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Supporting Older People with frailty. Andrew Hindle : Commissioner for Integration Dr Richard Bramble : Interim clinical lead for integration. Facts and figures for 2012/2013. 19,500+ over 65 arrived at ED 14,500 admissions over 65 10,000+ over 75 85% arrived by ambulance.

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supporting older people with frailty

Supporting Older People with frailty

Andrew Hindle: Commissioner for Integration

Dr Richard Bramble: Interim clinical lead for integration

facts and figures for 2012 2013
Facts and figures for 2012/2013
  • 19,500+ over 65 arrived at ED
  • 14,500 admissions over 65
  • 10,000+ over 75
  • 85% arrived by ambulance
what are we doing
What are we doing?
  • Commissioning a new ‘Community Rapid Response Team’ for frail elderly
  • A team of eight Advanced Nurse Practitioners
  • Combined with social care professionals
  • Improved interface with primary/community and secondary care

Community Rapid Response Team for Older People with Frailty

Patient seen or contacted by


NHS 111


Out of Hours

Virtual Ward

Single Point of Access for

Advanced Nurse Practitioner

Calls Triaged

(1) Refer to ANP for priority assessment

(2) Health/Social Care assistants undertake a preliminary assessment

Care Passport

Assessment By ANP or Care Home Practitioner

Palliative Care Nurse

MacMillan Nurse

Respiratory EOL Nurse

Care Home Palliative Nurses

- Initiate treatment → 48-72 hours (GP informed)

- Initiate care package → up to 7 days (then review)

- Rehab assessment → refer to OT if appropriate

- Night sitting service (MBC Peripatetic) or GP respite

- Refer if appropriate to MDT (specialist teams), CMHTOP, palliative care

Admit to EAU

Discharge to: (1) Step down to care of VW/Community Nursing/GP (2) Respite (3) Community Geriatrician

a new integrated care approach
A new integrated care approach
  • Teams working together in 5 localities
  • Caring for the same group of patients
  • Via a single point of access
  • To start with health teams from April 1st then later with social care
  • Move to 7 day working
  • Identifying people via risk stratification
a new integrated care approach1
A new integrated care approach
  • Integrated care group: involving older people’s experiences to be meaningful
  • Increase CCG support for carers
  • CCG working with Age UK Dudley to identify older people who are lonely and isolated and provide support services.
  • Increase support for palliative care
  • advance care plans to avoid unwanted admissions
  • Risk stratification
  • What do you think of the changes we are taking forward?
  • What would you like to see to support older people with frailty?