Frailty Vision for quality: A framework for action

Vision for quality:A framework for action - technical document

3. Frailty

3Vision for Quality - Frailty: 2013 - 2017

1.0 Introduction 1

2.0 The current situation in Warwickshire North 2

3.0 The case for change 4

4.0 Views and opinions 6

5.0 The future direction 7 6.0 What will change for our patients? 9

7.0 Timeframes for action 10

Contents

This document is part of the Warwickshire North Clinical Commissioning Group’s Vision for Quality clinical strategy.

The Vision for Quality clinical strategy is formed of a series of chapters:

Vision for Quality - provides a general overview of the strategy

This is supported by a series of chapters that provide more detailed information on the individual health service areas:

Urgent, emergency care and emergency general surgery

Cardiovascular disease, stroke, transient ischaemic attack and heart failure

Frailty

End of life

Mental health

Dementia


One of the successes of the NHS and new treatments is that we have more people living well for longer and to support this the NHS needs to change.

there is a body of evidence to suggest that itis a collection of biomedical factors that affectan individual’s psychological state in a way thatreduces their capacity to withstand environmentalfactors. Frailty is likely to be correlated withdisability and co-morbidity and should identifya group that is vulnerable to adverse outcomes.Frailty is often associated with old age however,

only a subset of elderly people, circa 6%, is atrisk of becoming frail. There is also a cohort ofyounger people who are deemed clinically to befrail due to multiple morbidity and lifestyle.

In this review the term “frailty” is used to describe a range of conditions in people, including general physical debility and cognitive impairment. Frail people are vulnerable to illness, social isolation, loss of independence and admission to hospital and nursing or residential home.

The diagram below shows the stages of frailty:

1.0 Introduction

Stages of Frailty

Illness stage

Hea

lth

sta

ge

HealthyAging

ChronicVulnerability

Chronic lossof capacity

AcuteIllness

Acute lossof capacity

Recovery


2.0 The current situation in Warwickshire North

There is no register of people who are frail, however we can estimate that there are around 2,000

In addition there is a cohort of patients under the age of 65 who will be frail as a consequence ofmultiple long term conditions (LTCs.)

Conditions people are living with that can be indicators of frailty

The diagram below shows the number of people living in Warwickshire North with conditions orfactors that can be indicators of frailty:

Discharges with social care packages are shown below:

Patients returning home from hospital with some social care support

This table shows the number of WNCCG patients discharged from George Eliot Hospital withsocial care support for the calendar year December 2011/November 2012:

Biological

HealthPsychological Sociological

2,925 over 65 living with depression

2,138 over 65 living with dementia

1,653 over 65 living with a longstanding health problem following a heart attack

765 over 65 living with a longstanding health problem following a stroke

12,193 over 65 live alone

873 over 65 live in a care home

13,337 over 65 unable to manage at least 1 domestic

task unaided

5,934 over 65 with impaired mobility

572 over 65 living with a longstanding health problem from bronchitis or

emphysema


Emergency Admissions for Frail Elderly

0

10

20

30

40

50

60

70

80

Apr-12

May-12

Jun-12

Jul-1

2

Aug

-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

There are 10 nursing homes across Warwickshire North with a total of 498 beds.

The data demonstrates the activity and cost of emergency admissions for patients in WNCCG who have frail elderly conditions: defined as patients aged over 65 who are admitted under clinical codes of Falls, UTI, Dehydration or Dementia. The graph shows the data split by those admitted from home versus those from a care home.

Emergency admissions from residential homes over the last 4 years

There has been a 65% increase in emergency admissions from residential homes during this period.

Frail ElderlyAdmissions from home

Frail ElderlyAdmissions from nursing homes

0

100

200

300

400

500

600

2009/10 2010/11 2011/12 2012/13


3.0 The case for change

There are a number of reasons why weneed to make changes to how we care forthose people who are frail. Some of theseare stated below and grouped into local andnational evidence:

3.1 Local evidence There are currently around 34,000 people over

65 (20% of population) in Warwickshire North and it is anticipated that 2,000 (6%) will be frail.

There is a cohort of patients under the age of 65 who will be frail as a consequence of their lifestyle or multiple long term conditions.

The Warwickshire Director of Public Health

is associated with more hospital admissions and higher mortality. This in turn leads to an increase in costs.

Of all 10,547 emergency admissions to GEH over a 12 month period, there were 5,191

admissions for patients aged over 65 and 3,504 of those admissions were in the speciality of general medicine.

emergency admissions to GEH from residential homes between 2009/2010 and 2012/2013 of 65%; that is 321 in 2009/2010 to 530 in 2012/2013.

Voluntary agency representatives told us that information, awareness and transport are priorities for this group, with community transport being important, as well as reaching harder to reach groups and providing information on available services.

Evidence in the Warwickshire Joint Director of

that more than 42% of the population could have one or more long term conditions and

key opportunities for improvement in care for those with long term conditions.


3.2 National evidence

The Geriatric Society and other nationalbodies such as the Kings Fund identify thatchange is required; most of the factorsbelow align with local evidence for change:

There is a pressing need to change how we care for older people with urgent care needs to

Older people are admitted to hospital more frequently, have longer lengths of stay and occupy more bed days in acute hospitals compared to other individual groups.

There are an increasing number of people who are frail attending emergency departments and accessing urgent health and social care services.

Over the next 20 years, the number of people aged 85 and over is set to increase by two-

thirds, compared with a 10 per cent growth in the overall population.

What matters most is clinical service-level integrated health and social care targeted at

everyone. (The Kings Fund 2011).

to focus support on those with the highest risks along with support for self care and shared decision-making to support and care for those with LTCs.

Several recent national reports, including from organisations such as Patient UK, the Care

Enquiry into Patient Outcome and Death (NCEPOD) and the Health Service Ombudsman,

of people in acute hospitals ranging from issues around privacy and dignity to improving perioperative care.

Emergency departments need to be supported to deliver the right care for those who are frail, as no one component of the health and social care system can manage this challenge in isolation; implementation of improved care for people requires a whole system approach.

Attendance at the Emergency Department is associated with a high likelihood of admission for older people, and the nature of the service and the environment in which it is provided

of healthcare in the 21st century, the bulk of which relates to increasingly frail people.

Commissioning evidence-based integrated health and social care systems that address care across the continuum will help deliver

holistic care for frail people in the years to come.

failings in care for older and vulnerable patients which illustrate the need to improve how older people are cared for and assessed in A&E and on hospital wards.


4.0 Views and opinions

4.1 Local GP opinionGPs in Warwickshire North considered frailtyin a workshop on 9 May 2013 with a rangeof evidence and information from the BritishGeriatric Society, the Kings Fund, the Francisreport, local evidence of service usage anda presentation from South WarwickshireFoundation Trust on the community servicescurrently in place. Feedback was also receivedfrom a number of GP practices about how services were operating based on their experience of seeing patients on a daily basis.

Key improvements suggested were:

To ensure nursing homes are providing services for patients in line with their contracted responsibilities ensuring quality, as well as activity metrics are being met. Where residents need community health services such as district nurses and therapy services, we provide this in recognition that if we support people this provides better care for our patients and may prevent an inappropriate admission.

A need for community geriatricians to treat more patients outside of hospital, especially in nursing homes, and support to GPs who undertake home visits.

Ability for GPs to access urgent advice from a geriatrician, either through a clinic appointment or a telephone call.

Integrated teams between health and social

approach.

Geriatric Assessment Team at acute providers to better manage patients and improve outcomes.

Increase in carer respite for those caring for their frail relatives.

4.2 Voluntary sector opinionAt the voluntary sector workshop on 19 June2013 the Frailty group considered ‘what isimportant for the future?’. Information,awareness and transport were the prioritythemes, with community transport beingimportant, as well as reaching harder to reachgroups and providing information on availableservices.There were also a number of comments andconcerns around nutrition including:

‘Ensure nutrition screening is carried out to identify malnutrition early and treatment is put in place.’

‘Increased dietetic provision in the community.’

‘Improve nutrition in care homes.’

‘Improve focus on food in hospitals.’


5.0 The future direction

The table below outlines the: issues we need to address, actions we will take, outcomes we will expect.

What issues do we need toaddress?

What actions are we going to take?

Outcomes

Poorly integrated services.surgeries to proactively manageand co-ordinate care of the peopleat risk outside of hospital.

Closely aligned health, social careand community teams workingwith acute providers to ensure aseamless admission into hospitaland discharge from inpatient stay.Some admissions and length ofstays will be avoidable with moreappropriate non-hospital servicesand workable pathways.

Ensuring that all opportunities forjoint commissioning of integratedservices are exploited.

Exploring ways to appropriatelyaddress the rising admissions fromresidential homes where care isbest provided in the community.

GPs improving quality of care andlife for patients and to help themto avoid emergency admissions tohospitals where possible (DirectEnhanced Service).

Increased number patients referredto community care teams as analternative to hospital admissionfrom agreed baseline.

Agree integrated working modelfor health and social care teamsacross primary care, secondarycare, social care and the voluntarysector.

Increase in the number of peopleliving well in the community withlong term conditions as a result ofthe enhanced service in primarycare.

Lack of geriontologist inputat GEH.

Development of a specialistmedical assessment unit (Frailty) at GEH site with geriontologistsupport in the community toprevent admissions and better treat patients outside of hospital. This is part of the Model for Urgent and Emergency Care.

Reduce inappropriateadmissions of over 65s tohospital.

Decrease length of stay for patientsover the age of 65.


What issues do we need to address?

What actions are we going to take? Outcomes

GPs’ inability to accessurgent specialist opinion.

Access to urgent specialist opinion for GPs to prevent patients being admitted unnecessarily.

Patient has quicker diagnosisand treatment in the mostappropriate place and reductionin unnecessary admissions.

nutrition.Scrutiny of quality measures in care providers on offering good nutrition and hydration for our frail patients.

Improved achievement of measures of good nutrition and hydration in hospital, and reduced complaints/incidents related to nutrition.

between community services and nursinghomes.

Provide an enhanced service (Nursing Home Local Enhanced Service) to ensure

admission to a nursing home and support to prevent unnecessary hospital admissions.

Uptake and delivery againstnursing home local enhancedservice delivered by GPs, anda reduction in the number ofinappropriate admissions toacute hospitals.

Lack of support for carers. Work with Warwickshire County Council to implement the Carers’ Strategy 2012-2015.

Carers will have clear options for respite.

Lack of outcomes information oncare for our frail patients for commissioners and the public.

Agree an Annual Plan from GEH outlining achievement against standards outlined in the Silver Book (The Geriatrics Society)as well as participating fully in all relevant national audits (e.g. stroke, hip fracture, dementia, falls, bone health and continence.)

Annual plan for frailty bypathway and organisation

patients.


Now Future

John is 79 years old. He has had cancer twice in thepast and has a series of long term conditions including diabetes.

He has been feeling progressively more poorly over the last week and eventually his daughter is so concerned she takes him into A&E.

He sees a junior doctor and it is not clear what is wrong with him so he is admitted for investigations. John sees the consultant on Monday as he was admitted during the night on Saturday. The consultant arranges a series of tests which are normal.

The consultant asks the nursing teams to involve the community teams and social care but this takes some time to arrange. John is still in hospital two weeks later.

John is 79 years old. He has had cancer twice in the past and has a series of long term conditions including diabetes.

He has been feeling progressively more poorly over the last week and eventually his daughter is so concerned she takes him into A&E.

He is seen by the geriatrician in the SpecialistMedical Assessment Unit (Frailty) within an hour of presentation.

there are no immediate reasons for concern. The geriatrician involves the community and social care team who are also based in the Urgent Care Centre and they arrange a package of care for John, rather than admitting him into hospital. John and, importantly his daughter, are clear about thepackage of care that has been arranged and have telephone numbers to contact.

The geriatrician sends an immediatedischarge letter to the GP who contacts John the next day to ensure everything is in place.

6.0 What will change for our patients?

There are times when the system does not work for our patients and we aim to improveon this. The following scenario provides an insight into what can happen now (whenthe system does not work well) and what would happen in the future following theproposed changes.


7.0 Timeframes for action

Warwickshire North CCG believes that the changes we have proposed will benefit patientsafety and improve quality of care. We anticipate that within the next three years all ofthese changes will have been implemented. A more detailed schedule of action is shownbelow.

Year 3Year 2Year 1

Implementation of integrated working between health, social care and voluntary sector.Training plan for nursing homes, linking with community team training.Implementation of Specialist Medical Assessment Team (Frailty) in Urgent Care Centre.Appointment of Geriatricians.

Receive inaugural Annual Plan for Frailty.Geriatricians working in the community and linking directly with primary care.

Teams working as a cohesive unit around the patient and across primary and secondary care.

2014/15 2015/16 2016/17

Address: NHS Warwickshire North CCG Room 1 Lewes House College Street Nuneaton CV10 7DJ

Tel: 02476 865243

Email: [email protected]

Web: www.warwickshirenorthccg.nhs.uk

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Frailty Vision for quality: A framework for action