Morriston team helping older people get back on their feet after a fall

A dedicated team in Swansea is helping hundreds of older people who have suffered a fall get back on their feet without having to go into hospital.

If they do have to be admitted, the Older Person’s Assessment Service (OPAS) aims to ensure they can leave as quickly as possible – reducing the risk of problems such as deconditioning or infection.

Since it started in April, the OPAS team has seen 437 people – and supported 333 of them to return home.

Only a small number had to be admitted to a ward in Morriston or be looked after in another hospital or care home.

OPAS, based in Morriston Hospital’s Emergency Department, is made up of healthcare professionals specialising in the care of older people.

They include consultant geriatricians, clinical nurse specialists, an advanced nurse practitioner, physiotherapist, occupational therapist and others.

Anyone aged over 65 who arrives at the Emergency Department after a fall is given a “front door” holistic assessment to ensure they are only admitted if they really need to be.

Clinical nurse specialist for frail and elderly Tina Newton said: “Patients are seen by a multidisciplinary team all working together to facilitate a discharge home if possible.

“This is supported by primary care and a consultant in our rapid access clinic.

“Patients and relatives are listened to and asked what they feel would help to support discharge and prevent readmission.

“Once back in the community, patients are referred to the appropriate community services for further support, such as ongoing physiotherapy or occupational therapy.

“Patients who do require admission are followed by the OPAS team and discharged home within 24-48 hours where possible.”

Some people who do not need acute care but do require additional monitoring and tests may be admitted directly from the ED to Gorseinon Hospital – avoiding the need for an inpatient stay in Morriston.

Swansea Council’s Bonymaen House can also be used for people who have no medical requirements but perhaps need some rehabilitation before they are ready to go home.

Consultant geriatrician Liz Davies said: “The main benefit to patients is that they are seen by a specialist earlier and are signposted to the right service rather than necessarily be admitted to hospital – with all the complications that can come with that.

“The Morriston service is different because it is nurse-led.

“The nurses who work within our team have specialist skills, training and experience in elderly care.

“They have effectively set up this pathway for older people that has standardised and ensured more timely access to existing elderly care services.

“In addition, the service offers rapid access ambulatory care clinics for fallers that weren’t available previously, and assessment by a consultant geriatrician on the day of admission for those who need it.”

Since OPAS started in April, the team has seen 437 patients, of whom 333 – or 76 per cent – were able to go home.

Of these, 90 were followed up in a “falls clinic” in Gorseinon Hospital, and a further 25 were followed up in Neath Port Talbot Hospital.

Only 60 were admitted to a Morriston Hospital ward. A further 15 went to Gorseinon Hospital and 14 to Bonymaen House; six went to Neath Port Talbot Hospital; and one went to Ystradgynlais Community Hospital.

The remaining few went to a residential or care home, were referred to trauma and orthopaedics or were referred to surgery.

Morriston Hospital’s lead manager for the project Gareth Barbour said: “OPAS has delivered significant benefit to patients in a relatively short period of time.

“The number of elderly patients reviewed by the team who are then readmitted to hospital is much lower than we anticipated. This underlines the service’s effectiveness in delivering good care.

“We are currently exploring opportunities to expand the service’s remit and to build on the successful links with community-based care providers to better meet the needs of patients.”