Living and dying well with frailty A National Collaborative Enabling health and social care improvement
Living Well in Communities Enabling people to live well in their community for longer Identifying Accessing Planning for people before preventative the future crisis support
Frailty A form of complexity, associated with developing multiple long-term conditions over time leading to low resilience to physical and emotional crisis and functional loss leading to gradual dependence on care. Mild frailty Moderate frailty Severe frailty Not frail Low function and High resilience to does not recover shock with ability from physical or to recover emotional shock Rockwood, K. et al. Canadian Medical Association Journal. 2005;173:5 489-495
Why Focus on frailty? 15% 5% moderate severe frailty frailty 45% not frail 35% mild frailty 13.5 23.4 36.4 Average length of stay per unplanned admission 1.2 3.3 3.7 Average days lost to delayed discharge per admission 10 14 18 Average GP appointments in a year Average number of individually prescribed items 9 12 15 per year
Why Focus on frailty? mild moderate severe All frailty groups Unplanned bed days £1,172m £396m £482m £293m Community prescribing £430m £231m £137m £62m Outpatient appointments £412m £240m £118m £54m GP appointments £394m £212m £127m £55m Community nursing £138m £84m £44m £10m Extrapolated costs over 12 months for people 65 and over with frailty
Our mission The purpose of the Living and Dying Well with Frailty Collaborative is for participating teams to improve how they identify and enable people aged 65 and over to live and die well with frailty in the community.
Measures of success • Reduce hospital bed days for people aged 65 and over by 10%, per 1,000 population. • Reduce unscheduled GP home visits for people aged 65 and over by 10%, per 1,000 population. • Increase percentage of anticipatory care plans in the Key Information Summary (KIS) for people living with frailty by 20%, per 1,000 population.
Drivers for change Identify Plan for the Access Multidisciplinary people before future preventative team working a crisis support
Identifying people before a crisis Current planned Planned population population tools Community Acute
Planning for the future Jean’s experience Hospital Hospital admission Hospital admission for 16 days admission for 3 days for 32 days Moved to Social Care Death in Outpatient care home Assessment hospital Clinic for 39 days 52 bed days and total July August September October November December costs of £18,000 4 bed days and total May June July August September October costs of £7,100 Care Moved to Social Care Social Care Death in package care home assessment assessment Care home provided for 73 days Hospital admission for 4 days Margaret’s experience Data provided by ISD.
Access to preventative support Mild Moderate Severe Nutritional Reablement Bed based interventions intermediate care Exercise and physical Polypharmacy review Community-based activity geriatric services Smoking cessation Primary care MDT Palliative care Reduce alcohol Falls management Hospital at home Reduce social isolation Anticipatory care Anticipatory care planning planning Housing adaptations Immunisation Adult carers support planning
Multidisciplinary team working An MDT case review meeting is a structured conversation with a range of practitioners about a person who has complex issues, to ensure timely and individualised care and to agree a plan of action based on intended outcomes for the patient. Identify person with Discuss at MDT case Agree how to frailty review meeting proceed
Drivers for change Outcome Primary driver Secondary drivers • Case find people at risk using the e Frailty Index Identify people aged 65 and over • Create diagnosis for frailty living with frailty in the • Multi-dimensional assessment community. • Monitor change and deterioration over time • Anticipatory care planning conversations, Support people living with frailty including recording information in the Key Information Summary to plan for their future care needs, • Carer’s assessment and when appropriate, death. • Informal/Adult carers support planning • Key worker • Exercise interventions and physical activity Reduce unplanned hospital bed days • Lifestyle and nutritional interventions Support people living with frailty • Polypharmacy review Reduce unscheduled GP home visits to access preventative support in • Reablement Increase use of anticipatory care the community. planning and Key Information • Vaccinations Summary • Community-based geriatric services • Palliative and end of life care • Communication and collaboration within a multi-disciplinary team, including a Develop effective multidisciplinary multidisciplinary review • Understand what support is available in team working focused on person- communities and how to access support centred, preventative care. • Use quality improvement methods, including data over time, to drive improvement •
Benefits you will receive Clinical care benefits • Support to use and interpret the eFI through SPIRE • Improve quality of life for people living with frailty • Guidance on multi-disciplinary working • Guidance and materials to improve anticipatory care approaches • Guidance for adopting a realistic medicine approach • Improvement and analytical expertise
Benefits you will receive Professional development • Recognition for innovating identification and support in a community setting • Learn from clinical and topic experts • Opportunities to meet and learn from others • A structure to learn about quality improvement and how to apply it in your work
Participating teams Sponsors Away team membership: • Health and Social Care Partnership Lead • GP Representative • Quality Improvement Lead Home Team – health Away Team – Role and social care represents and • Data Lead Role professionals involved provides leadership • Two team members from GP in implementing the to the Home Team practices and community change ideas in the throughout the teams community collaborative. Coordinator
Timescales for application process Applications Teams informed open and MoU issued 29 April 2019 19 July 2019 17 June 2019 16 August 2019 Collaborative Application launched close
Collaborative key dates Learning session 3 Learning session 1 27 or 28 August 2019 27 February 2020 October 2020 June 2020 19 September 2019 Introductory Learning session 2 Learning session 4 WebEx
How to apply hcis.livingwell@nhs.net https://ihub.scot/living-and-dying-well-with-frailty @LWiC_QI
National collaboratives Frailty at the front Living and dying well door with frailty Individuals at Planned the front door population Community Acute
Thoughts and questions Presentation image credits – from the noun project
Electronic frailty index Abnormal Disease State Symptoms / Signs Disability Lab Value Anaemia & Heart Valve Parkinson’s Skin Activity Requirement Arthritis Diabetes Dizziness Polypharmacy Haematinic Disease Disease Ulcer Limitation for Care Deficiency Atrial Foot Peptic Stroke Sleep Social Hypertension Dyspnoea Housebound Fibrillation Problems Ulcer and TIA Disturbance Vulnerability Chronic Kidney Fragility Hypotension Peripheral Thyroid Urinary Hearing Vision Problems Falls Disease Fracture /Syncope Vascular Disease Disorders Incontinence Loss - Blindness Memory and Coronary Heart Heart Respiratory Urinary Weight Loss Mobility and Osteoporosis Cognitive Disease Failure Disease System Disease and Anorexia Transfer problems Problems
How the eFI works 13C4. Mild 1C16. Frailty Moderate 8HIE. N331N Frailty Severe 14AN. Frailty H37.. 16D..
Electronic Frailty Index 35% 15% Mild frailty 5% Moderate frailty Severe frailty 20% 70% 40% Risk of hospitalisation People registered with test GP practices aged 65 and over
eFI on SPIRE
eFI on SPIRE
eFI on SPIRE
eFI on SPIRE
Breakthrough Series Collaborative An improvement method that focuses on spread and adaptation of existing knowledge to multiple settings to accomplish a common aim. IHI Breakthrough Series whitepaper, 2003
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