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230Tallaght Integrated Care for Older Persons Team – Bridging the Gap

Background: The Integrated Care for Older Person’s Team commenced in January 2017 and consists of an MDT including a geriatrician, two clinical case managers, a social worker, an occupational therapist and a physiotherapist. The objective of the team is to improve the quality and outcomes of care for older persons and their carers and support persons to live well in their own homes and communities. The team acts as a communication bridge between acute and community health and social care services, employing a person centred, anticipatory, timely, well-coordinated and evaluated approach to care. Methods: The team works with older persons with multiple health and social comorbidities. To access the team, a person is referred by their GP to the Age Related Healthcare Team in the Hospital. The geriatrician screens referrals. Each case is discussed at the team’s weekly MDT. Each service user is assigned a case manager and a keyworker. Upon referral, the team completes an interdisciplinary assessment of need, referring onwards and providing brief targeted therapeutic and rehab interventions where appropriate. Team members attend hospital MDTs and have daily contact with colleagues in both community and acute health and social care. Results: To date 75 older persons have accessed the team for comprehensive interdisciplinary assessment, care planning, intervention and referral. At point of referral, 44 per cent of referrals have had a diagnosis of cognitive impairment, 12 per cent a diagnosis of Parkinson’s Disease. Thirty three accessed the team’s weekly rapid access clinic, with five receiving a diagnosis at this. The team accessed three emergency homecare packages to prevent hospital admissions. Conclusions: Feedback from service users and carers has highlighted the team’s regular communication and support navigating the system as invaluable. Other professionals have observed service users’ improved wellbeing and presentation attributing this to the integrated care team intervention.