27THE WEYMOUTH AND PORTLAND INTEGRATED CARE HUB

Abstract

Background: The Weymouth and Portland Hub builds on the model of integrated community care developed in Bridport and presented at the BGS Spring Conference 2016(1). The Integrated hubs deliver multi-disciplinary care to frail patients at home, through the coordination of existing community & social services. Implementation has been without additional funding. Weymouth and Portland locality has 70,000 people; 23% are over 65 (National average 17%). The Hub opened in November 2015. Innovation: The Weymouth Hub builds on the existing Bridport model of geriatrician-led, multi-disciplinary case management in collaboration with primary care in the following ways: · Use of the Hub at Westhaven Community Hospital (CH) as a single point of access for all community services. · Daily multi-disciplinary case-management of patients on the Hub caseload. · Development of a full-time GP Extensivist role, providing medical input to the Hub and CH ward · Use of Nurse Practitioners to support urgent assessment and follow-up of medical patients. · Ambulance service coordination: an Emergency Care Practitioner is based in the Hub. · Collaboration with the local DGH's 'Acute Hospital at Home' service, providing domiciliary intravenous therapies. · Participation in all local GP practices' monthly MDTs for > 75 s. Using the eFI via SystmOne, these meetings identify patients with emerging frailty, and implement appropriate advanced care planning. This is shared via SystmOne on the Dorset Care Plan. Evaluation: The Hub now receives about 400 referrals a month. Since launch, there have been 6689 referrals. Most Hub referrals are managed at home: 5120 out of 6689 (77%). For Hub patients requiring hospital admission, CHs are used as an alternative to acute admission. In 2016/17, there were 151 direct CH admissions (vs 158 acute admissions). In 2017/18, there were 237 CH admissions (vs 197 acute admissions). In 2017-2018, unplanned admissions for >75s in Weymouth and Portland fell by 3.6%. In the rest of Dorset, over the same period, unplanned admissions for >75s rose 1.8%. Between March 2017 and March 2018, unplanned bed days for over 65s fell by 7.9% (vs 4.2% for the whole of Dorset). Conclusions: This revised Integrated Hub model supports more frail patients to remain at home. For local elderly patients, it has helped reduced unplanned admissions and length of stay.