Frailty in Midlothian eFrailty Programme
Outline • Midlothian… • What is eFI …and why? • History and strategic fit • What we’ve learned • So what?! • TEC Pathfinder
Midlothian Population: - 90,000 Area: - 354km 2 Integrated Budget: - £131m Workforce (head count)*: - Midlothian Council: 691 - NHS Lothian: 484 - Voluntary: 340 - Private: 1470 * 2016 figures - incomplete: https://www.midlothian.gov.uk/download/downloads/id/3083/ijb_workforce_planning_2017-22.pdf(p.7)
1 WHY Why do it? What’s the need?
1 Frailty is the Projected Percentage Population Change to 2037 (2012 Estimate Base Figure) Projected Population Change to 2037 (2012 Estimate Base Figure) Global Warming Children (0-15) Working Age Pensionable Ages 75+ 120 Children (0-15) WHY Working Ages Pensionable Ages 75+ 120,000 of Health & Social Percentage Population Change Why do it? Care 100 What’s the need? 100,000 80 80,000 Population 60 60,000 40 40,000 20 20,000 0 0 2017 2022 2027 2032 2037 2017 2022 2027 2032 2037 Year Year Data Sources: GROS – www.gro-scotland.gov.uk & 2011 Census http://www.scotlandscensusgov.uk Data Sources: GROS – www.gro-scotland.gov.uk https://inhabitat.com/photo-of-frail-polar-bear-illuminates-the-tragedy-unfolding-in-the-arctic/
What is eFI …and Why eFI What ( https://doi.org/10.1093/ageing/afw039 ) Cumulative deficit model of frailty • • Collaboratively developed • Validated Why Robust predictive validity for outcomes of mortality, • hospitalisation and nursing home admission • Available within our Primary Care Software The eFI will enable treatments and services to be targeted to a • person based on their frailty status rather than their chronological age thus providing a paradigm shift in care for older people living in the community.
Timeline Innovative Data Driven Discovery project 2016 2018 Health Foundation HIS Collaborate 2017 Building the Learning Quality about eFI and Improvement engaging with Collaborative work
1 Frailty is the Global Warming WHY of Health & Social Why do it? Care What’s the need? Frailty Stratification by eFI Score in Midlothian 50% of citizens 900 identified as frail are under 75 yrs old 2200 - 50% of citizen aged 5900 65+ are frail Mild Moderate Severe https://inhabitat.com/photo-of-frail-polar-bear-illuminates-the-tragedy-unfolding-in-the-arctic/
Service Use Profile 100% 90% 80% Unscheduled Primary Care A&E Care 70% 60% 23% of Emergence 50% 37% Total Department 20% of GP Unscheduled attendances 40% contacts Occupied Bed Days (UOBD) 30% 4,650 Emergency Department 20% Attendances 10% 26,000 Practice 30,600 UOBD Nurse contacts 50% Result in 0% Admission Midlothian Population Non-Frail Population Frail (All)
Stratified Service Use Profile All Frailty Severe Moderate Mild 10 % Population 1% population 2% population 7% population (GP Contacts) 23% Total ED 2% 7% 14% Total OBD Averaged in a 30.1 days 22.2 days 13.3 days Year (Unplanned Admission) Average Number 14.8 12.2 9.2 of BNF Sections
UNPLANNED HOSPITAL ACTIVITY BY ESTIMATED FRAILTY STRATA IN A GP PRACTICE (N=17,577) Severe or Moderate Frailty Other 68% 78% 92% 98% 32% 22% 8% 2% POPULATION OCCUPIED BED DAYS ADMISSIONS ED ATTENDANCES STRATIFICATION (FROM GP PRACTICE (FROM GP PRACTICE (FROM GP POPULATION) POPULATION) POPULATION) £1.91M per annum £ - The cost of unscheduled admissions of patients from a GP Practice who are estimated to have moderate or severe frailty
eFI Frailty Learning Collaborative Polypharmacy Review Rational Prescribing QI Projects Admissions Prevention Frequent users Continuity of Clinician Red Cross/OT Reliability of care Penicuik Housebound Collaborative
Severely Frail patients - QI Metric Before After Named GP 73% 100% Key Information 45% 100% Summary (KIS) Anticipatory Care 23% 100% Plan (ACP) On Palliative Care 8% 95% Register
Benefits Realisation – beyond Statutory Care - Dimension of Description citizen benefit Personal An assessment that gives time to find out ‘what matters’ - Early identification of carers: 1 in 3 referred to VOCAL. - Support 1 in 4 go onto receive support by Local Area Coordinators reducing social - isolation Falls prevention - Basic home adaptations in 50% of cases. OT training - will enable Red Cross to undertake the whole process and remove Safety duplication of assessment and reduce waiting time for individual Emergency Care Plans completed with four clients. On MOSAIC - (Midlothian Council Social Care Management System), shared with GP and KIS updated Financial Money and independence - Increase in claims to DWP and Blue Badge - applications. More than £100k in unclaimed benefits now allocated. Telecare referrals made - Environmental Boiler replaced to improve heating. -
Disconnected Connectedness VISION Red Cross Trak Trak Community Hospital 15 Mosaic
Timeline Innovative Data Driven Discovery Digital project transformation 2016 2018 Health TEC Foundation Pathfinder HIS Collaborate 2017 2019 Building the Learning Quality about eFI and Improvement engaging with Collaborative work
Technology Enabled Care National Programme Aim By developing local pathfinder sites, the TEC programme aims to facilitate transformation of local supports for health and wellbeing - embedding digital technology - to shift local delivery upstream towards prevention and supported self-management. More information: https://tec.scot/
Initial Problem Statement 1. Effort and data are siloed – the Partnership commissions and manages services but these exist largely in respective ‘bubbles’ because we lack the enabling organo-socio- technical infrastructure and service schemas to co-ordinate the assets of respective (physical world) partners to enhance care and empower citizens. Consequentially, services are working blind, perpetuating and exacerbating risk, repeating data collection tasks, not seeing a holistic patient view, sub-optimally organising care, and making patients dependent. 2. Our current operating model ‘puts’ the citizen at the centre rather than doing it ‘by design’ when co-ordinating care. 3. ‘ A Partnership of all the talents ’ is not possible due to governance constraints and a lack of systems integration. 4. We have no means of integrating effort and information across our care system – including statutory, third sector, and citizen held domains.
Scottish Approach to Service Design Year 1 Year 2 FY 2019/20 FY 2020/21
GP-led SAS model acute secondary care (front care door) GP-led withMDT inter- Discharge therapists mediate meeting to assess N care data primary quality GP-led care ofeFI records inreach model access to mental eFI health pathways Care PRE- inspectorate Red review encounter social (Guidance/ Crossvia and screening care update support) referrals ACP social KIS care opportunities other home & day innovative care models homecare third current transport sector model OLDER PEOPLE’S benefits private PERCEPTIONS OF FRAILTY sector - Strong aversion to the term ‘frail’ housing telecare - Understood to be an irreversiblestate - Do not self-identify with the term ‘frail’ - Deep fear of losing independence, dignity and control over one’s life OLDER PEOPLE’S PERCEPTIONS DIFICULTY KNOWING WHAT YOU ARE OLDER PEOPLE’S - Fear of becoming a burden to their OF GERIATRIC ASSESSMENTS ENTITLED TO AND NAVIGATING PERCEPTIONS OF SUPPORT loved ones MULTIPLE SYSTEMS - For some, decline and loss of function - Lack of understanding of what it is - Impressions of support tended to veer are inevitable rather than preventable - Lack of understanding of the goal - Too many services and no easy way to towards the extreme (i.e. care homes), of the assessment find the right one therefore fear of losing independence and - Lack of awareness of risk factors and prevention strategies - Do not want to talk about problems - Conflicting guidance online control is a barrier to accessingservices - Belief that doctors should not be ‘bothered’ - Medical professionals are not seen by they think are not medical - Shortage of Link workers with ‘trivial’ or non -clinical issues - If living with long term condition(s), older people as the first port of call for DIFICULTY PROVING YOUR NEEDS may not want further medical - Tendency to look for their own solutions receiving help with everydaychallenges - Manual system takes long periodsfor intervention in their lives rather than external sources of support communicate between organisations - Low levels of understanding of the support - Services only readily available after available is a barrier to accessing services significant negative events occur – to maintain independence difficult to qualify preventatively Frailty: Language and Perceptions. A report prepared by BritainThinks on behalf of Age UK and the British Geriatrics Society. 2015. Available from: https://www.nursingtimes.net/Journals/2015/07/23/o/e/e/Age-UK---BGS---Frailty-Final-Report.pdf [Accessed 24th May 2019] G.Teal
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