4th December 2013
Comprehensive Geriatric Assessment in Nottinghamshire
The Community Programme
Better Together
The Community Programme
2
Better Together
Identifying Seniors at Risk (ISAR)
ISAR tool involves answering the following questions in yes/no manner:
1)
2)
3)
4)
5)
6)
Does the patient have carers?
Have the carers found it more difficult to care?
Does the patient have any memory problems?
Does the patient have any visual problems?
Does the patient take more than 3 medications?
Has the patient been in hospital for more than 1 night in the past 6 months?
Every ‘yes’ response equates to 1 mark. The higher the score the higher the frailty of the
patient/citizen.
The Community Programme
3
Better Together
Project 1 – Jackie Butterworth
Hospital Threshold CGA - Comprehensive Geriatric Assessment at
the Front Door
Trial - Develop a multi-disciplinary team to provide CGA to Patients on Ward D57
Aim:
• To improve service user, carer and staff experience
• To reduce the likelihood of future crisis and readmission to the acute setting
• To expedite transfer of care to a community setting (where appropriate) and
reduce the time that frail older people, admitted as medical emergencies, spend in
hospital unnecessarily
“Having the CGA team to focus on
the frail older people on our ward
and help us to plan their care and
assist with discharge planning is
great.”
Staff Nurse – Ward D57
The Community Programme
4
Better Together
Strengthening our links for Dementia patients
through CGA
Project 1

During the initial trials links with the B47 team were made

Attendance by Mental Health Nurse at Delivery Group meetings


During the trials links with the Liaison Psychiatry Team were made
Referral process used for advise / assessment of D57 patients
Project 2

Links to Dementia Outreach Team when letters specify dementia
diagnoses

Mental Health Specialist Nurse working on “Triage to CGA” as part of
the Integrated Health and Social Care Team

Links to Mental Health Intermediate Care
The Community Programme
5
Better Together