Abstract
Background: A significant programme of reform was underway in Services for Older Persons and Chronic Disease supported by the strategic direction set out under Sláintecare, the Enhanced Community Care business case, HSE Corporate Plan, National Service Plan (2021) and the National Clinical Programmes. The Enhanced Community Care Reform Programme is focused on the transformation of community care with an emphasis on establishing Community Health Networks and Specialist Community Teams working within Ambulatory Community Hubs (Government of Ireland, 2021-2023). In Older Persons Services, our focus was on shifting the model of care away from the acute hospitals towards providing specialist care in the community.
Who is it for? The rapid access Specialist Gerontology Frailty Assessment Clinic in a (rural) General Practice setting was set up with a view to incorporating an element of an integrated model of care for older people living at home. Specifically, this pilot was aimed at:
Providing specialist gerontology and geriatric medicine opinion for frail older clients at the right time and right place, building on the ethos of case management and care at or near home.
Accepting direct referrals from the Primary care practice (the local GP), based on the inclusion criteria, or, older patients of the nominated primary care practice who have been recently discharged from hospital.
Seamlessly linking older people to older persons services and/or consultant geriatrician opinion if required
Who got involved: Direct referrals were accepted from General practitioner of the area, Integrated Care Team for Older Persons -Registered Advanced Nurse Practitioner (RANP) Older Persons Services and Integrated Care Geriatric Medicine Registrar.
- Supported by timely access to Consultant Geriatrician for advice and recommendations in more complex cases.
Impact: Patients received early access to specialist assessment with remarkably less waiting time. They also received quicker access to specific Older Persons Services in their own community. Patients who did not attend was followed up in their own homes. This clinic reduced the number of patients waiting for Geriatrician Outpatient Department in Sligo University Hospital. A three month review with the stakeholders was very positive. Directed referrals to Primary care, Specialist Older Persons Services and to well-being programmes to improve their Quality of life and Sustain them at home
Learning for international audience: To shift model of care away from acute hospital and provide specialist care in the community to improve their quality of life by early prevention and early intervention
Next steps: Included further scoping to assess potential to scale this pilot up to include other rurally located GP practices in the region, with a catchment demographic that would suit such a service, and an examination of resources required to support same
Reference:
1.Government of Ireland. Dublin. Slaintecare: Slaintecare implementation Strategy and Action Plan. 2021-2023.
2.Health Service Executive. Dublin. Making a start in Integrated Care for Older Persons: A practical guide to the local implementation of Integrated Care Programmes for Older Persons. 2017.