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Abstract Background The Community Specialist Team for Older Persons (CST-OP) was created to support older people to live well at home. The team primarily aims to reduce ED presentations and admissions into acute facilities for over 65s. The team became the first fully staffed CST-OP in Q3 2022. Referrals are responded to within 24-48 hours and each referral has a comprehensive geriatric assessment completed. Interdisciplinary assessment is used to identify interventional needs which the team then addresses. This abstract specifically examines the success of supporting people with a Clinical Frailty Score (CFS) of 7 and above to remain at home. Methods The team consists of a senior 1 WTE Social Worker, Physiotherapist, Therapy Assistant, Consultant Geriatrician, Advanced Nurse Practitioner and Clinical Nurse Specialist. The team also has 0.5 WTE Senior Speech and Language Therapist and Dietician. Referrals are accepted from the FIT team, GPs and Older Persons OPD clinic. The team operates on a 100% domiciliary based assessment. A comprehensive geriatric assessment is completed with each referral. A care plan is generated, and interdisciplinary intervention carried out. Results From September 2022 to December 2023 69 patients with a CFS of 7 or above were reviewed by the CST-OP. 60 remained at home, 7 transitioned to LTC and 2 RIP. These figures represent an 86% success rate. Conclusion Evidence suggests older people living with severe frailty can be supported to live well at home by Community Specialist Teams via timely interdisciplinary assessment and intervention and appropriate utilisation of community supports.
Dunne et al. (Sun,) studied this question.