Anja Clark - SA Health - Northern Community Geriatrics Services - Redesigning a Community Geriatric Service to Reduce Readmissions and Avoidable Presentations to the Modbury and Lyell

Redesigning a Community Geriatric

Service to reduce readmissions and

avoidable presentations to the Modbury

and Lyell McEwin Hospitals:

Our story so far.

Anja Clark

Clinical Services Coordinator

Community Geriatric Service.

Northern Adelaide

Local Health Network

Community Geriatric Service

Who are we and what do we do?

Our service comprises of Geriatricians, Nurses, Social

Workers, Occupational Therapists, Physiotherapists and

Pharmacist

We provide comprehensive geriatric assessment, short term

interventions and case management to clients in the Northern

Adelaide Local Health Network


Who are we and what do we do?

The focus of the service is:

• Hospital avoidance through identifying clients residing

in the community who are at high risk of presenting to an

emergency department and working with these clients to

establish longer term support networks to address their

health concerns

• Supported discharge from hospital by working with

acute and subacute hospital teams to ensure

intermediate care is coordinated and seamless for the

client


Who do we see?

Older people aged 65+ years or 50+ years ATSI who:

• Have had recent multiple admissions to hospital or the

Emergency Department

• Are experiencing a recent decline in health, cognition

(especially memory) or ability to self-care which increases their

risk of being admitted to hospital

• Have health conditions that can be assessed or managed

safely in the home environment


Who do we see?

• Would benefit from establishing services and supports to

manage their health in the community

• Require a multidisciplinary home assessment to determine

their level of independence in the home and to support their

discharge from hospital


History

Western

ClinicCentral

Clinic

Falls

Northern

Community

Geriatric

Service

MAST CGEM Team

Northern

Area

Geriatric

Service

MAST - Mobile Assessment and Support Team

CGEM - Community Geriatric Evaluation and Management

(MAST and Falls Prevention)

North and North

Eastern Clinic


Service Planning: The Broader Context


Objectives for Reform

To enable early identification and assessment of

patients’ needs to maximise the period of time that older

persons can live independently and with dignity.

Promote patient independence through an enablement

model.

Coordinate assessment and care planning of patients to

create a more efficient flow of patients across the

continuum of care and between settings.

SA Health Priorities for the Older Person Service Delivery


Objectives for Reforms

Work with acute services to facilitate timely transfer from

an acute hospital to sub-acute or home.

Work with community based services to potentially avoid

hospitalisation.

Provide services closer to a patient’s home.

SA Health Priorities for the Older Person Service Delivery


Why the service was redesigned

Not fully aligned with SA Health service priorities for the

older person

Service fragmented with no significant evidence of

achieving decreased client presentations to ED or

readmissions to the hospitals within the Northern

Adelaide Local Health Network – Modbury Hospital and

Lyell McEwin Hospital

MAST service initially only accepted referrals solely from

the community and its relationships with hospitals and

emergency departments were poorly developed, with

hospitals having limited knowledge of the service


Why the service was redesigned

Limited engagement with the client’s GPs

No formal access or input by Geriatricians

Limited networks with ACAT and service providers -

Clients often required similar multiple assessments

across spectrum of service providers for services to be

implemented


How the service was redesigned

Geriatrician dedicated to the service for access to

specialised clinical support and formal links with NALHN

Geriatrician team established

Co location at Modbury Hospital with:

• Inpatient Geriatric Evaluation and Management Unit

• Aged Care Assessment Team

Working parties formed to develop strong relationships

and referral pathways with the GEM Unit and ACAT

Service Integration



Stronger linking with client’s GPs to support ongoing

case management of client

Falls and MAST teams integrated to enable client’s to

access both services from the one referral

Formation of partnerships with external service providers

in particularly:

• Metropolitan Referral Unit

• Older People’s Mental Health

• Domicillary Care

• Community Aged Care Providers

• Chronic Disease Services



Actively formulated relationships with Modbury Hospital

GEM unit and Lyell McEwin’s Acute Care of the Elderly

team through:

• Attendance at GEM Unit’s twice weekly Case Management

and Discharge Planning meetings

• Attendance at weekly inter hospital discharge meetings

• In person clinical handover of clients

Actively formulated relationships with both hospital ED

liaison teams through meeting with the team and

presenting education sessions regarding the service

Service Integration –

Modbury and Lyell McEwin Hospitals.


The results of the redesign

More than 700 referrals were received to the service last

year, with 353 of these referrals supporting client

discharge from hospital

Geriatrician advice was sought for 49% of the clients,

resolving health issues in the community which

otherwise may have required a hospital admission

ACAT commenced for 46% of clients with streamlining of

the assessment through integrated case discussion of

the client’s situation along with their service wants and

needs.



In the past 6 months, where hospital admission was

required for medical stabilisation, a direct admission to

the hospital was arranged on 16 occasions which

enabled:

• The client to bypass ED

• The admitting team to have information of the client’s health

status, medical issues, concerns regarding their ability to manage

living at home and recommendations regarding care requirements

for discharge

During this year to date, over 500 more episodes of care

have been provided by the service than during the

previous year



Allowing for sufficient time for post implementation data to

be available, analyses of 22 patients who utilised the

service last year was undertaken:

• In the 6mths prior to the program, the 22 patients used

283 bed days (average of 12.8 bed days per person)

• This reduced to 58 bed days in the 6mths following the

program (average of 2.6 bed days per person).

• A reduction of 10.2 bed days per person.

Audit of the service also revealed a four fold increase in

utilisation of non-hospital community services following the

service’s intervention to establish a long term support

network for the clients.


The Future

Community and inpatient teams to rotate to enable more

holistic client care, service knowledge and enhancement

of the ‘in reach/outreach’ service model

Formation of one assessment tool for both Community

and inpatient GEM Unit to utilise to further enhance

seamless and thorough care coordination

Community GEM Service team members to undertake

ACAT training to become associate assessors to enable

one comprehensive geriatric assessment to be

undertaken to address all client concerns and for team

members to work across the services


The Future Central referral and triage for the service to also incorporate

Geriatric Outpatients to best enable correct service response for

the client

Expansion of geriatric nursing specialties offered by the service -

Parkinson's and Movement Disorders, Behaviors and Physical

Symptoms of Dementia, Continence

Formation of relationships with providers of the new

Commonwealth Home Support Program and Regional

Assessment Service programs

Expansion of the service in alignment with the SA Health

Transforming Health directive


Thank You

Gill Bartley

Samara Zubrinich

CGEM and NALHN Geriatric Service

Healthcare

Anja Clark - SA Health - Northern Community Geriatrics Services - Redesigning a Community Geriatric Service to Reduce Readmissions and Avoidable Presentations to the Modbury and Lyell