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. 2021 Mar 18;21(1):15. doi: 10.5334/ijic.4682

Table 1.

Summary of three pioneer site descriptions.

SITE A SITE B SITE C
Catchment – Geography Urban & large rural area Urban & large rural area Suburban
Catchment – Population demographic Older Significantly older Young but growing older population
Hub Location Day hospital for older people on the grounds of a model 4 acute hospital Community hospital close to a model 3 acute hospital Primary care centre close to a model 4 acute teaching hospital
Pioneer Site Background Green-field site (few services for older people outside of GP) Evolved from integrated care activities for older people in the acute hospital Creation of a community geriatrician post as catalyst
Project Sponsors
C = clinician
nc = non-clinician

  1. Hospital Geriatrician (c)

  2. Older person’s services manager (nc)

  1. Acute Hospital General Manager (nc)

  2. Community Health Organisation (CHO) Head of Social Care (nc)

  1. Consultant Geriatrician (Former community geriatrician) (c)

  2. CHO Head of Social Care (nc)
The Programme funded MDT Members

  1. Senior Physiotherapist

  2. Senior OT

  3. Administrator

  4. Clinical Nurse Specialist

  5. Social worker

  1. Clinical Nurse Specialist for Dementia

  2. Senior Grade Occupational Therapist

  3. Senior Grade Physiotherapist

  4. Administrator

  1. Consultant Geriatrician (rotates every 4 months)

  2. Clinical Case Manager × 2 (one to be filled)

  3. Senior Occupational Therapist

  4. Senior Physiotherapist

  5. Senior Social Worker

  6. Administrator
Referrals From GP and acute hospital From acute and community hospital From GP and acute hospital
Domiciliary Visits Provided by social worker Home visits and assessment provided by physio and OT Domiciliary visits undertaken by all members of the team
Governance Weekly MDT meetings. Steering Committee meets quarterly; Working groups (for ambulatory care, rehabilitations and early mobilisation) meet quarterly Weekly MDT meetings. Steering Committee meets bi-monthly; Implementation Team meets bi-monthly. Weekly MDT meetings. Steering Group meets every two months. Multidisciplinary business meetings held monthly.
Outreach Activities GP educational meetings; roadshow to raise awareness among public health nurses, presentation at national Integrated Care Conference Stakeholder planning workshop including patient advocates to map existing services and to set priorities for the year Presentations to GPs, Nurses, at Integrated Care Conference, Attendance at Age Friendly County Alliance, Relationships built with Alzheimer’s Day Centres/services
Next Steps Secure funding for a dietitian, psychologist, pharmacist, speech and language therapist, and a community geriatrician. Increase ICPOP services, scope supports for nursing homes (esp. for dementia patients), develop end of life care, frailty and delirium education and training Support long term care residents through the development of a nursing home liaison service and recruit a dietitian