336 GEMS: Geriatric Emergency Service - Home Team Outcomes (Age and Ageing)

AbstractBackgroundFrailty is now a key concept in healthcare service planning and delivery and is driving vertical and horizontal integration. Early identification of Frailty and early intervention with Comprehensive Geriatric Assessment (CGA) is fundamental to our GEMS. Older people with Frailty admitted to hospital who receive a CGA early are more likely to return home. Benefits are seen early and are sustained (Ellis et al 2011).MethodsThe aim of GEMS is to improve care, outcomes and the patient experience for older people living with Frailty. All people aged 75 years and older who attend as an emergency are screened on triage using the Variable Indicative of Placement Tool (VIP). The GEMS Acute Floor Team respond early to those who screen positive by starting a CGA. The GEMS Home Team was planned and developed in December 2018 to case manage those identified at risk of adverse outcomes by the Acute Floor Team.Results79% (502) of patients who received a CGA were case managed by the Home Team since December 2018. 3% were newly discharged to Long Term Care, 73% to their pre-admission residence. 14% of patients were discharged with an increase in Home Support Services (HSS) and 2% with new HSS. 24% were referred to 3rd sector supports in the community e.g. ALONE, SAGE etc. 48% were identified as appropriate for earlier discharge if supports e.g. Discharge To Assess were available at home.ConclusionThe GEMS Home Team have developed and delivered a pioneering integrated care approach to the management of the older person. The Team are positively influencing the culture of Home First in the hospital and driving horizontal and vertical integration.