Community team in-reach into ED can reduce admissions

Introduction

Frailty FIRST is a community led project aimed at getting frail older adults back to their own homes with support and engaging community services to try and prevent further admissions. Last winter long ambulance waits and ED stays increased which has the biggest impact and harm on our frail older adults. Many of them could have been managed in the community and along with putting measures in place to try and reduce conveyances we used community in-reach into ED to get patients out on to Virtual Ward. This developed to include early discharge with consultant review and CGA at home to optimise patient care and prevent reattendance to ED.

Method

ACPs from out virtual ward team were used to in-reach and find suitable patients to discharge with support from OT/Physio and a Pharmacist. Follow up was on Virtual Ward to allow CGA and ongoing care. We added 3 Consultant home visit review slots on a weekday morning, bookable to review patients who were complex and needed ongoing care or who might otherwise need to stay in hospital. We recorded data from in-reach projects and home visits to assess outcomes.

Results

Numbers of frail patients discharged directly from ED increased sufficiently so that ongoing funding for posts were found. Consultant review clinics struggled with small referral numbers but feedback was good. Data collection is ongoing to assess whether reattendance rates have fallen.

Conclusion

Frailty FIRST has been successful in getting patients out of hospital more quickly and breaking down some of the barriers between hospital care and community care. Funding is now available for rapid therapy assessment at home after discharge, we plan to continue moving care away from hospital and back to home for frailer adults reducing the harms of hospital and creating a patient centred approach.