreferences differ to current practice but have minimal variation by seizure type or stakeholder. Further work on feasibility of these pathways in England, and potentially beyond, is required.

Motives of patients presenting independently at the emergency department-aprospective monocentric observational study

In the ongoing professional, societal, and political discussion, the hypothesis is repeatedly put forward that alarge portion of patients who independently visit the emergency department could also be treated in other care settings such as by ageneral practitioner, the statutory medical on-call service, or in emergency clinics. Various reasons are cited for why these alternative care settings are not utilized in these cases. This study investigates the motives of patients who presented independently at the emergency department, as well as the socio-demographic parameters of this study cohort. The survey was carried out as part of aprospective monocentric observational study of internal medicine patients at auniversity emergency department. Atotal of 1086 patients were included in the study. In total, 33% of the study participants visited the emergency department based on aphysician's recommendation or referral instead of opting for an alternative care option. The main reason for visiting the emergency department was the subjectively assessed urgency of their symptoms. Among the patients who presented independently at the emergency department, 28% required further inpatient care during the course of treatment. Awareness of alternative care pathways, such as utilizing emergency medical services, seeking care from the statutory medical on-call service, or visiting an emergency clinic, was low. Emergency departments remain an important point of contact for patients who present there independently, without being brought by emergency medical services. The motives behind why patients choose avisit to the emergency department over treatment in an alternative care setting vary. If alternatives are to be used instead of emergency departments, structures first need to be established or expanded.

Paramedic Education and Training for the Management of Patients Presenting with Low-Acuity Clinical Conditions: A Scoping Review.

Ambulance services around the world are increasingly attending to calls for non-emergency conditions. These lower-acuity conditions do not always require patients to be transported to the emergency department. Consequently, over the past two decades, ambulance services have implemented strategies to support paramedics in diverting non-urgent patients to alternative care pathways. However, assessing and managing low-acuity conditions can be challenging for paramedics, especially when education and training has traditionally focussed on emergency care. This scoping review explores the education and training provided to paramedics on low-acuity clinical conditions and the use of alternative care pathways. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was applied. The databases searched included Scopus, CINAHL, Embase, Emcare, and MEDLINE (PubMed). The search identified one-hundred sixty-six records, with a total of nine articles reviewed after the removal of duplicates and the screening process. The articles were diverse, with education and training ranging from university degrees for extended care practitioners to short in-service-based training for a suite of protocols or assessment tools. However, the literature addressing education and training on low-acuity conditions and alternative care pathways is limited, with the type and length of education programs appearing to influence practice. There is a need for further research to establish a low acuity education model.

Living, Caring, Learning – Setting boundaries for the wellbeing of everyone in bleeding disorders care

Abstract Cathy, a haemophilia nurse specialist in the UK, reflects on a challenging patient with a rare inherited platelet disorder. The patient did not attend regular clinic appointments, and when presenting at clinic due to severe bleeding or feeling unwell was often aggressive and abusive towards staff. The care team were concerned that he was putting his health at risk and followed protocols for vulnerable adults to try and ensure he was accessing the care he needed. This involved bringing in expertise outside of the multidisciplinary team (MDT), including non-medical services. Steps were also taken to ensure staff safety and wellbeing through in-house psychological support and the agreement of strategies for dealing with difficult behaviour. Ultimately, it was necessary to find an alternative care pathway for the patient. While acknowledging her disappointment in this outcome, Cathy reflects on how the processes followed have reinforced the development of individualised care plans for all patients with complex needs, and the importance of access to specialist services beyond the MDT. She also highlights considerations around the safety and wellbeing of the care team, the role of discussion and ‘debriefing’, and the value of staff access to psychological support.

SYSTEMATIC REVIEW OF REHABILITATION IN SKILLED NURSING FACILITIES FOR PERSONS LIVING WITH DEMENTIA

Abstract We conducted a systematic review of published literature though April 2023 to identify the experiences and outcomes of persons living with dementia (PLWD) undergoing post-acute care rehabilitation in skilled nursing facilities (SNF). A systematic search for studies published in English was carried out in eight databases including PubMed, Scopus, Google Scholar, Embase, PsycINFO, CINAHL, Cochrane Library, and Web of Science. Two reviewers independently screened articles and conducted a quality appraisal of selected studies. Forty-one articles met inclusion criteria. There was heterogeneity of study designs with most articles (n=33) being observational and cross-sectional, while randomized clinical trials (n=3) and qualitative studies (n=5) were less represented. Certain themes emerged from the results regarding patient outcomes and experiences. Measured outcomes demonstrated increased health service utilization, varied functional outcomes, and suboptimal patient care. Patient experiences included significant challenges with health care transitions, gaps in healthcare worker and caregiver knowledge &amp; education, emphasis on alternate models of care, and importance of goal alignment. Overall, this systematic review provides a comprehensive understanding of the outcomes and experiences of post-acute care rehabilitation in SNFs for PLWD. The findings highlight the need for alternative care pathways, improved healthcare transitions, tailored rehabilitation approaches, enhanced dementia training for healthcare professionals, and person-centered goal setting. By addressing these critical aspects, future interventions can be developed to improve the delivery of post-acute care for PLWD and enhance their health outcomes.

183 Pathfinder emergency response to urgent urinary catheter issues in older adults; a service profile

Abstract Background Older adults are frequent attendees at the Emergency Department (ED) and experience high rates of adverse outcomes following ED presentation. There is growing evidence for alternative care pathways at the time of a low acuity Emergency Medical Services (EMS) call. The Pathfinder service is a collaboration between the National Ambulance Service and acute hospital Occupational Therapy and Physiotherapy Departments. The service responds to low acuity 999/112 calls for people aged 365 years within the hospitals catchment area, including low acuity calls for blocked or dislodged indwelling urinary catheters. Methods A retrospective analysis of the service’s database was completed (1/1/22–26/5/23). All of the patients seen where the reason for 999 call was recorded as ‘blocked catheter’, ‘dislodged catheter’ or ‘urinary issues’, were identified and analysed. Results One hundred patients were identified, with urinary catheter related issues. Of these patients, 70% were male. The average age was 81 years. The average Clinical Frailty Scale score was 7 (severely frail). Ninety One percent of these patients remained at home as a result of the services’ intervention at the time of the 999 call. Of these 91 patients, 54% were classified as ‘treat and discharge’ (no further input or onward referral required), and 37% were ‘treat and refer’ (with onward referral to other services including Hospital Urodynamics Team, Public Health Nursing, GP). Seventy five percent remained at home without representation at 24 hours; 90% at 7 days and 75% at 28 days. Conclusion The Pathfinder service is safely and effectively managing urgent indwelling catheter issues, at the time of a 999 call, in older peoples’ homes instead of the ED. This upskilling project was made possible by excellent cross-organisational collaboration with the Hospital Urology and Urodynamics Department. The next phase of upskilling will focus on the management of urgent suprapubic catheter related issues.

99 Pathfinder: a retrospective review of the first sixty patients

Abstract Background Pathfinder is designed to safely keep older adults who phone 999 at home by utilising alternative care pathways rather than taking them to a hospital Emergency Department (ED). Pathfinder began as a pilot initiative from a collaboration with Beaumont Hospital and the National Ambulance Service (NAS) in 2018. Due to its success a permanent team was set up in March 2020. The NAS began to roll Pathfinder out nationally and this team went live in the first quarter of 2023. Methods The first 60 patients who were seen by this Pathfinder service were included in a retrospective review. Data was collected using a Microsoft Excel® worksheet. The data recorded included: age, gender, Clinical Frailty Scale (CFS), the presenting complaint and the outcome of the assessment. Results Of the first 60 patients the mean age was 79 years, 48% (n = 29) were male and 52% (n = 31) were female. The median CFS was 6 indicating a moderately frail cohort. A total of 58% (n = 35) of patients remained at home after initial assessment, 74% (n = 26) received follow-up from the Pathfinder team, and 26% (n = 9) were treated and discharged at the scene. A total of 94% (n = 33) remained at home within 24 hours after initial review, and 80% (n = 28) remained at home after 7 days. A remaining 42% (n = 25) of patients were conveyed to ED at initial assessment. Of these patients, 76% (n = 19) were admitted and six patients were discharged home from the ED, of which four (67%) received follow-up from the Pathfinder team. Conclusion This new Pathfinder service to the area provides a safe alternative pathway to older adults who contact emergency services, with 58% of patients remaining at home post Pathfinder intervention. Further research is required to investigate the patient experience of the service.

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

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.

Prevalence and predictors of admission at the time of presentation in first episode psychosis.

Individuals presenting with first episode psychosis (FEP) constitute a population with high admission rates. Across psychiatric services, community based treatment is aimed for where appropriate. Therefore, further knowledge on predictors of admission is required. The objectives were to: (i) determine the proportion of individuals with FEP admitted at time of presentation (voluntarily and involuntarily) (ii) identify associated demographic and clinical factors. This study included all young people (aged 15-24) who presented with FEP to the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia from 01.01.11 to 31.12.16. Binary logistic regression was used to determine unadjusted and adjusted odds ratios. Of 1208 participants, 58.6% were male and the median age was 20years (I.Q.R.17-22). At time of presentation, 50.2% were admitted. On multivariate analysis, the following factors predicted admission: being a migrant (OR = 1.75, 95% CI [1.17, 2.62]), aggression (OR = 1.42, 95% CI [1.02, 1.99]), and more severe psychotic symptoms. Longer duration of untreated psychosis was associated with lower admission rates. 70.1% of admissions were involuntary (33.7% of the cohort). Risk factors for involuntary admission were consistent with any admission, other than aggression, and with the addition of older age and male sex. There remains a high admission rate for FEP, even in an established early intervention service, with severity of psychopathology being the strongest predictive factor. There is an independent association between migrancy and admission. Potential reasons for these findings are discussed, and initiatives to reduce admission rates including (i) interventions to prevent admission and (ii) alternative care pathways.

“Older People Want to Be in Their Own Homes”: A Service Evaluation of Patient and Carer Feedback after Pathfinder Responded to Their Emergency Calls

Objective Older people experience high rates of adverse outcomes following emergency department (ED) presentation. There is growing evidence to support alternative care pathways for certain types of emergency medical services (EMS) calls. Pathfinder is one such service and targets patients aged 65 years and over, whose presenting issues can be safely managed at home by immediate paramedic, occupational therapy, and/or physiotherapy interventions. The aim of this service evaluation was to understand how older people feel about being treated at home as a result of EMS calls and to understand their experiences of the Pathfinder service. Methods This was a thematic analysis of open-ended responses recorded from telephone interviews during routine service evaluation with service users (patients or their next-of-kin). Results Of 573 service users, telephone interviews were conducted with 429 (75%). Five primary themes were identified: (1) professionalism of the multidisciplinary clinical team; (2) “the right service, in the right place, at the right time”; (3) role of Pathfinder in “getting the ball rolling”; (4) lasting effects of the experience on the patient and his or her next-of-kin; (5) value of skilled communication with the older person. Conclusion Older people and their next-of-kin voiced a clear preference for hospital avoidance, and strongly valued the opportunity to be treated in their homes at the time of an EMS call rather than default conveyance to the ED. They appreciated the importance of a skilled multidisciplinary team with a follow-up service that effectively positions itself between the acute hospital and community services.

Are we there yet?' Distance to definitive care for Irish patients in the Better Data, Better Planning (BDBP) study.

Residing long distances from definitive care compromises patient safety and, in rural Ireland, travel distance to health care can be substantial, particularly in light of national General Practitioner (GP) shortages and hospital reconfigurations. The aim of this research is to describe the profile of patients attending Irish Emergency Departments (EDs) in terms of distance from GP care and definitive care in the ED. The 'Better Data, Better Planning' (BDBP) census was a multi-centre, cross-sectional study of n=5 urban and rural EDs in Ireland throughout 2020. At each site, all adults presenting over a 24-h census period were eligible for inclusion. Data were collected on demographics, healthcare utilisation, service awareness and factors influencing the decision to attend the ED, with analysis in SPSS. For n=306 participants, median distance to a GP was 3 km (range 1-100 km) and median distance to the ED was 15 km (range 1-160km). Most participants (n=167, 58%) lived within 5 km of their GP and within 10 km of the ED (n=114, 38%). However, 8% of patients lived ≥15 km from their GP and 9% of patients lived ≥50 km from their nearest ED. Patients living >50 km from the ED were more likely to be transported by Ambulance (p<0.05). Proximity to health services, by geographical location, is poorer in rural regions, so it's important that these patients have equity of access to definitive care. Therefore, expansion of alternative care pathways in the community and additional resourcing of the National Ambulance Service with enhanced aeromedical support is essential in the future.