PROJECT 

Hospital Based Community Outreach Team for Frail Older Adults

 

TEAM:

Dr. Megan Alcock, ANP Ms. Mary Hayes, Dr. Catherine O’Sullivan, Dr. Kieran O’Connor

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LOCATION:

Mercy University Hospital, Cork

 

THE PROBLEM:

There are increasing numbers of older adults living with severe frailty in the community, being supported by family carers and increasingly complex networks of community supports. Family carers often feel unsupported at home, and it is difficult for existing GP and community services to meet the needs of these patients, resulting in frequent emergency department attendances and hospital admissions, often for relatively low acuity illnesses. The Department for Older Persons Services at the Mercy University Hospital recognised many inpatients with advanced chronic disease and advanced frailty who had multiple recurrent hospitalisations towards the end of their life. While not always possible, when asked, most people express a preference for home as their place of death. According to TILDA, Ireland has high rates of hospital deaths, indicating inadequate community and home care supports.

 

THE SOLUTION:

Recognising hospital inpatients who are likely to benefit from supportive and palliative care approaches in the community with a goal to die at home can be done using a combination of tools and based on advanced care planning discussions. Patients are seen at home on discharge in order to support the transition of care to a supportive and palliative approach. A multidisciplinary team provides experienced medical and nursing expertise at home to patients living with severe frailty. We provide support to carers and try to anticipate future needs where possible. We also provide education on end-of-life care. Family carers are given a contact number which can be used on weekdays for support. We provide timely access to medical and nursing assessments and guidance through periods of acute deterioration. We link with Public Health Nurses, General Practitioners, and community Palliative care teams in order to support patients and carers.

 

BENEFITS:

This community outreach team provides a link between the hospital and community giving patients access to gerontological expertise in their own homes. We aim to improve communication during transitions of care and avoid unplanned healthcare utilisation where possible.  Finally, we support carers and provide patient centred care for older adults living with severe frailty nearing end of life in the community.

 

PROJECT CONTACT DETAILS:

Dr. Megan Alcock, Mercy University Hospital, Grenville Place, Cork

Email: ma34211@muh.ie