The Integrated Care Team (ICT) works with older people over 75 years of age and health professionals to make sure that these older adults who need to use acute or community services can do so as easily as possible. The team facilitates movement into, through and out of the system as quickly as possible while at the same time maintaining the highest quality and safest care, achieving the best possible outcomes. The ICT focuses on rehabilitation to ensure the best outcome for their clients. The ICT work across the acute hospital and community services in Cork City.
The three aims of the team in Cork are to:
· Improve access for older adults to hospital care
· Improve process of care when older adults do attend hospital
· Improve departure from hospitals with the Integrated Care Team. These older adults are rehabilitated in their place of residence
The team supports acute medically unwell older adults for two weeks if their care needs can be safely looked after in their home. The team includes a Geriatrician who will support patient care.
The integrated care team includes Clinical Nurse Specialists, an Occupational Therapist, Physiotherapists, a Case Manager and a Care Assistant. The team members all have experience so that they can assess patients, decide on the care needed and then provide that care. The team work in conjunction with a consultant in geriatric medicine.
The team provides rehabilitation supports so that older adults can either move from the acute hospital swiftly, or even avoid admission entirely where safe to do so. The team provides co-ordination of care, urgent specialist assessment, rapid access to therapy and urgent access to short-term supports including physiotherapy, occupational therapy and acute nursing in the client’s home and with the client’s existing services i.e. Public Health Nurse and home support is not affected. The team is able to provide some home support during the patent’s care under the programme with support from the Community Intervention Team.
All referrals are handled by the ICT case manager as a single point of contact,
(087 094 4521) Monday to Friday, 9am to 4:30pm.
The team currently provides an early discharge pathway for older adults (over 75 years) who can have their length of stay in hospital reduced. This is phase one of the programme and involves providing nurse care, re-ablement and rehabilitation services for up to two weeks at home.
The programme also helps older people avoid admission to hospital. This second phase involves the team making sure that older people are allowed home from emergency departments and acute medical assessment units as quickly as possible by providing the care they need at home.
In the future, phase three of the programme, GPs and community nursing home units will have direct access to the team to manage patients’ needs outside of the acute hospital setting.
The team at work: (patient example)
One of the people who the team worked with was a frail older man, who was admitted to hospital having fallen in the street injuring his head. This gentleman had poor mobility and had previously refused all offers of supports such as home help and physiotherapy. Following his admission to hospital, he developed urinary retention.
The gentleman lived alone, and had little contact with his brother who was his only family, he was reclusive and a hoarder.
While the gentleman was anxious to leave hospital, this proved difficult because of his poor mobility, his living conditions and his lack of insight into the challenges these posed.
The team worked with him, and he agreed that the team could make home visits to assist with his rehabilitation and his discharge home.
The work of the team meant that he was discharged from hospital far quicker than might otherwise have been the case. The case work approach meant that several issues could be addressed – for example, steps into his house made exit and entrance challenging for him. To address this, he was assessed by a Physiotherapist and given a wheeled rollator, allowing him access to the outdoors and to independently collect his pension and do his shopping.
The Occupational Therapist provided rails at the entrance to his house.
His bedroom and bathroom posed a risk of falling due to his collection of newspapers and cans, so safe access was organised. The gentleman agreed to and made an application to have his bathroom converted to a wet room.
Nurses provided wound care, catheter care and education.
Socially he accepted a daily “Friendly Call” (a daily telephone call from a volunteer) and also reconnected with his brother.
This gentleman can now move safely around his house and with the refurbished bathroom he is safer carrying out daily activities such as washing, dressing, light household chores etc. The intervention of the team helped this gentleman to regain his independence in his own environment and for the first time in years he has become open to some community intervention.
The team works with people:
· Over 75 years
· In need of some acute home nursing
· Who are suitable for discharge home under ICT
· Who require rapid access to rehabilitative services including Physiotherapy and Occupational Therapy
· Requiring some care coordination between acute and community sectors
· Who are resident in Cork City
The team provides supports for 14 days only between 9am and 4.30pm. Home support may be provided outside these hours. In the case of an out of hours emergency the client may contact their GP, SouthDoc or attend the Emergency department at Cork University Hospital or the Mercy University Hospital
How medical professionals can refer:
All referrals are handled by the Case Manager as a single point of contact
1. The ED/AMU Patient Flow Manager or the GP Liaison Nurse will identify suitable clients.