205 DESIGN OF AN AMBULATORY CARE HUB IN AN OLDER PERSONS SETTING. (25th October 2022)

• Record Type: Journal Article
• Authors: Cronin, A; Kennelly, S
• Is Part Of: Age and ageing. Volume 51(2022)Supplement 3
• Publication Date: 2022-10-25
• Subjects: Aging -- Periodicals; Geriatrics -- Periodicals; 618.97
• DOI: 10.1093/ageing/afac218.177
• Languages: English
• ISSNs: 0002-0729

Abstract

Abstract: Background: The service was established to deliver rehabilitation based in a day care setting. The Multi-Disciplinary Team (MDT) allocated to cover the unit often had other clinical responsibilities. Therapy was delivered in silo with differing plans/goals for individual patients. There was often reduced with insufficient/no cover to the department. The department was closed during the pandemic. Upon reopening a decision was made to restructure service delivery. A pathway of change was decided on to move from a day care setting to an ambulatory hub model of care. Methods: A Delphi method was undertaken and a review of processes conducted by the Clinical Nurse Manager 2 (CNM2). Consequently, all new referrals were screened and virtual telephone clinics held. Nursing Comprehensive Geriatric Assessments (CGA) were conducted on patients referred by their GP or who had not attended the Age-Related Healthcare Department within 6 months. This ensured clarity around patient needs. Individualised care plans were initiated before the patient's medical appointment took place. Any urgent reviews were flagged to specific therapists by the CNM2. Results: The service was restructured and is now interdisciplinary in approach. The Service moved from a day care setting reviewing approx. 60 patients weekly to an ambulatory care hub model with over 450 targeted interdisciplinary reviews weekly. A spreadsheet was developed and collated weekly by the CNM2 informing therapists of referrals received hence streamlining care- planning. This enabled MDT collaboration and merging of appointments to prevent multiple attendances. This development has been welcomed by patients and families. Conclusion: The Ambulatory Care Hub operates at a maximum capacity with patient's receiving targeted comprehensive interdisciplinary therapy input. There is a greater sense of teamwork within the department and patients benefit from this collaboration. This redesign has shown that a well-structured MDT provides essential support in many areas of disease management.