Knowledge Tree

Safer transitioning Optimising Frail Elderly Patients Care From Hospital to Home

Authors: Yvonne O’ Riordan , Paul Bernard, Paul Maloney, Alison Enright, Carmel McGrath

Abstract Beaumont Hospital is committed to delivering on the objectives of the National Clinical Programme of Older People (NCPOP). The hospital’s strategic plan promotes an ethos of a hospital without walls; integrated care planning from hospital to home embodies this philosophy. Spanning the last 3 months the Occupational Therapy (OT) Department in Beaumont Hospital and North Dublin have collaborated to deliver an integrated OT service to frail elderly patients deemed suitable for discharge home from the emergency department (ED) and also patients referred from the community virtual ward service to prevent avoidable admission to Beaumont’s ED. Geographically there is a 20% higher proportion of over 65 year olds living in Beaumont’s catchment area when compared to the national average. In September 2015 a multi disciplinary team comprising of occupational therapists, physiotherapists, social workers, speech and language therapists, dieticians and pharmacists, formed the frailty intervention therapy team (FIT team), and embedded itself in the hospital’s emergency department.The service aim being: To identify 100% of frail patients, over the age of 75 years, who presented to the Emergency Department during core working hours.To provide rapid access, comprehensive multidisciplinary team assessment to all those over 75 years and identified as frail in E.D.Initial service findings highlight the distinct and multi dimensional needs of these patients, with 75 % of over 75 year olds screening positive for frailty using the “Think Frailty” tool. Early identification of frailty was the first step in influencing proactive and positive care planning for this vulnerable population. The necessity to consider better ways of transferring patient care from hospital to home was clearly evident from both a patient feedback perspective and also home being identified as the most appropriate pathway destination. Utilising quality improvement methodology a whole service redesign occurred within the Care of the Elderly (COE) hospital service, including staff reallocation, allowing timely assessment and intervention to occur. Multiple PDSA cycles facilitated continual system improvements. Such change in work practice provided the conditions to question how best to support the frail older person who is medically optimised, but has deteriorated functionally, to return homesafely. Case by case single therapy outreach sessions became a norm in responding to this service gap, both directly from the emergency department (ED) and COE wards. However this was only as case load allowed. Realising the inequity of this as well as the utilising established evidence from both the NHS discharge to assess and early facilitated discharge models of care, the FIT Team proposed to standardise the patient hospital to home pathway. Key considerations were the distinct needs of this patient group and the necessity for a rapid response rehabilitation service, with strong experience in working with the frail elderly population. A test phase was initiated and delivered by a Beaumont OT assessing the impact of a responsive intensive rehabilitation/ case management in the patients home. Patients requiring ongoing input from primary care services are then handed over following the initial 2 – 4 weeks of intervention for continued treatment. Establishing formal integrated patient pathways enables the frail elderly patient the opportunity to live in their own home with the supports they need, while minimising the risk of unnecessary hospital presentations. While still in its infancy, the information gleaned from this test period has been enlightening. To date 23 patients have been selected as suitable for this test model. 71 % of referrals came directly from the Beaumont Hospital ED, 24% from the community virtual ward and 5% from various Beaumont wards. From a profiling perspective the mean age of patients was 86 years, with 42% living alone. On screening 47% screened positive for a cognitive vulnerability using the O3DY. Reason for referrals can be grossly themed on three acute presentations including: injurious falls (67%), functional deterioration secondary to acute medical issues (22%) and confusion (11%). Interestingly prior to hospital presentation only 26% where “known” to community occupational therapy i.e. currently active to a therapist or previously active now closed. 6% of the total group were known to community physiotherapist. We can assume by this and by patients’ collateral they were functioning at a relatively safe level at home prior to this acute illness. Concentrating on global improvement, 67% of patients Functional Independence Measure (FIM) significantly improved with rapid, intensive rehab in conjunction with simple environmental adaptations. The average length of input spanned 12.3 days, with the average of 3.6 face to face contacts.This period of testing has proved to not only enhance patient centred care by improving proactive hospital to home care planning, it intended to test daily systems and processes in an effort to inform the model of care for the Integrated Care Team due to be established in early 2017. With this in mind efforts are made to continue to collect information not only in relation to clinical care and patient outcomes, but also non clinical case work and travel.


frail elderly, collborative, integrated hospital community services

How to Cite:

O’ Riordan Y, Bernard P, Maloney P, Enright A, McGrath C. Safer transitioning Optimising Frail Elderly Patients Care From Hospital to Home. International Journal of Integrated Care. 2017;17(5):A591.

DOI: on 17th October 2017