The challenge
LLR has a growing population of significantly frail older people living in long-term residential care, as well as in the community. These people may have cognitive and functional impairment, with underlying complex health conditions and it is important to minimise admissions into hospital.
The solution
A clinically-led pilot scheme for pre-transfer clinical discussion and assessment was introduced in 2020, bringing together partners from primary and secondary care, community care, the ambulance service and social services, all working together to provide an effective community response and avoid assessment duplication.
This would often entail a swift clinical discussion with a consultant geriatrician, for decision making around hospital admission, exploring safer alternatives that might entail community-led work with other partners.
Impact
It is estimated that the pilot scheme has so far led to the avoidance of 577 hospital admissions, 2,885 bed days and 730 ambulance journeys, with collective savings of approximately £400k.
Integrated working has upskilled the knowledge of frailty and end-of-life care, resulting in a significant decrease in the risks posed by hospitalisation of care home residents and older people living in the community.
Working closely as a team has created a culture of respect that has helped to reduce the duplication of assessments, benefitting both patients and staff.
The provision of community assessment, as an alternative to hospital admission, is often the preferred option for people, their carers and families.
This pilot service can now be accessed by any community-based clinician who is considering a hospital admission for a person with significant frailty.