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Specialist Care for Older People - What we currently deliver

Specialist Care for Older People - What we currently deliver. Acute inpatient service (65+) with lowest LOS nationally Liaison teams working in acute medicine and A&E (OPAL) and surgery Outpatient clinics to reduce or shorten admissions

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Specialist Care for Older People - What we currently deliver

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  1. Specialist Care for Older People - What we currently deliver • Acute inpatient service (65+) with lowest LOS nationally • Liaison teams working in acute medicine and A&E (OPAL) and surgery • Outpatient clinics to reduce or shorten admissions • Subspeciality services (e.g. falls, continence, heart failure, Parkinson’s) bridging secondary and community care • Stroke - acute service incl thrombolysis and rehabilitation • Explicit links with MHOA

  2. What geriatricians currently deliver for Lambeth PCT • Community clinics (Whittington, LCCC, Pulross) • Specialist ward rounds / MDMs in bed-based IC (Lambeth) • Specialist sessions with community IC teams • Specialist support to PCT strategy/ operations • Specialist input to NHS Care Home (Minnie Kidd House) • Clinical Governance • Only 10 PA’s of consultant time

  3. Specialist Care for Older People - What we would like to happen Chaos of multiple assessment: costly, non-integrated, non-responsive service • Shared clinical information with IT linking primary and secondary and social care and patient • Integrated working (secondary, primary, social and IC) to reduce hospital discharge delays (e.g. ward-based excess bed days worker) • Integrated working to reduce A&E reattendances and hospital admissions (e.g. rapid response from community and social care)

  4. Specialist Care for Older People - What we would like to happen • Early home discharge linked to effective monitoring and intervention in community • Rapid access (48/72h) comprehensive assessment with geriatrician support • Community case management by geriatricians for patients failing to thrive at home or at risk of long-term placement • Effective community case-finding (e.g. Southwark POPP model) • Integrated health and social services community-based intermediate care with more geriatrician input

  5. Specialist Care for Older People - What we would like to happen • Effective bed-based intermediate care for targeted patient groups (e.g. post-op, post-acute frail OP, # NOF, stroke) • Assessment and community case management for patients on threshold of needing continuing care • Multidisciplinary care home support teams to deliver quality care, and reduce hospital admissions More community geriatician time

  6. Specialist Care for Older People - What we would like to happen • Skilled domiciliary care workers (rehab, mental health, medicine supervision, ‘handyman’) • Carer support (Day Centres, sitting services etc.) • Accessible health promotion (e.g. fitness groups, handouts with opportunity to discuss, domiciliary dentistry and optician for homebound)

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