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The FIT Service - Frailty Intervention Team

Dr Colm Byrne,

Consultant Geriatrician

Dr Byrne assesses patients on the acute floor (ED and AMAU) that require input from a geriatrician, including falls, delirium and frailty. We aim to get patients directly home, however if in-patient rehabilitation is required he looks after a rehabilitation unit (Lambay ward) in St. Mary's Hospital (SMH) that take patients directly from the acute floor. He also assesses and follows patients in outpatient clinics in SMH and MMUH. Sub-specialty clinics include a Falls and Syncope clinic in SMH and an Inclusion Health clinic in MMUH.

Dr Haswadi Hassan

Geriatric Emergency Medicine (GEM) Registrar

Wadi is a GEM Registrar working with the Frailty Intervention Team (FIT). Wadi acts as one of the clinical team leaders for Mater FIT together with Consultant Geriatrician, Dr. Colm Byrne. Wadi’s roles include providing specialist medical input, frailty review, consults and clinical decisions for all patients seen by the FIT team. Wadi is also the clinical team leader and ensures that all relevant medical, nursing and multi-disciplinary team members are continuously updated on patients’ care planning process and advocates on behalf of patients to be placed on appropriate pathways via CNMs, colleagues on the specialist geriatric ward, Patient flow and AMSSU teams.

Roisin Riches

Advanced Nurse Practitioner, Mater FIT

Roisin has dual qualifications and experience in both gerontology and emergency care nursing, Roisin’s role as the FIT ANP offers advanced nursing expertise and skills for our frail older adults on the Acute Floor.

Roisin performs an advanced physical health assessment on frail older adults who present to the ED with frailty syndromes. Depending on the outcome of assessment Roisin makes shared senior clinical decisions on ordering of diagnostics, diagnosis, plan of care, nurse prescribing and onward referral or discharge to the most appropriate destination of care. Roisin works collaboratively with FIT MDT performing a comprehensive geriatric assessment on frail older adults providing the gold standard of care. Roisin is involved in various QIP within the MMUH and has a keen interest in Implementation Science. She has developed and implemented alongside with key stakeholders’ offsite rehab, FIT clinic and delirium pathways direct from the ED. She is a key stakeholder on the Hospital Delirium Working Committee and provides education and support on the Acute Floor. Interests; delirium, falls and bone health.

Rico Laguna

Advanced Nurse Practitioner, Mater FIT

Rico has years of experience in adult medical, emergency, and gerontology nursing. His training and experience offers expert emergency intervention. He manages the complete episode of care for older adults with frailty syndrome who present with acute illness and injury. This involves advanced health assessment, performing investigation and diagnostic test, CGA, and develops patient centred medical and nursing care plan.

As an advocate for admission avoidance and safe patient discharge he developed ED-PACU Pathway, Mater FIT Virtual and Review Clinic, and actively utilises care pathways for the older person. He also provides education and support for nursing staff continuing and post-grad education. He is an active member in National Get UP Get Dressed Get Moving working group. He has interest in trauma, falls, urinary incontinence, palliative care, and venous eczema.

Laura Dillon

Senior Clinical Pharmacist, Mater FIT

Laura is a Senior Clinical Pharmacist working with FIT and she is dedicated to consistently putting the patient at the centre of her work. Laura completes a medication review, incorporating medicines reconciliation and medicines optimisation for all suitable patients who meet FIT criteria. Medicines reconciliation is undertaken in line with the MMUH Inpatient Medicines History and Medicines Reconciliation Procedure Policy. The medicines reconciliation document is completed and saved on Patient Centre. One of the main advantages of the electronic medication reconciliation is that the best medication history can be ensured through information sharing i.e. the form can be accessed by all healthcare professionals in the hospital at any time. A medication review form is also completed by Laura in conjunction with the GEM Registrar and / or Consultant Geriatrician for patients who have a medicine commenced, discontinued or changed in ED and who are not admitted to the hospital. The medication review form is also completed and saved on Patient Centre. Laura sends the medication review form to the patients’ Community Pharmacy and General Practitioner via Healthmail to support a seamless transition of care.

Aoife Ryan

Senior Medical Social Worker, Mater FIT

Aoife is a Senior Medical Social Worker on the Frailty Intervention Team (FIT) working in the Emergency Department, Mater Misericordiae University Hospital. Aoife’s role as the social worker involves the assessment and support of patients who present with complex social, emotional, and psychological needs and the development of resulting individualised person-centred care plans. Care plans are created in collaboration with patients and their families, with the help of an in-depth knowledge of supports and services available to patients in their local communities. For Aoife, a key role on the frailty team is the investigation of safeguarding issues and the promotion of decision-making capacity of all patients seen by our service.

Siobhán Magner

Clinical Specialist Physiotherapist, Mater FIT

Siobhán is a Clinical Specialist Physiotherapist working with Mater FIT. Her role is to complete formal mobility, balance, neurological, respiratory and vestibular assessments which contribute to formulating a diagnosis for patients. The role of the physiotherapist is to assess and treat people when they present to hospital with certain conditions - particularly falls. She educates patients and their families/carers on their conditions, and how to minimise the impact of these conditions on their function at home. She assists with goal setting and promotes healthy ageing. Siobhán works with the MDT to ensure older people's needs are met when they attend the ED.

Nicola Carrabine

Senior Occupational Therapist, Mater FIT

Nicola’s speciality is care of older person and frailty at the front door. Nicola is part of an MDT who plays a pivotal role in assessing patients function, cognition, ADL performance and home environment. By adopting a patient centred holistic approach she takes into consideration the patient’s preferences, social links and occupational goals to form a care plan that is unique to them. Nicola is competent in assessing and treating a wide range clinical presentations relevant to the frail population. She further ensures appropriate pathways of care developed for patient requiring admission/ ongoing HSCP intervention.

Ciara Pender

Clinical Specialist Dietitian, Mater FIT

Ciara undertakes a nutritional assessment, formulates a nutrition diagnosis and implements an intervention plan for frail older persons to prevent and/or treat malnutrition, maintain muscle mass and optimise wound healing.​ Ciara takes into account anthropometry, biochemical indices, clinical signs and symptoms as well as an assessment of recent and usual dietary intake. Ciara liaises with carers to assess need for assistance with meals, grocery shopping and provides information on easy-to-prepare nutritious meals and snacks to optimise dietary intake including for those with dysphagia ensuring adequate intake of all nutrients e.g. fibre, fluid and micronutrients. Ciara links with primary care and post-acute dietitians to ensure integrated care across emergency, acute and community services.

Áine Murphy

Clinical Specialist Speech & Language Therapist (SLT), Mater FIT

Áine identifies and provides assessment and intervention to frail older persons with swallowing difficulties (dysphagia) and communication needs (language, voice, speech, conversational skills). Áine provides person centered advice and training to staff, carers and patients themselves to optimise communication and safety of swallow and in turn improve quality of life. Áine ensures integrated care across emergency, acute and community services with early assessment and onward referrals when required. Áine also provides specialist instrumental assessment such as videofluoroscopy (swallow x-ray), fibre-optic evaluation of swallowing (swallow exam with a scope) and access to voice clinic where indicated.

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