Clinical Case Manager for Older Persons. Elaine Dunne

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1 Clinical Case Manager for Elaine Dunne

2 According to the World Health Organisations World Report on ageing (2015) the numbers of older people worldwide are dramatically increasing. In their Global Strategy and Action Plan ( ) they say for the first time in history most people can expect to live into their 60s and they report by in 5 people will be 60 years or older.

3 The Kings Fund (2014) reports that when the NHS was founded in 1948, 48% of the population died before they reached 65 years and this has now fallen to 14% and that the number of people over 85 years in the United Kingdom has doubled in the last three decades.

4 The Irish National Clinical Programme for Older People (2012) predicts that by 2031 the number of older persons over 85 years of age will have risen by 150%. as people age their health needs tend to become more chronic and complex (WHO 2015).

5 There is a national focus to develop a continuum of care to enable older persons to live in their own community for as long as possible (HSE 2006) common criticism of community services being fragmented and due to multiple services offered by different providers resulting in poor outcomes (Low et al 2011).

6 The Kings Fund publication (2014) report that when older frail people present to A/E they are 1. much more likely to be admitted to acute care 2. have longer inpatient stays, 3. much more likely move wards while in hospital, 4. experience delays in their discharge, 5. much more likely to require long term care 6. have higher rates of mortality.

7 35% of 70 year olds admitted to hospital show some form of functional loss on discharge and this increases to 65% for 90 year olds. In many cases the medical reason why an older person is admitted to hospital may well be stabilised long before the patient can be discharged as other issues including being able to undertake self-care, home care packages or social issues become centre stage (NCPOP 2012).

8 The NCPOP reports the role of nursing as being vital in the delivery of care to older persons and believes the improvement of nursing roles in older persons care will support a quality service to frail older person.

9 Integrating health services in Ireland has become an important agenda in the health service. Integration between acute inpatient care, day care and community services is vital to improving the quality of care for the patient.

10 CCM co-ordination of care of the older person across settings, deliver advanced and intensive nursing in a home care environment for older people with multiple complex conditions, be a single point of contact for the older persons who requires to navigate a very complex health system

11 The clinical case manager role Co-ordinating services Communicating and linking community and acute services Facilitating discharges

12 The role essentially Reduces length of stay in the hospital by supporting, facilitating or streamlining a discharge Avoids A/E admission where possible by managing case complexity and utilising alternative and community care

13 Referrals: Consultant Geriatrician Day Hospital staff (Doctors and Nurses) PHN/community RGNs Respite office Discharge co-coordinators/patient Flow Social workers

14 One of the approaches used to try and avoid A/E attendances for frail older people October 2014, 5 step up beds made available in St Mary s Phoenix Park Under the clinical governance of the Consultant Geriatrician from Connolly Hospital For patients identified as being at the cusp of an acute admission

15 Types of admissions: Medical admission requiring intervention e.g. blood transfusion/ivab/iv diuresis/radiological investigations Rehabilitation as evidence of functional decline Requiring both medical intervention and rehabilitation

16 Full MDT available Medical Nursing Physiotherapy Occupational Therapy Dietician Speech and Language Social Work Tissue Viability Psychiatry of Old Age when required Palliative Care when required

17 Admissions: Patients identified from either the Medicine for the Elderly Day Hospital, Domiciliary visits, patients known to MFTE who presented to A/E Co-ordinated through Clinical Case Manager who made the referral to the unit and monitored admissions

18 Consultant Geriatrician carries out ward rounds 2-3 times weekly and full MDT meeting once a week. Constant contact between unit staff and consultant and clinical case manager

19 Data from October 2014-October 2015: 60 patients admitted to unit (beds were filled 12 times over)

20 Cognitive impairment: Of the 60 patients admitted 35 had a cognitive impairment

21 Referral source: Patients were admitted either directly from home, Holly day Hospital, Inpatients from Connolly hospital and A/E in Connolly

22 Reason for admission: Medical intervention Rehabilitation Both medical intervention and rehabilitation

23 Length of stay:

24 Investigations preformed:

25 Allied Health Professional involvement:

26 Discharge destination: 51patients discharged home 3 patients admitted to long term care 2 patients admitted to housing with care 3 patients died in the unit 1 patient transferred back to acute care

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28 Aim and Objective: The aim was to provide access to care for the frail elderly patient that would ordinarily be provided in acute care using the appropriate medical, nursing and AHP skillmix. A case management approach to co-ordinate care in a planned approach ensured timely admission and discharge planning and provided an important support for patients and carers.

29 Evaluation and outcomes: The average length of stay was 28 days compared to 42.2 days in the acute care settings for a similar cohort of patients the same time period. 85% of frail elderly patients admitted were discharged home. Providing direct access to a medicine for the elderly facility which provides specialist medical care, nursing care and allied health support reduces the length of stay and increases the likelihood of being discharged home.

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