Abstract
In the absence of clinical governance from a Consultant Physician in Geriatric medicine in 2022, Kildare West Wicklow Integrated Care Programme for Older People (KWWICPOP) team developed an altered pathway in collaboration with acute and rehabilitation services within Dublin South, Kildare West Wicklow Community Healthcare. (DSKWW CH)
This service is for adults, aged 65 years and over in acute care or living in the community with complex needs, who would benefit from receiving multidisciplinary coordinated rehabilitation, from two or more disciplines currently employed on KWW ICPOP team.
This initiative involved various stakeholders including; Naas General Hospital (NGH), the Frailty teams, local General Practitioners (GP’s), community primary care team including the Community Health Networks, Older Person Services, and Kildare community partners. The KWW ICPOP Operational Lead liaised with various stakeholders to negotiate clinical governance for the patient through NGH and GP’s.
In the absence of clinical governance from a Consultant Physician in Geriatric medicine, the KWWICPOP team developed an altered pathway (figure 1) in collaboration with acute and community services within DSKWW CH. The KWW ICPOP team comprises of an Operational Lead, Senior Physiotherapist, Senior Occupational Therapist, Senior Dietitian, and Clinical Nurse Manager II. This Interdisciplinary team aims, in line with Sláintecare and the National Integrated Programme for Care of the Older Person (NICPOP), to provide timely planned coordinated care via a therapy at home model, minimise acute hospital admissions, facilitate early supported discharge and augment the link between acute and community services.
The KWW ICPOP early supported discharge pilot commenced in October 2022. The team received 203 referrals in the first 12 months of this pilot from inpatient wards and the Frailty Intervention Team in Naas General Hospital, and other sources in the community.
This initiative demonstrated the impact of integrated care teams in admission avoidance and facilitating early supported discharge to older adults. Clients demonstrated notable improvement in their function and independence. Each client received a feedback form at the end of the intervention period, which was returned anonymously to inform what could be improved. Feedback received has been very positive.
Through the development of an alternative care plan, this study demonstrated that a cohesive coordinated care plans across acute, primary care, older persons and community partners ensures that older adults receive the right care at the right time and in the most appropriate setting, which for most older adults is their own home.
We aim to further build this pathway by establishing future clinical sites throughout Kildare & West Wicklow. Health link will be rolled out in 2024 in Kildare West Wicklow, this will allow improved integration with the GPs across the area. The KWW ICPOP geriatrician will come into post in December 2023, allowing further development of pathways such as frailty, falls and dementia care pathways for older persons in Kildare West Wicklow.