Developing a Frailty Model for Causeway Hospital: facilitating enhanced short stay care and early supported discharge

2044
Stephen Collins, Carrie Coulter, Audrey Kelly, Michael McAteer, Emily McIntosh
Causeway Hospital, Northern Health and Social Care Trust
Frailty
Improving service delivery

Abstract

Introduction

Causeway Hospital’s frailty service consists of an Acute Elder Medicine/Stroke unit of 30 inpatient beds and a Frailty Direct Assessment Unit (DAU) for GP referrals and EmergenIntroductioncy Department (ED) patients suitable for same-day turnaround with comprehensive geriatric assessment (CGA) from our multidisciplinary team. 

We have devised a new Frailty Model to enhance our service, maximise integration between primary and secondary care services and facilitate more effective short-stay care and early supported discharge. 

 

Method

To initiate this model, we plan to: 

1. Strengthen our DAU admission pathways – by identifying ED patients more quickly, promoting anticipatory care pathways, and ensuring all GP’s in the Causeway locality are made aware of the direct referral pathway. 

2. Explore new ways of working within DAU – by collaborating with the NI Ambulance Service to develop a direct access pathway to DAU for patients meeting specific criteria (e.g. non-injurious falls), and setting up pathways for residential homes (offering CGA in DAU for new permanent admissions into residential homes). 

3. Open an Acute Frailty Unit – by developing a 6-bedded Acute Elderly Area, and testing a model in the coming months to assess the long-term viability of this project. 

 

Results

We expect early results for the impact of this model in the coming months, and hope our enhanced service will provide comprehensive short-stay care and support timely discharge back to the community with a safe wrap-around service. 

 

Conclusion

To meet the increasing needs of today’s ageing population, we need pathways that decrease reliance on acute secondary care services, promote independent living for frail, older people where possible and strengthen our relationship with primary care colleagues. 

Our Frailty Model aims to streamline services and create new ways of ensuring our older population are given the best chance to have a healthy, fulfilling and well-supported later life.

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