220 Kildare West Wicklow OPT: a pilot study to provide early supported discharge for older adults (>65) in Naas General Hospital

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Abstract Background In the absence of clinical governance from a Consultant Physician in Geriatric Medicine, KWWICPOP team developed an altered pathway in collaboration with Naas General Hospital (NGH). The Kildare West Wicklow Older Persons Team (KWWOPT) early supported discharge pilot commenced in October 2022. KWWOPT is an interdisciplinary team whose aims, in line with Slaintecare, are to: (1) Provide timely planned coordinated care via a therapy at home model, (2) Minimise acute hospital admissions, (3) Facilitate early supported discharge, (4) Augment the link between acute and community services and (5) Provide early supported discharge for older adults (>65 years) in NGH who would benefit from receiving multidisciplinary coordinated rehabilitation, (>2 disciplines currently employed on OPT) in the home. Methods Referrals are received from NGH. A keyworker is appointed and Comprehensive Geriatric Assessment is completed. The keyworker presents the results at MDT meeting and generate internal referrals to other team members. If referrals are required to other services not currently in post, referrals are generated to Primary Care Services. Clients may also be referred to external services. Each discipline carries out their own individual assessment and treatment and clients are discussed at MDTs at regular intervals to ensure care is coordinated. A discharge summary is prepared by each discipline involved in the clients care. The discharge summary is sent to the clients GP and local Primary Care Centre. All clients and their families are given a feedback form to complete at the end of their episode of care. Results Referrals in the first 5 months of this pilot: (1) 69% from inpatient wards (early supported discharge and reduced hospital bed days), (2) 25% from Naas General Hospital Frailty Intervention Team (Admission avoidance) and (3) 6% other sources. Conclusion The KWW OPT continues to grow and provide interdisciplinary integrated care as part of the National Care Programme for the Older Person.

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