TRIGGER EVENT

 

Successful implementation of a system for GP practice's elderly living at home and living in residential care.

Having established a CGA based, proactive, personalised care system for elderly persons living at home (early stage of implementation), and elderly persons in residential care in nursing homes (development of a more substatntial system), a GP practice can look towards the establishment of a broader based, more formal system system of care centered around a Multi Disciplinary Team (MDT).

 

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PROACTIVE CARE DELIVERED BY A MDT

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The delivery of proactive care and personalised care to frail/elderly patients requires a holistic and preventative system of care, aiming to meet clients physical health, mental health and social care needs and engaging in the ongoing task of :

 

1. Case finding and populating/maintaining a Frail/elderly register

2. Assessment
3. Case management

 

The task is achieved by a Dedicated Multidisciplinary Team (MDT) led by a General Practitioner and supported by a Community matron, Physiotherapist, Occupational therapist, Social Worker, Community Psychiatrist Nurse, Prevention and assessment team, Geriatrician support, Team lead and administrative support. Further support is obtained from Public Health and the Voluntary sector.

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The challenge for the  GP located in a community where the local authority has not yet met the challenge of providing a local integrated proactive care service for its frail/elderly population, is to provide proactive care within the time and resource constraints of  his/her own practice.

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It is hoped that  some of the more pioneering GP practices in the Republic of Ireland will soon reach this stage of development, and will enjoy the support of their local authority in establishing a MDT led service.

Their documented success stories will serve as beacons and guides to a broader nationwide thus improved and integrated care of the elderly.