A multidisciplinary mobile team is improving the quality of life for older people living in the community, reports Darragh O Keeffe.
It may be just 16 months in operation but a multidisciplinary 'geriatric flying squad' has already made a world of difference to the lives of elderly people living in the community.
The team, which brings together gerontology, nursing, social work, physiotherapy, occupational therapy and psychology, aims to provide assessment and case management, improve quality of life, maintain function and prevent hospitalisation - particularly emergency department visits.
The team is based in the out-patient's department of Uniting Care's War Memorial Hospital in Waverley, NSW, and can access the hospital's resources, which include a 35 bed rehab unit, day centre, onsite ACAT team, speech, continence, falls and geriatrics clinics.
"The team came about because the need for rapid response geriatric care in the community was clear," Amanda Klahr, clinical nurse consultant with the team, recently told the ACSA national conference in Sydney.
"If an elderly person required physio or OT, for example, there could be up to a six month wait for access. When there are multiple issues, things often fall apart and the person presents at the emergency department in crisis," she said.
A successful proposal for funding was put to the Council of Australian Governments and the flying squad was born in May last year.
How it works
The team takes referrals from various sources including the older person themselves, a carer or family member, a GP, an ACAT, a community care provider, police or paramedics.
"There are no barriers to referral," according to Klahr, who said the majority of referrals came from GPs, followed by family/carer, outpatients and community care providers.
The team aims to see clients within 24 to 48 hours of referral where possible, she said.
While multidisciplinary in nature, the model of care is nursing based, and nurses conduct the initial assessment - at the older person's home.
"The assessment is comprehensive, lasting from 45 minutes to three hours, and includes medical, social, cognitive and environmental," said Klahr.
Observations and urine samples can be taken if required, and standardised assessments and measures are used - such as MMSE and RUDAS.
There are three 'pathways of care' which clients could embark on, she said. The pathways are flexible, and can adapt to the individual's needs. No two clients go on the same path, she said.
The first is a direct admission to the Medical Assessment Unit at St Vincents and Price of Wales hospital; a geriatric specific ward where the client would stay for 48 hours to undergo tests. This stream means the client can "bypass the emergency department and go straight onto the ward for tests", Klahr said. The client is then discharged and put on an appropriate care plan.
"The second pathway is where you have someone living at home who you think will benefit from some rehab. We can admit them directly to the rehab unit at War Memorial. They usually spend two to three weeks on the ward; getting speech therapy, rehab or whatever is required."
The third option, which is the most common (60 per cent of clients) is that the client is "picked up by the whole team".
"We have a case conference each Wednesday morning where we go through the client's goals for treatment. Essentially they stay on the service until we have met all the client needs we can. When we feel we've achieved that, they are discharged from the program."
To illustrate the team in action, Klahr outlined the case of 'April', a 74 year old referred to the flying squad by her community care provider.
"April was on a CACP but required more than the six hours care she was entitled to. She was exhibiting difficult behaviours, hadn't changed her clothes in weeks and was eating infrequently... Her carers were quite stressed and were threatening to pull out," said Klahr.
"April had had extensive contact with the health services, though not in the last six months. She had osteoporosis, lung disease, back pain she rated as ten out of ten, and a diagnosis of bipolar. She lived with her son, who was her primary carer."
Klahr said she and an occupational therapist from the team went to April's house to assess her. There they found a woman with very poor mobility, severe anxiety (primary a fear of falling), and urinary incontinence. "April hadn't showered in two years. She had had a recent fall and suffered fractures. Her initial cognitive assessment was good. Her son was disgruntled with the care provided by the CACP provider."
Under the team, April was given a full nursing assessment, including a shower assessment and analgesia review in consultation with the geriatrician. The occupational therapist secured a hospital bed and bathroom modifications. The clinical psychologist did a full cognitive and psychological assessment. And a social worker provided support to the son.
Following the assessment, April was diagnosed with dementia/anxiety. A behavioural management program was developed for the carers. With regular analgesia her mobility improved. She was able to shower once a week, and an EACH package was secured.
Success to date
Since it was established last May, the flying squad has assessed 250 patients. There have been high levels of GP and client satisfaction, Klahr said. Some 80 emergency department visits were prevented as a result of the team; while it has also succeeded in maintaining function and preventing falls in clients.
There are, however, challenges for the future, Klahr said. There is a lot of effort required for very small gain; it's often hard to see what it being achieved, she said. The team is small; consisting of just 2.9 FTE staff. It also covers a large geographic area and has a large clinical load.
It is hoping to undertake research so as to further prove its efficacy. "We would like to grow in the future, and share our model of care for other services to pick up," she said.Do you have an idea for a story?
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