Date27/07/16

Site Aberdeen Royal Infirmary, Foresterhill Site, Aberdeen, AB252ZN

Contact Details Christina Cameron, Programme Manager 6EAUC , Louise Brodie, Quality improvement facilitator, ARI

Title OPAL Team – Older Persons Assessment and Liaison Team

6EA (choose one, see AED)

EA6: Ensuring Patients are Cared for in their Own Homes

Please describe the project Aim

To prevent unnecessary hospital admission for older people presenting to Emergency Department, and improve the quality of care and discharge pathways for older patients admitted as inpatients to non-Geriatric Medicine wards in the Acute Sector, Aberdeen Royal Infirmary by:

Providing responsive person-centred multidisciplinary assessment Enabling safe, effective and timely discharge or transfer Promoting effective links with community teams for follow up Supporting ward teams to provide effective care for frail older people whilst inpatient

Anticipated Benefit

To improve communication and ensure a safe, patient focussed discharge without delay, facilitating improved flow within the acute hospital. Admission avoidance to acute hospital bed with responsive multidisciplinary assessment and safe timely discharge facilitation.

Implementation & Approach

The team consists of 1 Consultant Geriatrician, 1 Specialist Nurse, 3 Physiotherapists and 2 Occupational Therapists.

Clinical staff within the Emergency Department (ED) identifies older patients with frailty that may be able to be discharged directly home.

They are referred directly to the OPAL team via mobile phone. The OPAL Team also conduct and facilitate multidisciplinary assessment of people on non-

Geriatric wards who have experienced functional decline, referral for this intervention is via the discharge hub with a same day response.

Outcome

We receive an average of 200 referrals monthly from all wards within Aberdeen Royal Infirmary.

All referrals are reviewed within 1 working day. Referrals within Emergency Department are reviewed, and assessed by the team within the 4

hour performance target. Of 304 referrals from the ED between August 2015 and May 2016, 85% were discharged

directly home, with the remaining patients requiring admission to either acute or intermediate care.

There has been a reduction in Delayed Discharges and Care Management referrals since the

Case Study Submission

inception of the OPAL team. (July 2016 ARI delays: 29)

Key Lessons Learned

Responsive ‘front door’ multidisciplinary assessment, and improved facilitation and coordination of multidisciplinary input on non-Geriatric Medicine wards has resulted in improved flow, reduced delay to discharge and improved quality of care within ARI.

Your case study with considered for presentation and publication in monthly update. Please indicate if you do not agree.

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Return to: UnscheduledCareTeam@gov.scot by first Monday of every month

6 Essential Actions - Action Effect Diagram