Slowing The Revolving Door? Re-admission To Hospital In Those Under The Care Of ICPOP Teams

Abstract Background The Integrated Care Programme for Older People (ICPOP) teams provide services to older adults living with frailty, to maintain their independence at home. Preventing admission and supporting transition from hospital to home are aims of the service. Our team takes referrals from hospital wards, ED, GPs, and Geriatric OPDs. Our study analyses the more complex patients that were supported by ICPOP at the point of discharge from hospital and the effect on hospital re-attendance. Methods The ICPOP database was reviewed from December 2022 to January 2025. Patients who were referred to the team to support a hospital discharge were included. We collected data on ED presentations and hospital admissions during the period of active ICPOP involvement in the patient’s care and in the three months following discharge from the ICPOP service. Results A total of 80 cases (average age 82) were included in this study. During the time of ICPOP involvement, 16 patients (20%) attended ED & 14 (17.5%) of these were re-admitted. In the 3 month period after discharge from the community team, a total of 15 (18%) patients were re-admitted to hospital. Falls were the most common reason for admission. There were 3 deaths in the cohort during the study period. Conclusion A systematic review demonstrated re-admission rates of 5.5-35% for the >65years at 90 days. One study showed the highest re-admission rates (34.3%) in moderately frail patients, a cohort similar to our population. Our re-admission rates are considerably lower for this high risk group, and support the theory that ICPOP care can have a positive effect on the use of emergency hospital services. References 1. Pedersen. et al. Risk factors for acute care hospital readmission in older persons in Western countries: A systematic review. JBI Database System Rev Implement Rep 2017. 2. Juma. et al. Clinical frailty scale in an acute medicine unit: a simple tool that predicts length of stay. Canadian Geriatrics Journal 2016.