The Hub - Age-Related Care Unit
The hub is the proposed setting for acute ambulatory services. It will also function as the coordination, information and training hub for services for older patients, supporting integration between hospital and community based services. In addition it will act as a resource for others involved with the care of older people.
The extant “Age-Related Care Unit” will be repurposed to function as the hub for specialist geriatric services. This hub will provide specialist multidisciplinary ambulatory day care targeted to frail older adults identified within the community, ED or AMU. It is anticipated that this will facilitate intervention for these struggling individuals prior to crisis presentation to the Emergency Department. Services within the hub will further target conditions known to correlate with frailty such as falls, movement disorders and memory loss.
Key personnel within the hub will be the case workers. These individuals will be Clinical Nurse Specialists / Advance Nurse Practitioners in Geriatric Medicine. It is intended that these case workers will provide a case management service to the most complex group of patients utilising our service.
The “Hub” will further be staffed by a multidisciplinary team of medical, health and social care professionals. It is intended that rapid response to frail patients struggling at home will be facilitated by the presence of senior professionals across the disciplines of;
• Geriatric Medicine
• Occupational Therapy
• Medical Social Work
The seniority of the HSCPs appointed will allow autonomous delivery of care to patients whose needs are best met by therapy professionals. This autonomy will however be supported by regular review of patients through the multidisciplinary team meeting.
It is expected that in future all patients passing through the hub will have their data stored in a database available to professionals across the entire network. This will be a “frailty register” and will ensure that the detailed Comprehensive Geriatric Assessment completed in the Hub will be available subsequently to professionals assessing the patient within other settings.