Gillian Fox, Alison Cracknell, Sadia Ismail and Eileen Burns are all Consultants in Interface Geriatrics at Leeds Teaching Hospitals NHS Trust
Leeds Teaching Hospitals has a 60 bedded general adult medical admissions unit and a 60 bedded Elderly Admissions Unit with comprehensive geriatric assessment (CGA) embedded to either facilitate discharge to community services with ongoing assessment and/or rehabilitation where needed or begin treatment and investigation before transfer to an elderly care ward.
As part of the Leeds acute care model, 2012 saw the introduction of Interface Geriatricians (IGs). This service was developed with initial funding from the PCT (later CCGs) aiming to avoid admission where appropriate. We have developed a model for working for the IG that covers 3 key areas of interface – community, PCAL (primary care access line) and the emergency department (ED).
Emergency Department (ED) Work
In response to high admission rates for older people from the Emergency Department there was a recognition that an early assessment by a specialist with the key skills and knowledge of community services could avoid some admissions and provide a high quality early assessment to others who require admission.
We developed a service offering Consultant Geriatrician review of older people presenting acutely to the ED. In conjunction with our early discharge assessment team (EDAT) the interface geriatricians perform an early CGA beginning within the first hour of presentation.
The results of our ED service in its first year:
- 590 patients seen and received CGA from expert clinicians
- 60 per cent of these were discharged from ED
- For comparison- the usual ED discharge rate is 20-25 per cent in the over 85s and 28-33 per cent of 75-85 year olds.
We monitored the rate of readmission (as a balance measure) for all the patients reviewed and found no difference in the readmission rate for this group discharged from ED (18 per cent) compared with the overall readmission rate after discharge from our Medicine for Older People wards (17 per cent).
Feedback from patients and the ED staff has been overwhelmingly positive.
Primary Care Access Line work
The Primary care access line (PCAL) is a nurse-led telephone service enabling GPs and other community staff (e.g. Matrons, ICT) direct access to specialty beds. Interface geriatricians are available to provide clinical advice on older patients using a conference call between the GP and PCAL nurse. We provide advice to general practitioners and other community staff, where appropriate considering alternatives to admission, including ICT, advance care planning and access to early Specialist outpatients review.
For the PCAL patients we have provided expert advice on 209 older patients of which:
- 19 per cent did not require an admission;
- 2 per cent were admitted directly to an intermediate care bed;
- 5 per cent had attended the acute trust for assessment only ; and
- A total of 26 per cent admissions were avoided.
Moreover, early outpatients use was lower than predicted, but has been a vital tool in appropriately investigating older people. (10 appointments used)
We monitored all the patients discussed for admission at a later date and found 19 per cent did not need admission at all.
An additional 7 per cent who were not admitted then were admitted later (within 28 days) – often to another specialty (i.e. likely unrelated) and this compares favourably with the average readmission rate for older people. (17 per cent).
Leeds is acknowledged nationally as one of the forerunners in the Integration of health and social care. A citywide transformation project is currently ongoing. The city has been divided into 12 neighbourhoods with an Integrated Health and Social Care (IHSC) team for each neighbourhood. These comprise a core team of social workers, district nurses and community matrons, who are co-located in the new teams. There are then strong links to other community services such as general practice, heart failure nurses, respiratory nurses etc.
For the community work there is clearly a real appetite for interface geriatricians, as feedback from community teams and general practitioners has shown, along with rising numbers of referrals to us as relationships are established. GPs and community staff really value our skills in CGA.
We have attended 40 risk stratification MDTs, we have provided 40 domiciliary visits and we have established case review meetings with the integrated teams in our areas, giving the chance to review patients who everybody within the team knows, but whose care has not been joined up until now.
A robust evaluation is taking place across the whole of the integration project looking at length of stay, admission rates, admissions to long term care and crucially patient and carer experience. Evaluation of the isolated impact of the geriatrician is challenging but activity data and feedback from community staff and patients has been collected, and the GP commissioners have funded the service for a further year of evaluation. A key aspect is the supportive relationships that have developed, and accessibility for GPs and other community staff to contact IGs about a patient who may be causing concern.
Our novel integrated acute care model has delivered high quality early assessment to frail older people and developed good multi-disciplinary working practices across traditional boundaries. It is already bringing efficiency improvements in terms of reduced admissions and a contribution to reducing length of stay.
New community working practices have led to improved staff support, and provided older people in the community with expert assessment by geriatricians, but it will take time for benefits such as admission avoidance and increased time spent in the community to be realised.
We continue to develop and refine our assessment processes. We are encouraged by our early successes and by reports from our patients and their carers of the improved experience of integrated care.
For the full article on the Leeds acute care model which incorporates Interface Geriatricians, click here.