32 Exploring the Efficacy of a Discharge to Assess Model using a Combined Approach Involving FITT, OPAT and CIT

Background Following hospital admission, older patients are at an increased risk of death and admission to nursing home care (Bachmann et al, 2010). Functional deterioration in older patients occurring prior to hospital admission is as a result of acute illness however deterioration following admission can be as a result of polypharmacy, excessive bedrest, sleep deprivation, institutionalisation and inadequate nutrition and may be amenable to changes in the processes of hospital care (Coleman et al, 2012) In terms of reducing costs in an ever-increasing older population, maintaining people in their own homes is more cost effective than high numbers going to residential care. Methods Therapists in the hospital identified appropriate patients and referred to FITT therapist’s (0.5 Occupational Therapist and Physiotherapist) and CIT nurses for review. Within 24 hours of discharge, patients were followed up by a home visit by FITT. The therapy team communicated the needs of the patient and the CIT nursing team would complete a visit. Once patient’s immediate needs were met and situation stabilised at home, onward referrals to both community and hospital services were co-ordinated as required. Results Sixteen patients over a four-week period were included. The main reason for referrals included: functional review in home environment, pain and medication management, patient and carer support.100% of patients were reviewed at home within 24 hours of discharge and required on average of 5 visits at home which equated to 119 bed days at home. This cross organisational project identified that rapid discharges can be facilitated which reduced length of stay and increased patient and family’s satisfaction with the discharge process. Conclusion This alternative model to the traditional hospital-based rehabilitation model needs to be considered in future service planning.