Figure 1
10-Step Integrated Care Framework for Older Persons.
Table 1
Summary of three pioneer site descriptions.
| SITE A | SITE B | SITE C | |
|---|---|---|---|
| Catchment – Geography | Urban & large rural area | Urban & large rural area | Suburban |
| Catchment – Population demographic | Older | Significantly older | Young but growing older population |
| Hub Location | Day hospital for older people on the grounds of a model 4 acute hospital | Community hospital close to a model 3 acute hospital | Primary care centre close to a model 4 acute teaching hospital |
| Pioneer Site Background | Green-field site (few services for older people outside of GP) | Evolved from integrated care activities for older people in the acute hospital | Creation of a community geriatrician post as catalyst |
| Project Sponsors C = clinician nc = non-clinician |
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|
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| The Programme funded MDT Members |
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|
|
| Referrals | From GP and acute hospital | From acute and community hospital | From GP and acute hospital |
| Domiciliary Visits | Provided by social worker | Home visits and assessment provided by physio and OT | Domiciliary visits undertaken by all members of the team |
| Governance | Weekly MDT meetings. Steering Committee meets quarterly; Working groups (for ambulatory care, rehabilitations and early mobilisation) meet quarterly | Weekly MDT meetings. Steering Committee meets bi-monthly; Implementation Team meets bi-monthly. | Weekly MDT meetings. Steering Group meets every two months. Multidisciplinary business meetings held monthly. |
| Outreach Activities | GP educational meetings; roadshow to raise awareness among public health nurses, presentation at national Integrated Care Conference | Stakeholder planning workshop including patient advocates to map existing services and to set priorities for the year | Presentations to GPs, Nurses, at Integrated Care Conference, Attendance at Age Friendly County Alliance, Relationships built with Alzheimer’s Day Centres/services |
| Next Steps | Secure funding for a dietitian, psychologist, pharmacist, speech and language therapist, and a community geriatrician. | Increase ICPOP services, scope supports for nursing homes (esp. for dementia patients), develop end of life care, frailty and delirium education and training | Support long term care residents through the development of a nursing home liaison service and recruit a dietitian |
Table 2
Factors influencing programme implementation progress.
| Local Level Factors |
|---|
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| Programme Level Factors |
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| System Level Factors |
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