3THE BRIDPORT PROJECT - INTEGRATED COMMUNITY SERVICES FOR FRAIL, ELDERLY PATIENTS IN WEST DORSET

Abstract

Background: West Dorset has 100,000 people; 13.5% are over 75 years old. Bridport is rural, with poor transport links and is 16 miles from an acute hospital. Over the last year, the Bridport Project has sought to deliver care to elderly patients as close to home as possible. Innovation: The Bridport Project has a number of components: (1) Use of the community hospital (CH) as an integrated care hub, supporting coordination of community teams' activities. (2) Use of CH beds as an alternative to acute admission. (3) Multidisciplinary care coordination based around primary care, with weekly virtual ward rounds at the GP practice. These are attended by GPs, a geriatrician, a psychiatrist, district nurses, physiotherapists, occupational therapists, mental health nurses and social services. (4) Teleconferenced MDTs on Mondays and Fridays to monitor and plan care over weekends. (5) Domiciliary assessment of frail, complex patients by a community geriatrician. (6) Joint domiciliary physical and mental health assessment of patients by a geriatrician and psychiatrist. (7) Appointment of Health and Social Care Coordinators to implement and administer collaborative community team working. (8) Consultant support of district nurses and community rehab teams, allowing direct referral and review of patients. (9) In-reach of district nursing teams to the community hospital, to share community knowledge of in-patients, and participate in discharge planning. (10) Colocation of social services in the community hospital. (11) Shared care record: GPs, the community teams and the CH all use SystmOne. (12) Post discharge follow-up: following discharge from the CH, patients remain under the care of the in-patient team for one week.