Care For Frail Older Patients Research Articles

'Hearing silences': Exploring culturally safe transitional care: A qualitative study among Turkish-speaking migrant frail older adults.

This study aimed to investigate the experiences and transitional care needs of Turkish frail older adults living in the UK and determine how this information can be utilized to improve the provision of culturally sensitive care during the transitional period. Qualitative descriptive research with semi-structured individual interviews. "The 'Silences' Framework guided the research design, from conceptualizing the research question to structuring the report of final outputs. For this study, semi-structured, in-depth interviews were conducted with sixteen older adults living with frailty and five family caregivers between January and May of 2023 in the United Kingdom. Major themes that were identified included: (i) information and communication, (ii) care and support, (iii) the role of culture and (iv) trust and satisfaction. Further analysis, through discussion and immersion in the data, revealed that care transition periods were presented alongside three phases of transitional care: pre-transition (during hospitalization), early-transition (the period between discharge and the 7th day after discharge) and late transition (the period between the 8th day and 12th month after discharge). Our study revealed that the communication and informational needs of frail older individuals change during the transition period. While Turkish older adults and family caregivers expressed satisfaction with healthcare services in the UK, many struggled due to a lack of knowledge on how to access them. The support of family caregivers is a crucial component in facilitating transitional care for frail older patients, as they help in accessing healthcare services and using technological devices or platforms. It should be noted that family caregivers often hold the same level of authority as their elderly Turkish counterparts. No patient or public contribution.

GPs' interest in integrated care for frail older adults and corresponding consulting and prescribing data: qualitative and quantitative analyses of the PAERPA integrated care project.

Integrated care pathways can help to avoid unnecessary admissions to hospital and improve the overall quality of care for frail older patients. Although these integrated care pathways should be coordinated by GPs their level of commitment may vary. To profile GPs who had participated or had declined to participate in the Personnes Agées En Risque de Perte d'Autonomie (PAERPA) integrated care project (ICP) in the Valenciennois-Quercitain area of France between 2014 and 2019. A combined qualitative and quantitative analysis of GPs who were participating in or had declined to participate in the PAERPA ICP. Some GPs were interested in the PAERPA ICP, whereas others were opposed. The 48 qualitative interviews revealed four issues that influenced participation in the PAERPA ICP: 1) awareness of issues in care of older adults and the value of collaborative work; 2) time saving; 3) task delegation; and 4) advantages of coordination. The level of interest in the ICP for frail older adults was indirectly reflected by the data on consulting and prescribing.In GPs who participated in the PAERPA ICP there was a greater proportion of older (aged ≥70 years) patients (P<0.05), a larger number of consultations per year (P<0.05), a larger number of home visits (P<0.01), relative to GPs who declined to participate. The level of interest in the PAERPA ICP for frail older adults varied widely among GPs. These findings suggest that commitment to an integrated care pathway could be increased by customising the recruitment strategy as a function of the GP's profile.

Health care for older adults in Europe: how has it evolved and what are the challenges?

Geriatric medicine has evolved to an accepted specialty in 23 European countries. Despite much heterogeneity of postgraduate geriatric curricula, European societies have succeeded in defining a common core curriculum with a list of minimum training requirements for obtaining the specialty title of geriatric medicine. Geriatricians play a leading role in finding solutions for the challenges of health care of multimorbid older patients. One of these challenges is the demographic shift with the number of adults aged 80years and older in Europe expected to double by 2050. Although geriatric units will play a role in the care of frail older patients, new care models are needed to integrate the comprehensive geriatric assessment approach for the care of the vast majority of older patients admitted to non-geriatric hospital units. Over the last few years, co-management approaches have been developed to address this gap. Innovative models are also in progress for ambulatory care, prevention and health promotion programs, and long-term care. Efforts to implement geriatric learning objectives in undergraduate training, and the generation of practice guidelines for geriatric syndromes may help to improve the quality of care for older patients.

GPs' interest in integrated care for frail older adults and corresponding consulting and prescribing data: qualitative and quantitative analyses of the PAERPA integrated care project.

Integrated care pathways can help to avoid unnecessary admissions to hospital and improve the overall quality of care for frail older patients. Although these integrated care pathways should be coordinated by GPs their level of commitment may vary. To profile GPs who had participated or had declined to participate in the Personnes Agées En Risque de Perte d'Autonomie (PAERPA) integrated care project (ICP) in the Valenciennois-Quercitain area of France between 2014 and 2019. A combined qualitative and quantitative analysis of GPs who were participating in or had declined to participate in the PAERPA ICP. Both GPs participating in the ICP and GPs who chose not to participate in the ICP were interviewed, and then consultation and prescription profiles for these two groups were compared. Some GPs were interested in the PAERPA ICP, whereas others were opposed. The 48 qualitative interviews revealed four issues that influenced participation in the PAERPA ICP: 1) awareness of issues in care of older adults and the value of collaborative work; 2) time saving; 3) task delegation; and 4) advantages of coordination. The level of interest in the ICP for frail older adults was indirectly reflected by the data on consulting and prescribing. In GPs who participated in the PAERPA ICP there was a greater proportion of older (aged ≥70 years) patients (P<0.05), a larger number of consultations per year (P<0.05), and a larger number of home visits (P<0.01), relative to GPs who declined to participate. The level of interest in the PAERPA ICP for frail older adults varied widely among GPs. These findings suggest that commitment to an integrated care pathway could be increased by customising the recruitment strategy as a function of the GP's profile.

Changing Hospital Care For Older Adults: The Case for Geriatric Hospitals in the United States.

Hospital care of frail older adults is far from optimal. Although some geriatric models of care have been shown to improve outcomes, the effect size is small and models are difficult to fully implement, sustain and replicate. The two root causes for these shortcomings are competing interests (high revenue generating diseases, procedures and surgeries) and current hospital cultures (for example a culture of safety that emphasizes bed alarms and immobility rather than frequent ambulation). Geriatric hospitals would be hospitals completely dedicated to the care of frail older patients, a group which is most vulnerable to the negative consequences of a hospitalization. They would differ from a typical adult hospital because they could implement evidence based principles of successful geriatric models of care on a hospital wide basis, which would make them sustainable and allow for scaling up of proven outcomes. Innovative structural designs, unachievable in a typical adult hospital, would enhance mobility while maintaining safety. Financial viability and stability would be a challenge but should be feasible, likely through affiliation with larger health care systems with other hospitals because of cost savings associated with geriatric models of care (decreased length of stay, increased likelihood of discharge home, without increasing costs).

64 MANAGING FRAILTY IN AN IRISH PRIMARY CARE SETTING: A QUALITATIVE STUDY

Abstract Background Frailty is a complex, age-related condition which confers a risk of adverse outcomes. Evidence supports the effectiveness of screening and Comprehensive Geriatric Assessment (CGA) to meet the needs of frail older people. Little is known about the views of key stakeholders on frailty in a Primary Care context. This study explored the views of healthcare professionals and patients on frailty management in Primary Care in Ireland. Methods A qualitative descriptive study using semi-structured interviews was conducted. Healthcare professionals and patients were recruited using purposive sampling. Patients were recruited through the Frailty Intervention Team at the local acute hospital. Patients with cognitive impairment were excluded. Written informed consent was provided. Data were audio-recorded, transcribed and analysed using thematic analysis. The research was approved by the local Ethics Committee. Results Three patients and 17 healthcare professionals from general practice, public health nursing, physiotherapy, occupational therapy and social work participated. Three themes emerged. (i) Perceptions of Frailty (ii) Current Management of Frailty and (iii) CGA in Primary Care. Results demonstrated variability of perspectives on the concept of frailty, with limited knowledge of screening and CGA. Healthcare professionals described a fragmented service with sub-standard care for frail older patients. Critical weaknesses were: absence of essential services, uni-disciplinary working, inadequate IT systems and integration. Support for screening and CGA in Primary Care was evident. The general consensus was that frailty management required an adequately resourced Primary Care and the suitability of the current pathway for patients requiring CGA should be reviewed. Conclusion This study highlights an absence of a complete understanding of frailty among healthcare professionals. Inter-professional training and education is advocated. Further development of a frailty pathway and investment in Primary Care is required to improve care for frail older people. An intermediate interface service with a dedicated frailty management team is suggested.

202 THE SILVER TRAUMA CLINIC—A MULTIDISCIPLINARY CLINIC FOR FRAIL OLDER PATIENTS FOLLOWING TRAUMATIC INJURY

Abstract Background Increasing numbers of older individuals are presenting to Irish emergency departments following trauma. Advances in the care of chronic diseases have increased the number of older people with active lifestyles, predisposing them to injury. ‘Silver trauma’ has been a relatively neglected despite deficits of traditional trauma care for this vulnerable cohort. The Silver trauma clinic was developed in conjunction with the Frailty Intervention Team, Geriatric services and HSCP service in May 2021. The goal of the clinic is to provide a comprehensive multidisciplinary management for frail older patients following non operative injuries. Methods Frail older patients discharged from the ED can be referred for short interval multidisciplinary trauma review. A trauma tertiary survey is carried out by an emergency physician with specialist interest in geriatric trauma. Rapid access to imaging ensures timely definitive diagnosis. The service integrates virtually with specialist services, such as spinal orthopaedic services and musculoskeletal interventional radiology. Physiotherapists initiate a tailored early rehabilitation plan. Consultant geriatrician and frailty ANP screen for complications of injury as well as bone health, falls risk and cognitive screening. The clinic integrates with existing outpatient and community services for older persons. Results The clinic has seen 30 patients since commencement in May 2021. Median patient age: 85. Injuries: 25% vertebral fractures, 30% limb fracture, 20% thoracic trauma, 30% pelvic trauma. Mean number assessments: 2. Disposition outcomes: Primary care 50%, Geriatric clinic 30%, Integrated Care Team 10%, specialist clinic 10%. Conclusion The Silver trauma clinic is a new approach of patient focused multidisciplinary trauma care for frail older patients following non operative trauma in the Irish health system.

A national intervention to support frail older adults in primary care: a protocol for an adapted implementation framework

BackgroundOlder Canadians are high users of health care services, however the health care system is not well-designed to meet the complex needs of many older adults. Older persons often look to their primary care practitioners to assess their needs and coordinate their care. The intervention seeks to improve primary care for older persons living with frailty and will be implemented in six primary care clinics in three Canadian provinces. Presently, more than 1.6 million older Canadians are living with frailty, and this is projected to increase to 2.5 million within a decade (Canadian Frailty Network, Frailty Matters, 2020). The model will include frailty screening, an online portal to expedite referrals and improve coordination with community services, and several tools and techniques to support patient and family engagement and shared decision-making. Our project is guided by the Consolidated Framework for Implementation Research (CFIR) (Damschroder LJ, et al. Implement Scil, 4, 50, 2009). As others have done, we adapted the CFIR for our work. Our adapted framework combines elements of the socio-ecological model, key concepts from the CFIR, and elements from other implementation science frameworks. Nested within a broader mixed-method implementation study, the focus of this paper is to outline our guiding conceptual framework and qualitative methods protocol.MethodsWe will use the adapted CFIR framework to inform the data we collect and our analytic approach. Our work is divided into three phases: (1) baseline assessment of ‘usual care’; (2) tailoring and implementing a new primary care model; and (3) evaluation. In each of these phases we will engage in qualitative data collection, including clinical observations, focus groups, in-depth interviews and extensive field notes. At each site we will collect data with health care providers, key informants (e.g., executive directors), and rostered patients ≥ 70 years. We will engage in team-based analysis across multiple sites, three provinces and two languages through regular telephone conferences, a comprehensive analysis codebook, leadership from our Qualitative Working Group and a collective appreciation that “science is a team sport” (Clinical Orthopaedics and Related Research 471, 701-702, 2013).DiscussionOutcomes of this research may be used by other research teams who chose to adapt the CFIR framework to reflect the unique contexts of their work, and clinicians seeking to implement our model, or other models of care for frail older patients in primary care.Trial RegistrationU.S. National Library of Medicine, NCT03442426. Registered 22 February 2018– Retrospectively registered.

The Impact of Geriatric Emergency Management Nurses on the Care of Frail Older Patients in the Emergency Department: a Systematic Review.

BackgroundFrail older adults are high users of emergency departments (EDs). Many Canadian EDs have hired Geriatric Emergency Management (GEM) nurses in an effort to improve care to older adults.MethodsWe conducted a systematic review to determine the impact of GEM nurses on care provided to frail older adults. We searched MEDLINE, Embase, CINAHL, and Cochrane databases. A grey literature search was also conducted. Inclusion criteria were English-language, evaluation of GEM nurse or geriatric-trained nurse assessments of older adults (age ≥ 65 years) within the ED, and reported clinical and/or health system outcomes. The PRISMA statement was followed, and article quality was assessed using GRADE.Results5,115 citations and 191 full text articles were screened; 8 articles from 7 different studies were included. Study quality varied between very low to high. Five included studies analyzed the effect of GEM nurses on ED revisits, with most finding they decreased revisits. Four included studies analyzed the effect of GEM nurses on hospital admissions/readmissions, demonstrating variable impact. One study looked at the cost-effectiveness and found the cost to be negligible. The impact on patient-specific outcomes was less clear.ConclusionsGEM nurses may be an effective option to help in the management of frail older adults in the ED.

Caring for frail older patients inthe last phase of life : Challenges for general practitioners in the integration of geriatric and palliative care.

The best possible care for frail older patients at the end of life can require the integration of geriatric and palliative approaches, possibly with different accentuations at different times. General practitioners (GP) are particularly important in this context: they provide patients with low-threshold primary care close to their homes and provide both general palliative care and geriatric services. What are the challenges for GPs in caring for frail older patients at the end of their lives? Asecondary data analysis of 52 qualitative interviews was carried out, which were serially obtained at 4 points in time over aperiod of 18months with 14family doctors. In addition, one focus group with five GPs took place. The analysis was carried out according to the principles of grounded theory. The results show that GPs see the care of frail older patients at the end of their lives through a)the growing number of older people, b)multimorbidity and complexity of the problem areas, c)the integration of geriatric and palliative approaches, d)the high average age of general practitioners and the lack of junior staff and e)the problem of ensuring care in rural areas as amajor challenge. The practical transition between geriatric and palliative care is considered by GPs to be fluid and there is adesire for more integration of both disciplines. In this study GPs perceived alarge overlap between geriatric and palliative care. Both approaches should be offered for aselection of patients as acombined service. In the future asystematic network between GPs and geriatricians in practices, clinics, and day clinics will be necessary.

Enabling public, patient and practitioner involvement in co-designing frailty pathways in the acute care setting

BackgroundAlthough not an inevitable part of ageing, frailty is an increasingly common condition in older people. Frail older patients are particularly vulnerable to the adverse effects of hospitalisation, including deconditioning, immobility and loss of independence (Chong et al, J Am Med Dir Assoc 18:638.e7–638.e11, 2017). The ‘Systematic Approach to improving care for Frail older patients’ (SAFE) study co-designed, with public and patient representatives, quality improvement initiatives aimed at enhancing the delivery of care to frail older patients within an acute hospital setting. This paper describes quality improvement initiatives which resulted from a co-design process aiming to improve service delivery in the acute setting for frail older people. These improvement initiatives were aligned to five priority areas identified by patients and public representatives.MethodsThe co-design work was supported by four pillars of effective and meaningful public and patient representative (PPR) involvement in health research (Bombard et al, Implement Sci 13:98, 2018; Black et al, J Health Serv Res Policy 23:158–67, 2018). These pillars were: research environment and receptive contexts; expectations and role clarity; support for participation and inclusive representation and; commitment to the value of co-learning involving institutional leadership.ResultsFive priority areas were identified by the co-design team for targeted quality improvement initiatives: Collaboration along the integrated care continuum; continence care; improved mobility; access to food and hydration and improved patient information. These priority areas and the responding quality improvement initiatives are discussed in relation to patient-centred outcomes for enhanced care delivery for frail older people in an acute hospital setting.ConclusionsThe co-design approach to quality improvement places patient-centred outcomes such as dignity, identity, respectful communication as well as independence as key drivers for implementation. Enhanced inter-personal communication was consistently emphasised by the co-design team and much of the quality improvement initiatives target more effective, respectful and clear communication between healthcare personnel and patients. Measurement and evaluation of these patient-centred outcomes, while challenging, should be prioritised in the implementation of quality improvement initiatives. Adequate resourcing and administrative commitment pose the greatest challenges to the sustainability of the interventions developed along the SAFE pathways. The inclusion of organisational leadership in the co-design and implementation teams is a critical factor in the success of interventions targeting service delivery and quality improvement.

Can comprehensive geriatric assessment be delivered without the need for geriatricians? A formative evaluation in two perioperative surgical settings.

the aim of this study was to design an approach to improving care for frail older patients in hospital services where comprehensive geriatric assessment (CGA) was not part of the clinical tradition. the intervention was based on the principles of CGA, using quality improvement methodology to embed care processes. Qualitative methods and coproduction were used to inform development of the intervention, which was directed towards the health care professionals involved in peri-operative/surgical cancer care pathways in two large UK teaching hospitals. A formative, qualitative evaluation was undertaken; data collection and analysis were guided by normalisation process theory. the clinicians involved agreed to use the toolkit, identifying potential benefits including improved surgical decision making and delivery of interventions pre-operatively. However, sites concluded that pre-operative assessment was not the best place for CGA, and at the end of the 12-month trial, implementation was still nascent. Efforts competed against the dominance of national time-limited targets, and concerns relating to patients' immediate treatment and recovery. Some participants involved in the peri-operative pathway felt that CGA required ongoing specialist input from geriatricians, but it was not clear that this was sustainable. clinical toolkits designed to empower non-geriatric teams to deliver CGA were received with initial enthusiasm, but did not fully achieve their stated aims due to the need for an extended period of service development with geriatrician support, competing priorities, and divergent views about appropriate professional domains.

"It is two worlds" cross-sectoral nurse collaboration related to care transitions: A qualitative study.

To explore how the hospital and home care nurses talk about and experience cross-sectoral collaboration related to the transitional care of frail older patients. Effective communication and collaboration between nurses involved in care transition are crucial for a safe patient handover. Organisational systems to support cross-sectoral collaboration have been developed but do not always promote the intended dialogue and precise and useful exchange of information. Other factors may also be of importance to an effective and constructive cross-sectoral nurse collaboration. A qualitative design using thematic analysis. Data were extracted from 24 focus group interviews conducted with registered nurses from eight hospital wards and six municipalities and a total of 165hr of observations conducted in three hospital wards and three municipalities. The study was reported according to the COREQ guidelines. The perception of nursing and care differed across sectors. The nurses expressed having shared goals for the patients-however, these goals derived from different values, the perception of nursing and approach to the patients. The lack of knowledge of each other's working conditions created assumptions and preconceptions, which affected communication and collaboration related to planning and executing care transition negatively. The nurses perceived the hospital and home care as" two worlds". The collaboration between the nurses was characterised by insufficient communication and preconceptions rather than concrete knowledge and different cultures and professional identities. It can be questioned whether cross-sectoral collaboration between nurses should be characterised as interprofessional rather than intraprofessional collaboration as the features of the nurses' collaboration. Organisational and political systems should recognise that nurses in different sectors are taking care of various aspects of nursing when planning on policies to support cross-sectoral collaboration. More possibilities for nurses across sectors to meet should be made available.

The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person's pathway.

Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people's acute admissions. Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation. Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.

The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person’s pathway

Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people’s acute admissions. Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation. Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.

The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person’s pathway

Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people's acute admissions. Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation. Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.

Medical and moral considerations regarding complex medical decisions in older patients with multimorbidity: a compact deliberation framework

In health care for older adults, patients with multimorbidity usually receive the same interventions as those patients without multimorbidity. However, standard curative or life-sustaining treatment options have to be considered carefully in view of the maximally attainable result in older and frail patients. To guide such complex medical decisions, we present a compact deliberation framework that could assist physician(s) in charge of the medical treatment of a specific elderly patient to systematize his own thinking about treatment and decisional responsibilities, in case of an intercurrent disease.The framework includes four questions to be addressed when deciding on a single urgent standard curative or life-sustaining intervention in acute medical problems of an elderly patient with multimorbidity: 1) What is known about the patient’s aims and preferences? 2) Will the intervention be effective? 3) Will the intervention support the aims and preferences of the patient? 4) In view of the aims and preferences, will the risks and benefits be in balance?If all four considerations are answered favorably, the intervention will fit patient-centered and appropriate care for frail older patients with multimorbidity.Application to a patient case illustrates how our framework can improve the quality of the shared decision-making process in care for older people and helps clarify medical and moral considerations regarding how to appropriately treat the individual patient.

Integrated Healthcare for the Frail Older Adult

Background: In Ireland, the proportion of persons aged over 65 years is set to increase from 11.4% to 18% over the next 30 years1. A significant proportion of older people presenting to hospital settings are frail and less able to adapt to stressors such as acute illness. This increased vulnerability contributes to adverse outcomes such as falls, delirium and increased hospital stays. Comprehensive geriatric assessment has been shown to be effective and improves an older persons chance of maintaining their independance at home after an acute hospital admission2. Aims: This project set out to improve the experience of care for frail older patients by: Increasing patient satisfaction Reduced length of stay (LOS) of 1 bed day for patients over 70 years of age, with no increase in readmission rate No increase in adverse events These aims were addressed by establishing a frailty pathway with a particular focus on integration between community and acute services. Methods: Development and introduction of frailty screening tool for all patients >70 years of age presenting to the hospital. Designation of a Specialist Gerontology Ward (SGW) within the hospital where frail older patients are cohorted according to an agreed Standard Operating Policy. Appointment of a nurse specialist in gerontology, to provide initial assessment of those highlighted by the screening tool, and to co-ordinate transition of care to the SGW and back to the community. Implementation of a daily multidisciplinary (MDT) meeting on the SGW. Implementation of a weekly integrated care planning meeting involving members of multidisciplinary teams both from the hospital and the community. Implementation of an interdisciplinary falls programme for frail older patients on the SGW and supported by the community falls service. A clear focus on admission avoidance where appropriate from the Emergency Department and Acute Assessment Unit. Implementation of a cross programme governance structure to oversee and drive the project. Results: A patient centered questionnaire showed an increase in patient satisfaction levels from 67% on the previous ward to 79.6%, 3 months after the SGW opened. The median length of stay for this cohort of patients reduced from 12.6 days to 10.39 days (17.5% reduction in LOS), with no increase in readmission rates or adverse events. This equates to 695.25 bed days saved over the first 6 months of this project. The turnover (median number of discharges per month) has increased by 59%. Conclusions: Our integrated care pathyway for older people has proven itself to be of high quality, effective and efficent. This is largely due to improved interdisciplinary teamwork with patient centred care at the core. Limitations of this study are its retrospective nature. We plan to complete a prospective analysis in January 2017. We propose that reinvesting costs saved, back into the frailty pathway, would lead to better outcomes for older people living in our community,

Co-designing a Systematic Approach to improving care for Frail Older Patients

The concept of frailty, is associated with key clinical syndromes including loss of mobility, falls, confusion, incontinence, and polypharmacy. Frail elderly patients are particularly vulnerable to adverse effects of hospitalisation, including deconditioning, immobility, and loss of independence.[i] [ii] [iii] Within St Vincent’s University (SVUH) hospital data analysis from the Special Delivery Unit for the period from January to August 2014 conducted on a sample of 382,334 attendances shows that more than one-third of attendances at ED during this period were in the 65+ age cohort, with 12.37% aged 75+.[iv] This from a population of over 65s that account for 11.67% of the total population, indicating a disproportionate level of use of ED by the older population.[v] This raises concern about whether services will be able to cope with rapidly increasing demand. Recently attention has focused on identifying the best pathways for treating frail elderly patients identified as a priority of the national program for older persons and the emergency department task force to develop pathways and processes aimed at improving care in this age group.[vi] [vii]. As a response the HRB funded SAFE project is project focused upon co-designing a systematic Approach to improving care for Frail Elderly patients within SVUH. This poster will present the findings of work stream one of the project that commenced in November 2016. In particular, findings from the rapid realist review[viii] of the evidence and results of a scoping of existing care pathways for frail older persons in SVUH will be presented. A range of ethnographic qualitative data collection methods will inform the development of a map of current care pathways, including the challenges and bottlenecks that cause delays and dissatisfaction and/or pose a risk to the quality and timeliness of patient care. The analysis presented will increase our understanding of the advantages and problems with the current model of care. Additionally, this will allow us to better plan for appropriate implementation of a solution.

Telemedicine - quality improvement during organisational change - experience of C@rtref RCP Future Hospital development site.

C@rtref aims to improve access to care for frail older patients in rural Wales by enabling patients to have follow-up reviews closer to their own home. Usage of telemedicine for geriatric medicine will measurably reduce need for ambulance resource to transport patients to a hospital 60–90 minutes’ drive from their home within 12 months by 20% against a rising baseline chronic health needs by bringing access to specialist care into easy reach of those living at considerable distance from secondary care centres. Standard quality improvement methodology using PDSA cycles. Metrics included a comprehensive patient satisfaction questionnaire with extensive demographic …