21 The Jean Bishop Team, Hull: A New Model of Care for Comprehensive Geriatric Assessment of the Frail Population

Abstract

workforce deficits, requiring a modernised service model for frail older people that moved from individual provider focus to system-wide perspective, with emphasis on proactive care. Methods: Electronic Frailty Index (eFI) in primary care system identified 3,200 out of 300,000 Hull residentsHull with severe frailty. Recruited 9 GPs with extended role in older people’s care and Advanced Nurse Practitioners to support 4 Community Geriatricians. Redesigned roles for pharmacy, social services and non-clinical care coordinator teams. New therapy roles created, multiple third sector organisations involved, including carer support, and purpose-built location with older people in mind. Interventions: Structured and anticipatory comprehensive geriatric assessment of all 3200 residents (either at home or in care homes) by the multidisciplinary multiagency team. Pre-assessment home visit by support worker to complete patient concern’s questionnaire. Dedicated patient transport and one-stop multi-disciplinary team assessment in one building. Proactive discussion of RESPECT and advance care planning, electronic personalised care plan delivered with system-wide record sharing across providers, Same day basic diagnostics available. Complex care coordinators ongoing support in community. Multidisciplinary outreach to care homes and truly housebound. Results: • 99.7% patients and carers extremely likely/likely to recommend the service • 21,000 interventions for 2,500 patients seen since June 2018 • Majority of patients moderately frail by Clinical Frailty Score • Average saving on drug costs - £110.17 /patient/year • 15% reduction in ED attendances, 29% reduction in emergency admissions • Patients’ survey: adequate time and opportunity to discuss health problems/concerns, felt informed and empowered during consultation and in future planning • Very high levels of staff satisfaction Conclusions and future: • Innovative high quality, cost-effective new model of care delivering improved patient care and experience with emphasis on proactive care and future planning • High levels of patient and staff satisfaction • Future expansion with disease specific teams including COPD, parkinsonism and diabetes and targeting moderately frail by eFI. • Redesign of community services with improved integration across teams and providers can be a blue-print for other services.