General Practice Research Articles

Effectiveness of Community-Based Multidisciplinary Integrated Care for Older Adults with General Practitioner Involvement: A Systematic Review and Meta-Analysis

Abstract Background Changing demographics has led to healthcare systems reorientating healthcare delivery towards the community setting and implementing integrated models of care worldwide. A knowledge gap exists with regards to what elements of integrated care facilitate effective age-attuned healthcare delivery. This systematic review examines the effectiveness of community-based multidisciplinary integrated care strategies with General Practitioner (GP) participation for community-dwelling older adults and describes the level of care integration in each study. Methods PUBMED, EMBASE, CINAHL, Central Register of Controlled Trials in the Cochrane Library and MEDLINE were systematically searched in April 2023. Randomised controlled trials (RCTs) or cluster RCTs that focused on interventions for community-dwelling older adults delivered by health and social care professionals with GPs were included. Two reviewers independently conducted the risk of bias assessment, applied the GRADE tool to quantify the certainty of evidence and used the Rainbow Model of Integrated Care taxonomy to describe the elements of integrated care used within studies. The primary outcome was functional status. Meta-analyses were performed using Review Manager 5.4. Results Twelve trials (14 reports) recruiting 8069 participants across 8 countries were included. Community-based multidisciplinary team (MDT) integrated care demonstrated significant improvements in functional status (standardised mean difference (SMD) 0.21, 95% confidence interval (CI) 0.05-0.37; low certainty evidence), hospitalisation (risk ratio (RR) 0.77, 95% CI 0.63-0.95; very low certainty evidence) and participant satisfaction with care (SMD 0.46, 95%c CI 0.15-0.76; low certainty evidence) from 12-36 months. No statistically significant effects favouring community-based MDT interventions for functional status at 6-month follow-up, Emergency Department presentation, mortality, health-related quality of life, or nursing home admission were established. Conclusion Community-based MDT integrated care with GP participation improves clinical and process outcomes for community-dwelling older adults. Future research should focus on models of integrated care that respond to the needs and preferences of older adults.

The Ghost Of Hip Arthroplasties Past: It Takes A Geriatrician To Mine For Metal

Abstract Background An 84-year-old female presented to Geriatric Medicine out-patient clinic with many years of persistent right hip pain, generalised myalgia; and several months of constipation, weight loss and persistent elevation of C-reactive protein and Erythrocyte Sedimentation Rate. The General Practitioner's concern was occult neoplasm. History of right hip arthroplasty in 2011. 6 years prior, she had wide local excision and adjuvant radiotherapy for a grade 3, “triple negative”, invasive ductal carcinoma of the right breast. Serial imaging identified a right parasternal, internal mammary chain neurofibroma. A Rheumatologist had administered intra-articular steroid to both glenohumeral joints for plain X-ray confirmed osteoarthritis, in the absence of serological vasculitic or autoimmune rheumatological disease. Benefit was transient. Her Oncologist had arranged MRI spine for “sciatica” demonstrating L3/4 and L4/5 stenosis and a large right adnexal cyst. Subsequently, the Gynaecology team assessed and planned interval MRI pelvis as initial MRI suggested a right partial hydrosalpinx, left internal chain lymphadenopathy and nodule adjacent to sacroiliac joint. Methods History, examination and imaging results were checked against the Medical Device Alert number 18 from the Medicines and Healthcare products Regulatory Agency (UK) in 2017. Oxford Hip Score Assessment was 29. Lymphatic drainage from medial hip joint is towards right iliac chain. Results In the absence of Gadolinium based contrast agents within 96hours, metal testing demonstrated: Serum Cobalt was 232nmol/L or 13.7 ug/L; Serum Chromium was 78.8nmol/L or 4.1ug/L; Chromium Urine: Creatinine Urine Ratio was 24.54nmol/mmol; and Cobalt Urine: Creatinine Urine Ratio73.96nmol/mmol. These elevated blood and urine results confirmed metal-on-metal hip disease. Conclusion Consider symptomatic metal-on-metal hip disease with soft-tissue involvement in patients presenting with post-hip arthroplasty joint pain, generalised myalgia and raised inflammatory markers; particularly if there is unexplained ipsilateral internal iliac chain lymphadenopathy and pelvic fluid collections. If confirmed, metalwork explanation is the treatment.

Preventing Hospitalisation- Providing Specialist Geriatric Services To Nursing Home Patients

Abstract Background Nursing home (NH) residents often require acute hospital care in unexpected deterioration and may have repeated Emergency Department (ED) attendances. Grunier et al (2018) reported 48% of NH residents reattend ED within 1 year. Our aim is to determine if those who require acute hospital admission are more likely to reattend ED or require NH outreach services. Methods Nursing home residents who attended Mater ED in March 2023 were identified through Electronic Patient Record. Their age, gender, reattendance of ED within 28 days and 6 months, visit by NH outreach team within 28 days then 6 months and 6-month mortality were recorded. The residents were categorised as admitted or discharged from their sentinel visit in March 2023. Chi-square test was used, and statistical significance was set at p<0.05. Results Sixty-three nursing home residents attended within 1-month, median age 85 years (range 67-95), 43 were women. Forty-five (71%) required admission, 6 (9.5%) and 24 (38.1%) reattended ED within 28 days and 6 months respectively. There was no difference in 28-day or 6-month ED reattendance between those who were admitted or discharged in the sentinel visit to ED. Those discharged from ED were more likely to receive NH outreach visit within 28 days (84% vs 6.8%) and 6 months (84% vs 11%) than those who were admitted, p<0.0001. There was no difference in 6 months mortality between the groups. Conclusion Our study found that 71% of NH residents who attend ED require admissions showing that the transfer was warranted. More than one-third of NH residents reattend ED within 6 months. Those discharged from ED were more likely to be reviewed by NH outreach team as per service delivery. Working closely with the resident’s General Practitioner, NH and ED staff may help to manage these complex patients to coordinate their treatment and prevent ED reattendance.

Managing End of Life Needs of Frail, Older Adults in the Community: The Role of a Hospital-Based Community Outreach Team

Abstract Background Our current healthcare systems are designed around periods of acute illness and are ill equipped to meet the needs of multimorbid and frail adults with worsening mobility, cognition and function. According to The Irish Longitudinal Study on Aging (TILDA), Ireland has a high proportion of hospital deaths, indicating inadequate community and home care supports. Recognizing patients who are likely to benefit from supportive and palliative approaches with a goal to die at home can be done using a combination of tools and based on advanced care planning discussions. Methods In 2021, our Department for Older Persons Services allocated a team consisting of a Registrar and Advanced Nurse Practitioner in Frailty to form an outreach service. Inpatients who appear nearing end of life who have expressed wishes to avoid further hospitalization and to die at home are identified during their admission. Home visits allow for a holistic assessment and family members are given the opportunity to ask questions. We provide education on end of life, trying to anticipate needs and often see patients and families through periods of deterioration until they stabilize again in a ‘new normal’ or begin the process of active dying. We communicate with Public Health Nurses, General Practitioners and the Community Palliative Care Team. Results Families and carers supporting loved ones who wish to avoid further hospitalization and die at home benefit from combined medical and nursing support & specialist expertise the team brings. Conclusion Addressing end of life for multimorbid patients living with severe frailty is a global challenge. Hospital admission is an ideal time to begin conversations regarding goals of care and initiate advanced care planning. The outreach team work together with hospital and community colleagues to the common goal of following patients’ wishes at end of life.

Advance Healthcare Directives: the Irish Implementation Reality from an Interdisciplinary Group Concept Mapping Study

Abstract Background Advance Healthcare Directives became legal in Ireland on 26th April 2023. While Advance Healthcare Directives are primarily rooted in patients’ legally binding refusal of treatments or interventions, they also encourage patients to set out their care preferences for the future (Government of Ireland 2015). Despite care of the older adult broadly transitioning from acute hospital to community, and a greater than ever focus on keeping older adults living at home for longer, low awareness of, and professional uncertainty around, Advance Healthcare Directives and how to integrate them into the care of the older adult has been widely expressed by Irish hospital physicians (Crowley and Doran 2022). Methods In this implementation study, Group Concept Mapping, using the relatively novel ‘GroupWisdom™’ software, is used to collect and analyse data from multiple healthcare professions to identify contextual issues that affect the implementation of Advance Healthcare Directives. 44 frontline healthcare professionals including Hospital Consultants (n=6), General Practitioners (n=5), Paramedics (n=7), Advance Nurse Practitioners (n=4), Clinical Nurse Specialists (n=4), Public Health Nurses (n=5), Critical Care Nurses (n=3), Nurse Managers (n=2), Healthcare Managers (n=2), Occupational Therapists (n=2) and Social Workers (n=4) participate in this mixed method study. Policymakers and other stakeholders are also involved throughout. Results The main implementation issues for Advance Healthcare Directives in order of importance as outlined by Healthcare Professionals are: 1) Public Education; 2) Homecare Services; 3) Timing and Location; 4) Family Members; 5) Lack of Education for the Healthcare Professional; 6) Complications for the Healthcare Professional; 7) Individual and Cultural Beliefs. Conclusion This study contributes a valuable understanding of where the implementation issues reside for healthcare professionals and policymakers, and how these can be addressed to ensure successful implementation. This implementation study focuses on practical considerations, offering multiple workable solutions to help to resolve these implementation issues on the ground.

Assess, Diagnose and Intervene: Are Hospital Based Out-patient Frailty Intervention Teams Perfectly Positioned to Prevent the Frailty Crisis?

Abstract Background This Frailty Intervention Team (FIT) is relatively novel in the sense that it is a hospital based multidisciplinary team (MDT) that provides an outpatient service to community based frail adults. Its main source of referral is from General Practitioners (GP)1, with the average Clinical Frailty Score of those assessed being 4.98 (4.91 men, 5.05 women) 1. Indicating that the mean service user is ‘Living with Mild Frailty’2. Our objective was to establish if this model of service provision is identifying any new diagnoses and what interventions it provides. Our overarching aim is to establish ‘what we are adding to the patient journey’. Methods 3 independent researchers came together to develop a database for the service that would record new diagnoses made, medical & non-medical interventions provided and frequency of on-wards referral. Standard definitions and codes were agreed upon, and the information inputted by patients facing staff on a daily basis. A descriptive data analysis of this database was carried out after the first quarter. Results 51 new patients were assessed in 4 months. Of these patients, 37.25% of cases received new diagnoses; Parkinson’s disease (15.68%), Orthostatic Hypotension (11.76%), Cognitive Impairment / Dementia (11.76%) and Idiopathic Normal Pressure Hydrocephalus (iNPH) (5.88%). Subsequently 62.74% had changes made to their medications. 96.08% of new service users received at least 1 non-medical intervention. Onward referral was made for 58.82% of service users, to a total of 22 organizations. The total amount of onward referrals made was 54. 51 new patients were assessed in 4 months. Conclusion A hospital-based frailty intervention team adds value to a patient’s journey as it is perfectly placed to make rapid diagnosis due to their MDT nature and access to diagnostics. Furthermore, it provides immediate intervention and appropriate onwards referral. Is this a model of service provision that should be made more readily available nationally?

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.

Competencies Required By All Hospital Doctors Caring for Older Adults: A Group Concept Mapping Study

Abstract Background The number of older adults accessing the healthcare service far exceeds the available geriatric specialist services. It is recognised that for the foreseeable future most hospital inpatient contacts with older adults will be completed by doctors not specifically trained in geriatric medicine. To ensure the provision of adequate healthcare, it is imperative that that all hospital doctors are trained in the minimum geriatric competencies. Allowing for the broad, complex, and multidisciplinary nature of geriatric medicine, we conducted a group concept mapping (GCM) study to permit multiple stakeholders with various expertise to convey their thoughts on the competencies required by all hospital doctors caring for older adults. Methods GCM is a mixed methods approach utilising six phases to generate expert group consensus, enabling participants to organise and represent their ideas. We invited healthcare professionals, patient advocacy groups and clinical educators to participate in GCM via an online platform. Hierarchical cluster analysis and multi-dimensional scaling were utilised to analyse participant input regarding competencies required by doctors caring for older adults. Results Forty-eight participants completed the brainstorming stage, generating eighty-eight statements, and twenty-two participants took part in the subsequent sorting stage. Participants included hospital doctors, general practitioners, allied health professionals and patient advocacy groups. Nine competency domains were identified as integral for all hospital doctors to care for older adults. Domains rated most important related to interpersonal communication skills, ethical and legal matters relating to older adults, recognition and management of delirium and medication management. Conclusion The twelve competency domains indicate the diverse skillset required by all doctors to provide comprehensive care to older adults within a hospital setting. This study identifies competencies that may serve as a foundational framework for ensuring quality healthcare for the ageing population. Future initiatives should consider incorporating these competencies to improve inpatient care provided by hospital doctors to older adults.

How general practitioners in France are coping with increased healthcare demand and physician shortages. A panel data survey and hierarchical clustering

BackgroundGeneral practitioners (GPs) face quantitative and qualitative changes in patient demand and doctor shortages. ObjectivesTo investigate how GPs cope with doctor shortage issues. Materials and methodsTwo cross-sectional surveys of a representative panel of 1530 GPs in 2019 and 2022 about their perceptions of physician shortages, working hours worked (WHW), and adaptive behaviors. Hierarchical clustering enabled identification of profiles with different adaptation patterns. Multiple Poisson or logistic regression models studied associations between GPs’ profiles and professional characteristics. Results87.4 % of GPs applied at least one adaptation to control patients’ healthcare demand. 24 % adopted task-shifting while their average WHW decreased by 3.6 h between 2019 and 2022. Four GP profiles were identified. “Low adapters/low workload” and “Low adapters/high workload” (25 % of the sample each) reported 2.4 adaptive measures: 75.5 % refused to be new patients' preferred doctor in the former group (vs 5.1 %). “High adapters/unchanged consultations” (30.7 %) and “High adapters/shortened consultations” (18.9 %) reported 4.8 and 6.1 adaptations, respectively. They were more likely to practice in medically underserved areas. ConclusionThese results call into question GPs’ gatekeeper role in the French healthcare system. Moreover, the marked reduction in WHW in underserved areas is likely to exacerbate their uneven distribution nationwide. Encouraging vertical integration between HCPs while enhancing cooperation and task-shifting is probably a pathway toward improving the relative GP shortage.

Implementation Of A Novel And Integrated Community Flexible Endoscopic Evaluation Of Swallowing (FEES) Service Model For Older Persons

Abstract Background FEES is a gold standard Speech & Language Therapy (SLT) led diagnostic instrument that facilitates evidence-based dysphagia care. A novel community-based FEES service for older persons’ services was recently established in Ireland's Mid-West. New pathways, integrated across divisions, were designed and implemented to complement existing dysphagia pathways within Integrated Care Programme for Older Persons (ICPOP), inpatient rehabilitation for older persons and primary care. An integrated pathway was also established with acute services (Otolaryngology). The aim of this abstract is to describe the implementation process for this novel community FEES service. Methods An SLT-led FEES team engaged with a range of community- and acute-based stakeholders across policy and practice: SLTs, Otolaryngologists, management teams, ICPOP teams, Gerontology Consultants, General Practitioners, Infection Prevention and Control (IPC) teams. Normalisation Process Theory (NPT), an empirically tested and theoretically-sound implementation science framework, scaffolded discussion across a range of implementation and consultation activities including co-design workshops and educational presentations and training, using Health Service Executive (HSE) Change Management tools. Results Stakeholders co-developed a shared understanding of current and new pathways to identify and enact implementation strategies at individual, discipline and system-levels. The project involved stakeholder mapping, communication/engagement planning, risk management, resource planning, and large-scale targeted education/training across settings and disciplines. A FEES working group was formed to coordinate, sustain, monitor, and futureproof implementation activities. Conclusion This collaborative project generated interdisciplinary vision and action to enact an innovative dysphagia care pathway for older people in the community. Articulated through an NPT lens, the project provides insights into the collaboration needed to implement truly integrated care and to identify enablers at individual, disciplinary, and organisational levels. Such knowledge is essential for enhancing integrated care and enacting change and innovation in the Irish health service.

A Systematic Review Of Medication Knowledge In Older Adults

Abstract Background Medication knowledge, as defined by six aspects, is the person's awareness of their medication name, dose, purpose, adverse drug reaction (ADR), administration schedule and special instructions, is essential in the older patient's treatment journey. This review aimed to assess medication knowledge in older adults. Methods A systematic search of six electronic databases, grey literature and citation indexes included studies conducted in any setting or any country on those 65 or older, published over the last ten years, reporting primary data with full-text access, and assessing patients' six aspects of medication knowledge. Joanna Briggs Institute Critical appraisal tool was used to evaluate quality of studies. Results Of the 67871 articles searched, only 10 cross-sectional studies were included. Medication knowledge data was collected from pharmacies, community, general practices and outpatient clinics. Surveys used face-to-face interviews and electronic, written, and mail questionnaires. Five studies assessed knowledge on single medications. None assessed all six aspects of medication knowledge. One study assessed five aspects, while the rest assessed fewer aspects. The percentage of those who knew their medication names ranged from 41.9% to 97%, dose 19.4%, purpose 15% to 90%, administration schedule 65% to 92.6%, ADR 42% to 80% and special instructions 32.4% to 94.8%. Data lacked the source of medication knowledge or evidence of a patient-centred care approach. There were repeated calls for further education and research. Conclusion Research indicates that older adults have a mixed knowledge of their medications, with some areas well grasped and others lacking. Additionally, it appears that medication knowledge is not thoroughly evaluated initially. Despite ongoing advice to employ all six aspects of medication knowledge for assessment and education enhancement, no progress is seen in older adults' medication knowledge. Therefore, there's a need for better research that anticipates the application of these six aspects, concentrating on education for older adults or their caregivers through patient-centred methods.

Introduction of A Proforma to Improve Communication to General Practitioners from an Acute Orthogeriatric Service

Abstract Background The National Office of Clinical Audit Irish Hip Fracture Standards 5 and 6 advise “patients with hip fracture should have their bone health assessed to determine their need for therapy to prevent future osteoporotic fractures” and “hip fracture patients should receive a specialist falls assessment and intervention to prevent further falls”. Ideally, these assessments should be communicated clearly via discharge summaries to avoid omission or duplication of treatment. Methods An admission proforma for an acute orthogeriatric service assessing inpatients with fragility fractures was developed. We retrospectively audited orthogeriatric patients’ discharge summaries prior and post introduction of the proforma. Patients who had atraumatic fractures were appropriately excluded from audit on their falls assessment. Results The total number of patients was 98. There were 70 patients in the pre-orthogeriatric proforma group and 28 patients in the post-orthogeriatric proforma group. The average age was 80.34 (SD 8.78). There were 55 females. The average length of stay was 18.08 days (SD 10.49). In the pre-orthogeriatric proforma group a falls assessment was reported in the discharge summary for 85.29% (n=58), bone protection; 60% (n=42). In the post-orthogeriatric proforma group a falls assessment was reported in the discharge summary for; 96.15% (n=25), bone protection; 61% (n=17). 100% of patients included had a bone protection plan: IV Zoledronic acid for 56 patients, denosumab for 26 patients, DEXA for 4 patients, virtual follow-up for 8 patients, onward specialty referral for 2. One patient was from overseas and for follow-up locally. Conclusion An orthogeriatric proforma may improve communication of falls assessment and bone protection plans in discharge summaries. Despite 100% of patients having a bone protection plan, there was a discrepancy of this in the discharge summaries. A dedicated orthogeriatric intern would ensure communication is accurate. This could avoid potential duplication or omission of prescribing of anti-resorptive treatment.

The Prevalence of Frailty Among People Experiencing Homelessness Attending a Primary Care Clinic: A Service Evaluation and Quality Improvement Initiative

Abstract Background Frailty is traditionally considered a geriatric syndrome though can present at a younger chronological age among people experiencing homelessness (PEH) due to risk factors such as poor nutrition, addiction and loneliness. Our walk-in primary care clinic for PEH has not previously recorded frailty status or prevalence among attendees, which would provide an opportunity to offer effective, evidence-based interventions. As part of a quality improvement initiative (QI), we evaluated frailty prevalence to improve our service to PEH. Methods The frailty status of adults presenting consecutively to a general practitioner at an urban, walk-in primary care clinic in Ireland dedicated to PEH was measured each Monday during a service evaluation in the first two months of 2024. Frail Scale (criteria: fatigue, resistance, ambulation, illness and weight loss; 0=robust, 1-2=pre-frail, 3-5=frail)) and the Clinical Frailty Scale (CFS) were used. Results 73 adults presented (median age 41.5), 21 female (28.8%)). 24 were frail on the Frail Scale (32.9% of total presenting), of which 4 were female (19.0% of females presenting) and 20 were male (38.5% of males presenting). 43 were pre-frail on the Frail Scale (58.9% of total presenting), of which 15 were female (71.4% of females presenting) and 28 were male (53.8% of males presenting). The median CFS was 4 (vulnerable). The most common frailty indicators were fatigue (68.5%) and weight loss (64.4%). Conclusion Frailty and pre-frailty were highly prevalent among PEH at our primary care clinic. A third were frail and over half pre-frail. The prevalence of this reversible syndrome had not previously been evaluated. Our findings underline the opportunity to improve our service by screening for frailty among PEH and offer appropriate interventions to reverse frailty and build resilience. Service evaluation and QI initiatives can enable application of research evidence and improvement of real-world clinical care.

The Australian Frailty Network: Development of a consumer-focussed national response to frailty.

Frailty is an important concept in the care of older adults. Over the past two decades, significant advances have been made in measuring frailty. While it is now well-recognised that frailty status is an important determinant of outcomes from medical illnesses or surgical interventions, frailty measurement is not currently routinely integrated into clinical practice. In the community setting, it is uncommon for general practitioners to deliver frailty-optimised care. In hospitals, there is substantial variability in how people living with frailty are managed. This variability is notable between and even within disciplines. Furthermore, gains from understanding frailty mechanisms and risk factors are not yet applied/implemented at scale to delay the progression of frailty in community-dwellers. The Australian Frailty Network (AFN) is a national collaborative group of researchers, clinicians, non-government organisations, consumers and policymakers, in which the engagement and active involvement of consumers has been embedded from the outset. The AFN aims to generate new knowledge to improve health outcomes, to ensure evidence-based management is translated into clinical practice and to build capacity in multidisciplinary and translational frailty research. Here, we describe the development of the AFN, highlighting important milestones: (i) securing funding for the network and flagship elements; (ii) an inaugural summit to establish the strategic vision, values and scope with end-users; (iii) sabbatical visits to learn from international examples; and (iv) developing the governance structure and an actionable plan encompassing consumer engagement, research, education and policy and practice to maximise impact.

Community Specialist Team for Older Adults - Who Do You Think We Are? Co-Design Of A Patient Information Leaflet

Abstract Background Navigating care pathways can be challenging and confusing for patients and caregivers. With the emergence of several new clinical specialist teams, we identified the need for accurate, clear and relevant information, provided as a printed leaflet and available at referral stage for both older adults and referring practitioners. Methods A draft Patient Information Leaflet (PIL) was developed with contributions from all members of the Community Specialist Team for Older Adults (CSTOA) explaining the purpose of the service. A review of referral sources was undertaken to identify those key stakeholders from whom feedback should be sought to ensure content validity. The draft PIL and a feedback questionnaire were distributed to patients and their caregivers who have had intervention from the CSTOA in addition to General Practitioners and Community Health Network colleagues. Results There were 27/35 responses to the questionnaire. Data was collated and analysed. All respondents reported that from reading the PIL, they understood clearly what the service provides, and all agreed that the leaflet accurately describes the service. Details such as what to expect from intervention of the team and advice to bring a family member to the initial appointment were mentioned as particularly useful content. Supplementary feedback commended the co-location and accessibility of the service compared to a hospital setting. It was suggested that other services should be included in the CSTOA. Based on survey responses, minor edits were made to the PIL to meet stakeholder satisfaction. Conclusion Feedback from this survey helped endorse the provision of a printed PIL to be provided at referral stage. Additional commentary gathered, re-enforces the need for continuous interaction and information sharing with service stakeholders. Next steps include making this PIL available electronically to allow for real time updates and translating to other languages to ensure inclusivity.

Ensuring Patient Care Continuity: An Audit of Discharge Letter Completeness in Accordance with National Standards

Abstract Background Discharge letters serve as a crucial communication tool to convey essential patient's healthcare information from hospital teams to general practitioners and step-down institutions. In 2013, the Health Information and Quality Authority (HIQA) introduced the National Standard for Patient Discharge Summary Information guideline. Reference 1. Health Information and Quality Authority. (2013). National Standard for Patient Discharge Summary Information. Retrieved from https://www.hiqa.ie/hiqa-news-updates/hiqa-publishes-national-standard-patient-discharge-summary-information. Methods This audit reviewed the completeness of discharge letters of patients admitted under the geriatric service of a tertiary hospital, covering the period between 1st September and 31st December 2023. Twenty-five variables were selected from the HIQA standards. The discharge letters were audited for completeness based on the inclusion of these recommended variables. An acceptable completeness rate of 80% for each variable was established. Results Of the total 89 discharge letters meeting the inclusion criteria, the average age of patients was 80.75 [SD12.95] years, with males comprising 60%. Seventeen out of 25 selected variables were 100% complete as they were automatically included by the electronic software. All discharge letters also invariably included diagnosis and hospital course information. Over 80% of the discharge letters met the acceptable threshold of including the items: discharge medication and future actions/follow-up. However, documentation of allergic status and inclusion radiological and blood investigations were only found in 27% and 49% of the letters, respectively. Conclusion The audited discharge letters had acceptable rates of completeness regarding inclusion of important items, while documentation of allergic status and inclusion of blood and radiological investigations fell below the acceptable standard. Of note, those that were automatized achieved 100% compliance. Regular auditing of discharge letters should become standard practice to improve completeness and ensure patient care continuity and safety. Consideration should be given to automatization of inclusion of reports of investigations.

Loneliness in the Republic of Srpska: advocating for social prescribing.

This study explores the potential implementation of social prescribing in the Republic of Srpska, Bosnia and Herzegovina, where the approach is non-existent, and supporting structures are underdeveloped despite a recognized need for intervention. As social prescribing gains global recognition for improving health, the study investigates its feasibility in an uncharted area. The research assesses the necessity for social prescribing by examining loneliness rates and healthcare utilization in the Republic of Srpska, a region seldom studied in public health literature. Data from 1231 individuals aged 16-86 were collected in May 2021, marking the first initiative to gather information on loneliness and healthcare usage in the country. Loneliness rates in the Republic of Srpska were comparable to the UK. Using a negative binomial model, the study establishes significant links between loneliness, chronic health conditions, age, and healthcare service utilization. Loneliness, chronic health conditions, and age predict the use of general practitioner services. In the 44-54 and 65+ age groups, loneliness predicts accident and emergency service use. Specialist healthcare services are positively predicted by loneliness, having one chronic health condition, and being above 44 years of age. Notably, a COVID-19 diagnosis negatively predicts the use of all healthcare services. Gender and place of residence do not significantly impact healthcare service utilization. The study concludes that observed loneliness rates and correlated healthcare usage patterns in the Republic of Srpska indicate a need for social prescribing. The paper discusses the feasibility of implementing social prescribing in this particular case.

An Audit of the Fifth Irish Hip Fracture Standard in patients >=70 years following hip fracture

Abstract Background Hip fractures are a significant cause of morbidity and mortality in older adults. Bone health assessment is key in the reduction of future fracture risk. The aim of our study was to examine the adherence to the fifth Irish Hip Fracture Standard in patients >=70 years presenting to Letterkenny University Hospital (LUH) with a hip fracture and to examine the number of patients who were commenced on bone protection. Methods We included patients >=70 years who were admitted under the Orthopaedic service following a hip fracture between January and June 2023 in LUH and were identified the database maintained by the using Fracture Liaison Nurse. Data collected included age, month in which hip fracture occurred, patient resident in Ireland, patient alive/deceased, patient on bone protection prior to fracture, patient commenced on bone protection or patient declined treatment. Data was recorded in a Microsoft excel spreadsheet and was analysed by the clinical audit facilitator. We measured our data against the British Geriatric Society guideline on the use of IV zoledronate following hip fracture. Results 76 patients were admitted to LUH with a hip fracture >=70 years between January and June 2023. 100% of patients were reviewed by the fracture liaison service and following this it was recommended that 46 patients (60%) be commenced on bone protection. A letter was sent to each patient’s General Practitioner outlining the recommendation for bone protection. On follow up only 7/46 (15.2%) had been started on treatment. Conclusion The fracture liaison service is appropriately identifying patients who require treatment, despite this, patients are not starting the necessary bone protection in the community. This has prompted our service to establish an IV zoledronate clinic for patients following hip fracture and to generate a plan for ongoing treatment of this patient cohort.

Community Flexible Endoscopic Evaluation Of Swallowing (FEES): A Prospective Cohort Study Of Clinical, Process And Patient-Reported Outcomes

Abstract Background Dysphagia prevalence increases with age, impacts on quality of life and increases healthcare utilisation and cost (Atrill 2018). Instrumental swallowing assessment is essential for accurate diagnosis and treatment of dysphagia but can be difficult to access in the community. FEES is a gold-standard instrumental assessment delivered by speech and language therapists (SLTs). The aim of this abstract is to report clinical, process and patient-reported outcomes of participants who had a community FEES over a 6-month period. Methods A prospective cohort study recruiting adults who accessed community FEES in Ireland's Mid-West. Baseline assessment data (demographics, a range of validated tools and process data) were recorded at index visit. A structured phone interview was completed at six months. The primary outcome was the rate of medical complications potentially caused by dysphagia at follow-up. Secondary outcomes included healthcare utilisation, dysphagia severity, functional status and quality of life. Results 62 participants were recruited: mean age: 70.98 (SD=15.01), 55.4% were female. At follow-up, 27.42% reported medical complications potentially attributable to dysphagia, 27.4% had attended general practice, 3.23% attended medical assessment units, 6.45% attended emergency departments. 82.26% were diagnosed with dysphagia or modified independence: Dysphagia Outcome Severity Scale (DOSS) ≤6, (M=5.2, SD=1.53). Changes to dysphagia care plans were recommended in 60.94% of cases. There was significant difference in Functional Oral Index Scale (FOIS) scores across time, F (1.75, 106.78) = 5.38, p = 0.008. FOIS scores at 6 months (M=5.92, SD=1.50) were significantly higher than pre-FEES (M=6.42, SD=1.37). Significant differences in quality of life (EQ5D5L-VAS) scores p<0.001 were detected: higher scores at 6-months (M=69.35; SD=20.42) compared to index visit (M=64.52; SD=19.44). Conclusion Access to community FEES for older persons may improve outcomes by reducing the frequency of dysphagia-related complications and healthcare utilisation, improving functional swallowing status, enhancing quality of life and contribute to evidence-based dysphagia diagnosis and care planning.

The Prevalence of Potentially Inappropriate Medications (PIMs) Among Frail Older Participants of The Irish Longitudinal Study on Ageing (TILDA)

Abstract Background This study aimed to assess PIMsprevalence among frail older participants of The Irish Longitudinal Study on Ageing (TILDA), using a newly developed OPTI-3S criteria (criteria for OPTImising medicines by Stopping, Stepping down, or Switching to safer alternatives). Methods All TILDA participants with polypharmacy (i.e. ≥5 medicines) and frailty based on Clinical Frailty Scale (CFS) ≥4 were included. PIMswere assessed based on the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail v2) [1], Poudel et al. algorithm [1], the Norwegian General Practice--Nursing Home criteria (NORGEP-NH) [1], and OPTI-3S. The prevalence of PIMsidentified by each tool was assessed across all frailty levels (CFS ≥4). Poisson regression assessed associations between PIM prevalence and covariates (e.g. medications). Results Most of the study cohort (86.5%, n=504) had at least one PIM identified by any of the four tools. OPTI-3S identified at least one PIM in 62.6% of participants, followed by Poudel’s algorithm (53.9%) and NORGEP-NH (40.5%). OPTI-3S could identify at least one PIM in 97.8% of participants with CFS ≥7, followed by STOPPFrail (88.9%). Overall, 34.8% of prescribed medications were considered to be PIMsThe OPTI-3S list detected more PIMsthan any other tool for all frailty levels (e.g. OPTI-3S, 78.4% vs STOPPFrail, 40.2% in CFS ≥7). Deprescribing all OPTI-3S-defined PIMswould reduce polypharmacy by 20.6% compared to NORGEP-NH (13.3%) and Poudel’s algorithm (12.0%). The most prevalent PIMswere aspirin, benzodiazepines and z-drugs, and antihypertensive medications. The number of medications, anticholinergic burden, and being on specific medications (e.g. aspirin, NSAIDs, benzodiazepines, antidepressants) were significantly associated with increased PIMs. Conclusion OPTI-3S is a useful PIM screening tool in community-dwelling frail older adults, pending further testing in the hospital setting. Reference 1. Anlay, D.Z et al. Br J Clin Pharmacol. 2024;90(1):12-106.