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52 A Community Cure for Frequent Reattenders: Developing An Interface Geriatrics Service by Davies, O; James, S is a Medicine article available to read on EtoBox.

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## Abstract ## Topic Setting up an interface geriatrics service in a seaside area with a large elderly population. Many elderly patients are readmitted due to the challenge of managing their chronic health conditions in the community. These patients are frail, with frequently exacerbated chronic conditions causing regular readmissions. We noted that treatment was rarely changed during these admissions and patients were not uniformly managed. ## Aims Aims for this project were to improve care for older people, reduce readmissions and produce clear patient care plans. ## Interventions Our first PDSA cycle involved implementing geriatrician presence at community MDTs (involving social services, GPs, intermediate care teams, and various others). This generated home visits to several patients, with a mix of acute and chronic issues. We offered Advance Care planning where appropriate to these patients. We noted several patients were repeatedly discussed at MDT. This brought into focus frequent attenders who were usually well-known to the community. In the next cycle we introduced ‘frequent attender’ plans for these patients, ensuring a unified approach to their management. Subsequent cyc

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Author

Davies, O; James, S

Publisher

Oxford University Press; Oxford University Press (OUP) (ISSN 0002-0729)

Published

2020

Language

EN

Field

Medicine (Health Sciences)