dorset frailty toolkit - nihr clahrc wessex · 2017-12-08 · first dorset frailty toolkit a model...
TRANSCRIPT
[Typehere]First
DORSETFRAILTYTOOLKIT
Amodelfortheidentification,assessmentandcareplanningoffrailpatients
Version1.November2017
CONTENTS
Introduction………………………………………………………………………………………………………………………………………1
GPMultidisciplinaryTeamMeetings…………………………………………………………………………………………………2
MDTProcessChart……………………………………………………………………………………………………………………………3
TermsofReference…………………………………………………………………………………………………………………….…….4
MDTDiscussionTool…………………………………………………………………………………………………………………………6
RiskProfiling……………………………………………………………………………………………………………………………….…….7
eFI………………………………………………………………………………………………………………………………………….….…....8
Hub referrals / MDT data………………………………………………………………………………………………………….….….12
DailyAdmissions………………………………………………………………………………………………………………….………….13
TheDorsetCarePlan…………………………………………………………………………………………………….….…………….14
CGA………………………………………………………………………………………………………………………………………………...21
Outcomemeasures…………………………………………………………………………………………………………………………22
Mild Frailty / E-learning.…………………………………………………………………………………………………………….…….23
CaseStudy,Acknowledgements&References…………………………………………………………………………..……24
Appendices……………………………………………………………………………………………………………………………..….….25
Page|1
IntroductionFrailtyisdefinedbytheBritishGeriatricsSociety(BGS)as‘adistinctivehealthstaterelatedtotheageingprocessinwhichmultiplebodysystemsgraduallylosetheirin-builtreserves.’
Overrecentyears,frailtyhasbeenincreasinglyrecognizedasalongtermconditionanditisofparticularconcernbecauseindividualslivingwithfrailtyareatriskofdramaticdeteriorationintheirphysicalandmentalwellbeingafterevenapparentlyminorevents.Howeverthereisevidencethatindividualswithfrailtycanhaveimprovedoutcomesandpotentiallyreducedhospitaladmissionsifaperson-centered,goal-orientatedcomprehensiveapproachistaken.ThisissummarizedintheBGSdocument‘FitforFrailty’publishedin2014.
InOctober2016theWeymouth&PortlandLocalityweresuccessfulinabidtoreceiveayear’sfundingfromHealthEducationWessextodevelopandimplementamodelthatwouldenableustoprovideproactiveinterventionsforpatientsincreasinginfrailty.
Thistoolkitexplainstheprocessofongoingidentificationof‘atrisk’patientsusingdifferentinformationsources.ItcomplementsandenhancestherequirementsofthecurrentGPcontractrelatingtofrailty(July2017)andensuresthattheright,oftenunknownpatientsareidentified.ItalsosupportsthegoalsofIntegratedCommunityandPrimaryCareServicesensuringajoined-upapproach,reducingduplicationandenhancingpatientcare.
Itisintendedasapracticalguide;formalisingthestructureoftheMulti-DisciplinaryTeam(MDT)processwithstepbystepguidanceonriskprofiling,TheDorsetCarePlan(DCP)andanintroductiontotheComprehensiveGeriatricAssessment(CGA).
ThismodelisrecommendedtobedeliveredatalocalityleveltoenablestronglinksbetweenDorsetHealthCareUniversityFoundationNHSTrust(DHC)andPrimaryCare,butcanbeadaptedtobeusedwithinindividualpractices.
Introduction .......................................................................................................................................... 1
GP Multidisciplinary Team Meetings ..................................................................................................... 2
MDT Process Chart ................................................................................................................................ 3
Terms of Reference ................................................................................................................................ 4
MDT Discussion Tool .............................................................................................................................. 6
Risk Profiling .......................................................................................................................................... 7
eFI .......................................................................................................................................................... 8
Hub referrals / MDT data ..................................................................................................................... 12
Daily Admissions.................................................................................................................................. 13
The Dorset Care Plan ........................................................................................................................... 14
CGA ...................................................................................................................................................... 21
Outcome measures ............................................................................................................................. 22
Mild Frailty / E-learning ....................................................................................................................... 23
Case Study, Acknowledgements & References ....................................................................................24
Appendix 1: eFI formulae .................................................................................................................... 25
Appendix 2: Pareto chart .................................................................................................................... 26
Appendix 3: DCP additional examples ................................................................................................27
Appendix 4: Frailty Leaflets ..................................................................................................... 28, 29,30
Appendix 5: Frailty Poster ................................................................................................................... 30
Page|2
GPPractice-MDTMeetingsMDTmeetingsarerecommendedtoberunmonthlywithanidentifiedlistofpatientsfromriskprofilingandpatientsofconcernputforwardbyclinicians.
StructureofanMDT
ToensureanMDTmeetingissetuptoenableallteammemberstocontribute,thefollowingarerecommended:-
• AsuitablesizedroomtoseatallMDTmembers• GPSystemaccessavailableinthemeeting• AprojectortoenableallMDTmemberstoviewGPsystemandrelevantrecords• AnuptodatelistofalllinkworkersattendingthesurgeryMDTrepresentingtheirservice• MDTdatesagreedayearinadvancetoensurealllinkworkersplantheirdiariesand
guaranteeattendance• TheriskprofilingdatashouldbesenttoGPpracticesandlinkworkersaweekinadvanceof
theMDTtoallowadequatetimetogatheranybackgroundinformationthatmaybehelpfultothediscussion
• Allattendeesmustsignaconfidentialdeclaration• TheMDTtermsofreferenceshouldbesenttoalllinkworkers• AllsurgeriesshouldhaveanMDTcoordinator• Anominatedscribemustbeavailableinthemeetingtorecordtherelevantpointsonthe
MDTdiscussiontool-Thisshouldnotbethechairofthemeeting• TheChaircanbeaGPoracompetentalternative
Page|3
MDTProcessChartThefollowingchartdemonstratestheprocessfromriskprofilingtoMDToutcome
7/8dayspriortomeeting...theriskprofilingteam•RuneFIandHubreferralsreport•Provideclinicaltranslationofdata•ProducemanageablelistofpatientswhowouldbenefitfromMDTdiscussionormoredetailedreview&assessment
1weekpriortomeeting...LinkWorkersReviewdatasentbyriskprofilingteam&highlightanypatientstheywishtodiscuss
MDTCoordinatorForwarddatatoGPs/relevantPracticestaffCollatelistofpatientsidentifiedfordiscussionbyotherMDTmembers
MDTMeeting...•UseMDTdiscussiontooltemplatetoguideandrecorddiscussion•Makeuseofthebroadestrangeofprofessionalsasappropriate•Discussidentifiedpatients•Eachpatientdiscussedmusthaveaclearoutcomewithanamedpersonresponisiblefortheaction•MDTCoordinatortofollowupactions2weeksaftermeeting
SenddatatoSurgeryMDTCoordinator
&linkworkers
SendidentifiedpatientstonamedGPsforanyprep
work
Page|4
PrimaryCareMDT-TermsofreferenceThepurposeoftheMDTmeetingis:
• Toprovideamulti-disciplinaryforumforthediscussionandmanagementofrelevantpatients
• ToensurethatthepatientisatthecentreoftheMDTdecisionmakingprocess• Toensurethatthediscussionaroundeachpatientcoversallrelevantpoints,whichcan
befacilitatedbytheuseofaMDTdiscussiontooltemplate• Tomaintaincommunicationbetweenallorganisationsmakingupthemulti-disciplinary
teaminordertopromotebestpracticeandtoensuretimely,holisticindividualisedcare• Toagreeaplanofactionbasedonintendedoutcomesforthepatient.
Attendance:
• GPs• NursePractitioners/ECP’s• Communitymatrons• Districtnurses• Health&SocialCareCoordinators
(H&SCCO)• Palliativecarenurses
• ICRTmembers–physiotherapy/OT• CMHT–adultandolderpeoples• SocialServices• Administrationstaff/MDTCoordinator• Thirdsectorrepresentativeforappropriate
partsoftheMDT(Theyshouldnotbeinattendancewhendiscussingpatientsnotontheircaseload)
Expectationsofthechairperson:
• Thechairpersonmaybeaclinicalornon-clinicalteammember• Toensurethemeetingcommencesandfinishesontime• Tohavecollatedandreviewedinadvanceofthemeetingallrelevantdatasourcesincluding
(butnotexclusively):palliativecarepatients,admissionsdata,frailtyandhubreportsprovidedbytheH&SCCoordinatorandidentifiedpatientsfromanyofthemulti-disciplinaryteamsmembers
• ToreviewpreviousactionplansfromthelastMDTmeeting• Toeffectivelymanagethemeeting,takingintoconsiderationtimeconstraints,preventing
repetitionandensuringthatteammembersremainfocused,succinctandrelevanttoMDTworking
• Torelayanyrelevantinformationtothewiderteamonbehalfofanypersonsunabletoattend
• Toensurethatanyactionsgiventoabsentteammembersareconveyedtotheminatimelyandclearmanner
• Tosummarizethedecisionsandactionplanandensuretheyarerecordedaccurately.
Page|5
Expectationsofattendees
• Membersareexpectedtoattendandbepreparedtocontributebothactivelyandconstructivelytothemeeting
• Presentationofpatientsshouldclearlyandconciselyspecifythemainissuestoenableconstructivediscussiontotakeplace.Discussionshouldbepresentedwithobjectivity,brevityandwithclearpurpose
• Memberswhoareunabletoattendshouldsendtheirapologiesandanupdatetotheadministrator/chairpersonpriortothemeeting
• Toshowrespectforothersknowledgeandvalueequallytheinputofallinattendanceo Onlyonegroupmembertospeakatatimeo Tobemindfuloflanguageusedwhendescribingpatients,theirsignificantothers
andotherprofessionalso Tonotinterruptinappropriatelyo Tolisteno Topromoteasupportiveenvironment
• Toberesponsibleforthesafekeepingofanyidentifiableinformationprintedforthepurposeofthemeeting,andifnotrequired,tobehandedbacktotheadministrator/chairpersonforconfidentialdisposal
• Laptops/handheldelectronicdevicesareallowableonlyiftheyarenecessaryforinformingthemeeting
• AgenciesshouldbewillingandabletoacceptreferralsdirectlyfromtheMDT• Attendancefromserviceswillbemonitored.
Recordkeeping:
• AnominatedadminsupportpersonwillcirculatemeetingdatespriortothemeetingandwillcirculateallrelevantdocumentationtoallmembersoftheMDTatleast48hoursbeforethemeeting
• Ensurearegisterofattendeesiskeptalongwithrelevantconfidentialitydeclaration• Torecordthediscussioninanappropriateformatinthepatientsrecordsandbyuseofe.g.
MDTdiscussiontemplate• Torecordthedecisionsandactionplanassummarizedbythechairperson• Torecordthenominatedprofessional(s)tocompletetheactionplan.
Processes:
• MDTmeetingswilltakeplacemonthly,thedurationtobedecidedbytheindividualsurgery• PreparationfortheMDTmeetingwilltakeplaceaspertheMDTprocessesflowchart• PatientsfordiscussionwillbesubmittedtothesurgeryMDTadministratororchairpersonat
least24hoursinadvanceofthemeeting• Thechairpersonwilldeterminetheorderofdiscussioninvitingrelevantmulti-professional
teammemberstopresenttheiridentifiedpatients.
Page|6
MDTDiscussionToolTheMDTdiscussiontoolisrecommendedtobeusedduringthePrimaryCareMDTdiscussiontoenabletheconversationregardingthepatienttoberecordeddirectlyintotheir
notes.ItoffersaguidetosteertheMDTdiscussionensuringactionsandoutcomesarerecorded.
Reasonfordiscussionboxis
theonlyonethatisrequired
tobefilledinduring
discussion;therestofthe
templatecanbeusedas
necessary.Actionsshouldbe
recordedfollowingpatient
discussion.
Use‘Suspend’tocomeinand
outoftemplatetospeed
thingsup.
IfaDorsetCarePlanhasbeen
completedthentheclinical&
self-managementplanswill
bevisiblehere.
Page|6
MDTDiscussionToolTheMDTdiscussiontoolisrecommendedtobeusedduringthePrimaryCareMDTdiscussiontoenabletheconversationregardingthepatienttoberecordeddirectlyintotheir
notes.ItoffersaguidetosteertheMDTdiscussionensuringactionsandoutcomesarerecorded.
Reasonfordiscussionboxis
theonlyonethatisrequired
tobefilledinduring
discussion;therestofthe
templatecanbeusedas
necessary.Actionsshouldbe
recordedfollowingpatient
discussion.
Use‘Suspend’tocomeinand
outoftemplatetospeed
thingsup.
IfaDorsetCarePlanhasbeen
completedthentheclinical&
self-managementplanswill
bevisiblehere.
Page|6
MDTDiscussionToolTheMDTdiscussiontoolisrecommendedtobeusedduringthePrimaryCareMDTdiscussiontoenabletheconversationregardingthepatienttoberecordeddirectlyintotheir
notes.ItoffersaguidetosteertheMDTdiscussionensuringactionsandoutcomesarerecorded.
Reasonfordiscussionboxis
theonlyonethatisrequired
tobefilledinduring
discussion;therestofthe
templatecanbeusedas
necessary.Actionsshouldbe
recordedfollowingpatient
discussion.
Use‘Suspend’tocomeinand
outoftemplatetospeed
thingsup.
IfaDorsetCarePlanhasbeen
completedthentheclinical&
self-managementplanswill
bevisiblehere.
Page|6
MDTDiscussionToolTheMDTdiscussiontoolisrecommendedtobeusedduringthePrimaryCareMDTdiscussiontoenabletheconversationregardingthepatienttoberecordeddirectlyintotheir
notes.ItoffersaguidetosteertheMDTdiscussionensuringactionsandoutcomesarerecorded.
Reasonfordiscussionboxis
theonlyonethatisrequired
tobefilledinduring
discussion;therestofthe
templatecanbeusedas
necessary.Actionsshouldbe
recordedfollowingpatient
discussion.
Use‘Suspend’tocomeinand
outoftemplatetospeed
thingsup.
IfaDorsetCarePlanhasbeen
completedthentheclinical&
self-managementplanswill
bevisiblehere.
Page|6
MDTDiscussionToolTheMDTdiscussiontoolisrecommendedtobeusedduringthePrimaryCareMDTdiscussiontoenabletheconversationregardingthepatienttoberecordeddirectlyintotheir
notes.ItoffersaguidetosteertheMDTdiscussionensuringactionsandoutcomesarerecorded.
Reasonfordiscussionboxis
theonlyonethatisrequired
tobefilledinduring
discussion;therestofthe
templatecanbeusedas
necessary.Actionsshouldbe
recordedfollowingpatient
discussion.
Use‘Suspend’tocomeinand
outoftemplatetospeed
thingsup.
IfaDorsetCarePlanhasbeen
completedthentheclinical&
self-managementplanswill
bevisiblehere.
Page|8
EFIRiskprofilinginstructionsforRPTAdministrator–EFItool
SYSTMONE:
Tofind/runtheElectronicFrailtyIndexreport….
• OpentherequiredGPPracticeSystmOne
• Select‘Reporting’• Select‘MiscellaneousReports’• Select‘ElectronicFrailtyIndex
Report’• Goto‘Showtop’typein
percentageofpopulationyouwishtosearchandensurethat‘Percent’isselected(forriskprofilingyouwillneedtoincludeallpatientswithascoreof0.13orabove–thiscanbeachievedbysearchingfor100%ofpopulationanddiscardingthosenotrequiredorbyworkingoutapproximate‘frail’populationsforyourPractices)
• Select‘RunReport’• Oncethereporthasbeen
populatedrightclickonanypatient,select‘Table’then‘OpenasCSV’whichwillexportthetabletoanExcelSpreadsheetallowingdatatobemanipulated.
• OncedocumenthasopenedscrolldowntobottomofEFIlistanddeleteanypatientswithascorebelow0.13.
• DonotclosethePracticeSystmOneasyoumayneeditagainlater
• ***IfyouhaveaGPS1thatservesmultiplePracticeMDTsyouwillneedfurtherinstructions***
SystmOneEFIscoreguidance:
• Fit0–0.12• Mildfrailty0.13–0.24• Moderatefrailty0.25–0.36• SevereFrailty>0.36
Page|7
RiskProfilingRiskprofilingisaprocessofidentifyingpatientsthroughastructuredmethod;ensuringpatientswhoareatriskduetoanincreaseintheirfrailtyscoringarehighlighted.
TheElectronicFrailtyIndex(eFI)isanevidencebasedtoolrecommendedbytheBGStobeusedtoidentifyfrailtyinanidentifiedpopulation.TheeFIusesasetof36deficitsthatmayindicatefactorswhichincreaseapatient’schanceoffrailty,basedonReadcodesrecordedinaGPpractice.
TheeFIistheminimumstandardrequiredforriskprofilingyourpopulation.Toenrichthisprocesswerecommendyoualsoriskprofileusingadmissiondatafromyoursecondarycareservices,thisdataanalysiswillalsoassistcommunityteamstosatisfytheCQUINNtargetof‘Supportingproactiveandsafedischarge’whichaimstoreducelengthofstaytounder7daysforover65s.Admissiondataalsoallowsyoutolookforspecificconditionsthatrepresent‘frailtysyndromes’identifiedin‘FitforFrailty’asfalls,immobility,delirium,new/worseningincontinenceandsusceptibilitytosideeffectsofmedication.Datafromreferralstolocalityhubs/virtualwardcanalsobeusedtoaddvaluetoGPMDTs.Instructionsonhowtodothisareincludedinthetoolkit.
GPpracticeresponsibility
Fromthe1stJuly2017theGeneralMedicalService’scontractwillrequirepracticestoroutinelyidentifymoderateandseverefrailtyinpatientsaged65yearsandover.TheNHSFiveYearForwardViewidentifiesolderpeoplelivingwithfrailtyasoneoftheareaswheretheNHSfacesparticularchallenges.Practiceswillberequiredtouseanappropriatetoolandrecordtheappropriatediagnosisofmoderateorseverefrailtyinthepatientrecords.
Thisriskprofilingprocessisnotdesignedtogenerateanentirefrailtyregister.Itisamethodofidentifyingpatientswhoareincreasinginriskandmayrequireinputtoimplementproactive,preventativecarethanmayreduce,orinsomecases,reversetheirfrailtydeficits.
RiskProfilingTeam
ThefollowingguidancewillprovideinformationforHealth&SocialCareCoordinatorsorotherappropriatepracticebasedstaffmemberonhowtorunthenecessaryreportstoriskprofileapopulation.InadditiontothisitprovidesguidanceforCommunityMatronsorotheridentifiedclinicianstotranslatethedatawhichaddsvaluetousinganelectronictoolandbringsclinicalreviewintotheprocessasnoriskprofilingtoolis100%sensitive.
Theriskprofilingteam(RPT),dependingonyourchosenapproachoflocalityorpracticelevelcoordinationshouldbemadeupofthefollowingteammembers:
Localityteam
Surgeryteam
• Health&SocialCareCoordinator(RPTadministrator)
• CommunityMatron/OtherClinician(RPTClinician)
• SurgeryMDTCoordinator
• GP/PracticeAdvancedNursePractitioner(RPTClinician)
• SurgeryMDTCoordinator(RPTadministrator)
Page|9
• OpentheEFIspreadsheet
• YouwillnoticethatcellsF&GonCurrentEFIlisttabarealreadypopulatedDONOTamendthesecellsastheycontainformulaewhichmakeyourjobmucheasier!
• PleasenotethatthefirsttimeyouruntheEFIyouwillonlyneedtocopyandpasteyour
S1/Emislistinto‘CurrentEFIlist’tab
• Select‘PreviousmonthEFIlist’tabandclearcontentsofpreviousEFI
• Select‘CurrentEFIlist’tab(ensurethat‘Diff’columnfilterisremoved)selectcolumnsA-E,
copyandpasteinto‘PreviousmonthEFIlist’thenclearcontents
• GobacktoyourspreadsheetthatcontainsyournewlypopulatedEFIlistandcopyand
pasteinto‘CurrentEFIlist’tabyouwillnoticethatthecolumnsF&Ghavepopulated
themselves
• Alwayscheckthattheformulaearecorrect-pleaserefertotheformuladocumentin
Appendix1• Filter‘Diff’columnanddeselect‘0’andanyminusscoresthenclick‘OK’
• CopyandpastethepatientsintoanewtabandrenameittoreflectMDTmonth.Youwill
onlyneedtoincludepatientswitha‘severe’ormoderate’score
• Younowhaveatablethatonlyshowspatientswheretherehasbeenachangesincethe
lastMDT
• Savedocument.
• IfyouhaveaVirtualWardSystmOneandMDTcaseloads…o Registerpatients
o Select‘Other’asReferralsource
o Select‘MDT–Frailty’asPrimaryReferralinReason
o SelectappropriatePracticeMDTasCaseload
o WhencompletingInfoGathering&ReferralScreeningtemplateensurethatyou
recordIncreasedEFIscoreasreasonforreferralandincludeifthepatienthasa
careplan,whatfrailcategorytheyareinandwhethertheyhaveincreasedby
category
o InformRPTclinicianoncepatientsareregisteredtoS1andreadyforclinical
input.
• IfyoudonothaveaVirtualWardSystmOne…o InformRPTclinicianthatEFIspreadsheetiscompleteandensurethattheyhave
accesstodocumentsotheyareabletorecordtheirclinicalinput.
ItisrecommendedthattheRPTadministratorEFIinputiscompleted8dayspriortoMDT.
FollowingclinicaltranslationofdatathenextdayRPTadministratortorunHubreferralsreport.
EFISPREADSHEETEXAMPLE/INSTRUCTIONS
YouwillbeprovidedwithaspreadsheetthatyoureFIlistcanbetransferredintothat
will identify patients with an increased eFI score using the VLOOKUP function and
utilisesconditionalformattingtocolourcodescoresaccordingtofrailtycategories.It
canalsobesetuptoidentifypatientswithcareplans/incarehomesetc.
Page|9
• OpentheEFIspreadsheet
• YouwillnoticethatcellsF&GonCurrentEFIlisttabarealreadypopulatedDONOTamendthesecellsastheycontainformulaewhichmakeyourjobmucheasier!
• PleasenotethatthefirsttimeyouruntheEFIyouwillonlyneedtocopyandpasteyour
S1/Emislistinto‘CurrentEFIlist’tab
• Select‘PreviousmonthEFIlist’tabandclearcontentsofpreviousEFI
• Select‘CurrentEFIlist’tab(ensurethat‘Diff’columnfilterisremoved)selectcolumnsA-E,
copyandpasteinto‘PreviousmonthEFIlist’thenclearcontents
• GobacktoyourspreadsheetthatcontainsyournewlypopulatedEFIlistandcopyand
pasteinto‘CurrentEFIlist’tabyouwillnoticethatthecolumnsF&Ghavepopulated
themselves
• Alwayscheckthattheformulaearecorrect-pleaserefertotheformuladocumentin
Appendix1• Filter‘Diff’columnanddeselect‘0’andanyminusscoresthenclick‘OK’
• CopyandpastethepatientsintoanewtabandrenameittoreflectMDTmonth.Youwill
onlyneedtoincludepatientswitha‘severe’ormoderate’score
• Younowhaveatablethatonlyshowspatientswheretherehasbeenachangesincethe
lastMDT
• Savedocument.
• IfyouhaveaVirtualWardSystmOneandMDTcaseloads…o Registerpatients
o Select‘Other’asReferralsource
o Select‘MDT–Frailty’asPrimaryReferralinReason
o SelectappropriatePracticeMDTasCaseload
o WhencompletingInfoGathering&ReferralScreeningtemplateensurethatyou
recordIncreasedEFIscoreasreasonforreferralandincludeifthepatienthasa
careplan,whatfrailcategorytheyareinandwhethertheyhaveincreasedby
category
o InformRPTclinicianoncepatientsareregisteredtoS1andreadyforclinical
input.
• IfyoudonothaveaVirtualWardSystmOne…o InformRPTclinicianthatEFIspreadsheetiscompleteandensurethattheyhave
accesstodocumentsotheyareabletorecordtheirclinicalinput.
ItisrecommendedthattheRPTadministratorEFIinputiscompleted8dayspriortoMDT.
FollowingclinicaltranslationofdatathenextdayRPTadministratortorunHubreferralsreport.
EFISPREADSHEETEXAMPLE/INSTRUCTIONS
YouwillbeprovidedwithaspreadsheetthatyoureFIlistcanbetransferredintothat
will identify patients with an increased eFI score using the VLOOKUP function and
utilisesconditionalformattingtocolourcodescoresaccordingtofrailtycategories.It
canalsobesetuptoidentifypatientswithcareplans/incarehomesetc.
Page|11
7. Lookinthetabbedjournaltoestablishanycontactoverthepastmonth8. Identifyanyadmissions,infections,falls,delirium,exacerbationofLTC,deteriorationinconditionor
increasedfrailty9. Reviewmedicationstoidentifyriskofpolypharmacy(specifymedstoreviewifrelevant),identify
weightloss,newdiagnosis,increaseincareneeds10. CheckifaDorsetCarePlanrequirescompletingorupdating.Thisshouldincludeaclearescalation
plananddescriptionofpatient’sbaseline11. Reviewanyletterfromaspecialistthatprovidesinformationwhichmayaddtothecurrentpicture12. HighlightifaRockwoodscoreneedstobecompleted13. Recordanythingsignificantbyclickingon‘hubdashboard’followedby‘quicknote’andsummarise
yourfindings14. IfthepatientdoesnotrequireanMDTdiscussion–Save,admintemplate,endreferral,usualplaceof
residence,treatmentcompletedthensaveandrefreshlist15. IfthepatientdoesrequireanMDTdiscussion,save,admintemplatethensave16. Whenyouhavelookedthroughthewholelist,youwillhaveoneshorterlistofpatientsthatrequire
MDTdiscussion17. EmailRPTadminmembertonotifythatthistaskhasbeencompleted18. Theywillthencompileanemailwiththenamesofpatientstobediscussedalongwiththecomplete
listofpatientswhohavebeenraisedthatmonthduetotheirEfi,anadmissionorreferraltothehub.ThiswillbeattachedtoinformationsenttothePractice.theGPpracticeinformation.
Page|10
ClinicianGuidanceontranslatingdata
Allocatingtimeforriskprofiling–Theidentifiedclinicianwillneedtoallocatetimewithintheirdaythese
pointsareguidanceonhowthiscanbedone
• KeeparecordofallriskprofilingpreparationdatesandyourlinksurgeryMDTdates• Blockouttimeinyourdiarytocompletethedataanalysisonthepreparationday• Theadministrationmemberoftheriskprofilingteam(RPT)willensureyouhavethedatainyour
inboxthedaybefore• Aimtoreturnthedatacompletedtoadministrationmemberoftheriskprofilingteambymiddayon
thesameday.
Howtotranslatethedata/riskprofilingforEfiIfyouareNOTusinghub
module
Monthly
1. TheadministrationmemberoftheRPTwillhaveprovidedyouwithalistofdataforyoutotranslatedrawnfromtheElectronicFrailtyIndex(Efi)
2. Thedataincludespatientswhohave‘risen’orare‘new’onthelist.Itisbrokendownintomild(green),moderate(yellow)andsevere(red)frailtycategories.Thecolourcodingwillhelpidentifypatientswhohave‘jumped’upacategoryorwhohave‘risen’withintheircategory
3. AccesstheGPmodulesforyourpracticesandlookupthepatient4. Lookinthetabbedjournaltoestablishanycontactoverthepastmonth5. Identifyanyadmissions,infections,falls,delirium,exacerbationofLTC,deteriorationinconditionor
increasedfrailty6. Reviewmedicationstoidentifyriskofpolypharmacy,identifyweightloss,newdiagnosis,increasein
careneeds7. CheckifaDorsetCarePlanrequirescompletingorupdating.Thisshouldincludeaclearescalation
plananddescriptionofpatientsbaseline8. Reviewanyletterfromaspecialistthatprovidesinformationwhichmayaddtothecurrentpicture9. HighlightifaRockwoodscoreneedstobecompleted10. Recordanythingsignificantintheappropriatecolumnonthedatasheets11. Highlightpatientsthathavesignificantchangesthatwouldbenefitfrombeingdiscussedatthe
surgeryMDT.
HowtotranslatedataviathehubmoduleinSystmOne
1. YouwillreceiveanemailfromtheadministrationmemberoftheRPTtellingyouyourEficaseloadisreadytoviewonthehubmodule
2. Logintothehubmodule3. Clickoncaseloads4. LookundertheMDTcaseloadforyoursurgery–hereyouwillfindthelistofpatientswhohave
increasedinfrailtyoverthepastmonth(seepoint2inthesectionabove)5. Workdownthelistandretrievetherecordsforeachpatient6. TheAdminRPTmemberwillhaverecordedinthepatientnotesiftheyare‘moderate’or‘severely’
frail,iftheyhavejumpedacategory,iftheyhaveaDorsetCarePlan(ornot)andiftheyareanin-patient
Page|13
DailyAdmissionsRiskprofilingadmissiondataensurespatientsadmittedduetofrailtysyndromesarebeingidentifiedinaproactivetimelyway.ThefollowingcriteriaisbasedonacuteadmissiondatabetweenApriltoMarch2015/16&2016/17andfocusesonthetopreasonsforadmissionthatrelatetofrailty*SeeAppendix2
RiskProfilingCriteria:
Ø Over65andoneofthefollowing:Ø AdmissionforafallorUTIØ 2ormoreadmissionsinthepastyear
RiskprofilinginstructionsforRPTAdministrator–DailyAdmissions
Youwillneedtohaveaccesstodailyadmissionsalertsemail,acutehospitalsystemandtheHubS1tocompletethistask.(IfyoudonothaveaHubs1thenyoucanstillcarryouttaskbutwillneedtocreateaspreadsheettokeepyourdata)
• Opendailyadmissionsalertsemailandenableediting(saveasrequired)• Select‘Data’tabandclickon‘Sort’buttonthenselectSortbyDOBandok• Onlyover65’sneedtobeincludedsoallotherpatientrowscanbedeleted.In2017a65y/owould
havebeenbornin1952• SelectColumnCthenselect‘ConditionalFormatting’,‘HighlightCellRules’,‘DuplicateValues’then
‘OK’• DeleteduplicateNHSnumbersonly–donotdeleteentirerow• Filter‘Admissionspreviousyr’columnanddeselect‘0’&‘1’• RegisterpatientstoS1
o Select‘Other’asReferralsourceo Select‘MDT–Frailty’asPrimaryReferralinReasono Select‘Admissions’asCaseload
• Gobacktodailyalertsheetandun-filter‘Admissionspreviousyr’column• Filter‘InitialComplaint’columnandselect‘FALL’and/or‘UTI’• Repeatabovestepsforthesepatients,theydonotneedtoberegisteredtwiceifalreadyonfor2+
admissions• OpenandlogintoacutehospitalsystemtofindrelevantinformationtoberecordedinInfoGathering
&ReferralScreeningtemplateensuringthatyourecordtheadmissioncriteriaasreasonforreferral.
Thisdatawillbeanalyseddailybytheriskprofilingteam.
Ø Ifthepatientisstillanin-patientthewardiscontactedtoseeif:-thehubcanfacilitatedischarge,toaddinformationalreadyknowaboutthepatientortoidentifyreasonforongoingadmission
Ø Alinkisestablishedwithourserviceandthewardandrequestedthatwearekeptupdatedifanongoingadmissionisrequired
Ø IfthepatientisalreadyathometheRPTclinicianwillreviewdischargeletterandcontactpatient/carertoensurepatientisrecoveringwellandarrangeavisitwithin48hoursifappropriatetorevieworasurgentifrequired
Page|12
Hubreferrals/MDTdataHubreferrals/MDTinstructionsforRPTAdministrator-YouwillneedaccesstotheLocalityHubSystmOnemoduleandbeabletoaccessClinicalReporting
PleasenoteifyoudonothaveaccesstoHubS1,youwillnotbeabletocompletethisstageandinsteadwillneedtosendyourEfi&admissionsdatatoGPPracticeandlinkworkers.
TocreateanMDTHubreferralsreport…
• Select‘Reporting’• Select‘ClinicalReporting’• Select‘LocalReports’• Select‘New’• NameyourreportandcreatenewcategorycalledMDT• Openthe‘Registration’folder• Select‘GP’then‘RegisteredGPpracticeattimeofevent’andsearchforthePracticerequired.• Select‘RegistrationStatus’andensurethat‘Deceased’‘Active’andDeducted’areallticked• Openthe‘Clinical’folder• Select‘EventDates’then‘Eventdate’andentertheappropriatetimeperiod• Select‘ReferralsIn’then‘Areferralinexists’andensurethat‘Bothnewandre-referrals’and‘Limittoreferralsto
here’areticked• Select‘Ok’atbottomofscreenandyourreporthasbeencreated
Tofind/runtheMDTHubreferralsreport….
• OpenHubSystmOne• Select‘Reporting’• Select‘ClinicalReporting’• Select‘LocalReports’andclickonthetriangletotheleft-handside• Select‘MDT’• RightclickontheappropriatePracticereportandselect‘Amend’• Scrolldownto‘EventDates’andchangetheeventdateto‘After’thedatethepreviousreportended• Changethenameofthereporttoreflectthetimeperioditnowshows(reportwillonlyincludedaterecorded
before5pmthefollowingday)• Select‘Ok’• Rightclickonyourreportandselect‘Run’• Oncegreentickhasappearednexttoreportitisreadytoview(ifthisistakingawhilethenclickon‘Refresh’)• Rightclickonyourreportandselect‘BreakdownResults’• Dropdown‘ReferralsIn’listandtick‘ReferralID’&‘Reasonforreferral’thendropdown‘Registration’listand
tick‘RegisteredGP(GMS)’• Select‘Refresh’andthen‘Close’• Rightclickonyourreportandselect‘Showpatients’• Select‘SaveallpagestoCSV’whichwillopenaspreadsheet• OpenMDTdatadocument• OpenandrenameanewtabtoreflecttheMDTmonthyouareworkingon.• Copyandpasterelevantinformationfromyour‘Showpatients’spreadsheetintoMDTdatadocument• Ifapatientappearsonlistmorethanonce,condenseinformationintoonerow.• Highlightpatientsidentifiedasneedingfurtherdiscussioninred.(PatientsidentifiedwillbethoseleftinHub
MDTcaseloadorsenttoyoubyCommunityMatrons)• SendMDTdatatoGPPracticeandlinkworkers
Page|15
ThepagenumbersandscreenshotsrefertothePrimaryCareSystmOneversionoftheDorsetCarePlan.HoweverthisisavailableforPrimaryCareEMISsystemsandforDorsetHealthCareCommunitySystmOnemodules.Thedescriptionsandexamplesarerelevanttoallversions.
PAGE3:SummariesandFunctionalStatus
Patients/carersperspective
Recordtheviewsofthatpatientand/orcarer–whataretheirprioritiesandhowwouldtheydescribetheirhealth?Theirprioritiesmaybenon-medical.Dotheywantalltreatmentsaimedatprolongingtheirliferegardlessofoutcome,oristheirprioritycomfortandqualityoflife?
e.g.Bobfeelsthatalthoughhedoesgetseverechestinfectionsattimes,hisqualityoflifeisgoodin-betweentheseandheisstillabletodomostofthethingshewantstodo.Ifhebecomesseverelyunwellhewouldwantadmissiontohospitalforanyintensivetreatmentaimedatprolonginghislife.
PAGE1:CoreCarePlan
RecordnamedGP,admissionavoidancecareandreviews,otherprofessionals
involved.
PAGE2:Carers&Relationships
Carers,occupationandnextofkindetails
Page|14
TheDorsetCarePlan
TheDorsetCarePlan(DCP)isadetailedtemplatewhichcanallowrecordingofacomprehensivemanagementplanandbackgroundhistoryforanypatient(althoughitisparticularlyrelevanttofrailorcomplexpatients).Itwasdevelopedtoallowastandardisedapproachtoadmissionavoidance/advancemedicalcareplanninganditcanincludeanyorallofthefollowinginformation:thepatient’sprioritiesforcare,asummarybaselineforthatpatient,anadvancecareplan,atreatmentescalationplanandself-managementadvice.Thefieldscloselylinktotheenhancedsummarycarerecord(highlightedonthetemplate)allowingittobesharedeasilywithotherHealthCareprofessionalsusingdifferentITsystems.
ThingstothinkaboutwhenconsideringwhetherapatientissuitableforaDorsetCarePlan:
• DoesthispersonhavecomplexneedswhereaDCPwouldhelpanexternalpersonmanagethoseneeds?
• Doesthispersonneedinstructionstohelpthemmanagelongtermconditionsintheformofasharedcareplan?
• Isthisperson’sconditionlikelytodeteriorateorchangequicklyanditisimportantthatbaselineinformationisknown?
• Isthereaclearnonescalatoryplanthatisessentialtoshare?
WhencompletingaDorsetCarePlan,byclickinginanyofthefields,itispossibletoseewhatdatahasalreadybeenenteredlinkedtothatcode(inthewindowonrightsideofscreen).Thisallowsdifferenthealth-careteammemberstocompletedifferentpartsofthecareplan.Ifthelastentryontherighthandsideiscompleteandaccurate,thereisnoneedtore-enterthisinformationinthecareplan.Ifthelastentryisincompleteorhaschanged–eitherre-enterallnewdataorrightclickontheentryandpressctrl+C.Thenclickinthedataentryboxandpressctrl+V–theentrywillbecopiedacrossandcanthenbeamendedasrequired.RememberthatthemarkedreadcodeslinktotheeSCRandeveryentryisvisible.Onlyre-enterdataifthereisachangeornewinformation.Theprintablecareplangeneratedattheendofthetemplatewillpullinthelastentryintoitregardlessofwhenitwasadded.
Page|17
PAGE4:AdmissionAvoidanceCarePlan(Pleasenotepages4&5areonthesamepageontheDHCversion)
Clinicalescalationplan
Thiscantakeavarietyofformsdependingonthepatientandtherisks.Considergivingguidancerelatedtochronichealthproblemsandsuggestedactions.Considerlikelyscenariosfordeterioration(includingbutnotexclusively–stroke,MI,infection,fall,suddenunexpecteddeteriorationinhealth,poororalintake)andthelevelofcareapatientwouldwantinthatsituation.Youcouldusethefollowingcategoriesofcare–Intensive(allacuteinterventionsincludingintensivecareifnecessary),Hospital(admissiontohospitalforanyinterventionsapartfromITU/HDU),Home(careinthehomeonlyincludinganytreatmentsthatarepossibleinthecommunity),Comfort(palliativemanagementratherthanactivetreatment).Considermajorhealthproblemsthatmayneedintervention.
e.g.Bobpreferstobetreatedinhishomewhensafetodoso,butheisacceptingofhospitaladmissionifitisclinicallynecessaryandappropriate.
Heisatriskofchestinfections/infectiveexacerbationsofCOPD.Heisawareofsignsofdeterioration(increasedcough/sputum,increasedshortnessofbreath).ThesesometimesrespondwelltooralAmoxicillinandashortcourseofPrednisolone,howeversometimeshedeterioratesrapidlyandwillneedconsiderationofhospitalisationifhissatsdrop(hisusualsatsare93-95%)orifheshowssignsofsepsis.Heisagreeablefortreatmentwithintravenousantibioticsandconsiderationofnon-invasiveventilationsupportifthisisnecessaryandappropriate.
Hehasoccasionalfalls(relatedtoposturalhypotension&residualweaknessfromapreviousCVA).Ifhefallsandcan’tgetup,hehasaCareline.Suspectedfracture/woundswillneedassessmentandappropriatetreatmentinA&E.
HehashadaCVApreviouslyresultinginmildresidualrightsidedweakness.HewouldwanthospitaladmissionforafurtherCVA,althoughhewouldnotwantartificialfeedingandhasanadvancedirectivetorefusetreatmentrelatingtothisscenario.
Atrialfibrillation–rateiscontrolledwithlowdosebisoprololandheisanticoagulated–atpresentthebenefitsoutweightherisks,butthismayneedreconsideringiffallsincreaseinfrequency/resultinsevereinjury.
Intheeventofasuddenunexpecteddeteriorationinhealth–hospitaladmissionwouldbeacceptedifhecouldnotbesafelyinvestigatedortreatedathome.
Hyponatraemia–previousepisodeofsymptomatichyponatraemiasecondarytoomeprazole.ConsidercheckingU&Esurgentlyifhedevelopssignsofrecurrenthyponatraemia.
Page|16
PAGE3:continued
HealthProfessionalssummary
Abriefdescriptionofthepatient–wheredotheylive,howmuchsupportdotheyneedtomeettheircareneeds(ifany),whatarethemainriskstodeteriorationofhealth?
e.g.Boblivesinhisownbungalowwiththesupportofhisdaughterwhohelpswithshopping,cleaningandcollectingmedication.HeisstillmanagingtocompleteallotherADLsindependentlybutthisisgettingharderandhemayneedasmallcarepackageinthenextfewmonths.HehasCOPDandhasbeenadmittedtohospitaltwiceinthelastyearwithexacerbations,despiteprompttreatmentwithhisrescuemedication.Earlytreatmentdoeshoweverpreventsomeadmissions.
FunctionalStatus
Usethisboxtodescribethepatient’sabilitytoself-care–considerany/allofthefollowingareas-mobility,continence,abilitytowashanddress,abilitytoself-feed,skinintegrity
e.g.Bobisindependentlymobilewithoneortwosticks,heisfullycontinent.Heisindependentwithshoweringanddressing,butisstartingtofindthisquitedifficultandisconsideringthathemayneedacarertoassisthim.Heeatsanormaldietandisabletoreheatreadymeals,butnottoprepareamealhimself.
Furtherinformation–tickboxes&clickonpenciltorecordfurtherinformation
Rockwoodfrailtyscore(PleasenotethisisnotontheDHCversion)ClickonthisboxandtheRockwoodscoring(andguidance)willpopup–chooserating1-9andifappropriatemild/moderate/severefrailtyfromdropdownbox.
Page|19
(PleasenotethePEACEinformationisnotontheDHCversion)
LinktoPEACEform(thresholdsofcareforpatientsincarehomeswithandwithoutcapacity–alotofthisinformationcouldberecordedintheclinicalescalationplan,butitisalsoincludeshelpfulguidancenotesforcarehomere:Intensive/Hospital/Home/ComfortthresholdsofcareandhowtoachieveHomeandComfortoptions).Thisisausefuldocumentforanursinghomeandgivesstructuretodecisions,howeveritdoesnotuploadorlinktotheenhancedSummaryCareRecord.
PAGE5:AllowaNaturalDeathdecisions&ADRT
Optionstorecorddecisionsrelatingtoresuscitationandadvancedirectivesto
refusetreatment.
PAGE6:Palliativecare
ToensurethatthepalliativecaresectionisaddedtothecompletedCarePlandocument,
tickthis‘anticipatorypalliativecare’boxhighlighted.
OptionstorecordGSFstatus,preferredplaceofdeath,linkstocreatepalliativecaredrugcharts,
specialmessageformsforoutofhours/ambulanceservice,prescribingfor
anticipatorymedication.
PAGE7:Dementia
Youmusttickthe‘dementiacareplanagreed’boxtoincludethisinthe
completeddocument
RecorddetailsaboutDOLS,Powerofattorney&capacityhere
Page|18
PAGE4:continued
Self-managementplan
ThisisguidancefromHealthCareprofessionaltothepatient/carers.Whatsymptoms/signsshouldtheylookoutfor,whatshouldtheydoifaparticularsymptomstarts.Whenshouldtheycallforhelpandwhoshouldtheycall?
e.gBob–ExacerbationofCOPD–ifyoudevelopyourusualsignsofachestinfection(increasedcough/sputum/breathlessness)–thenstartyouremergencyantibioticsandprednisolone.Re-orderfromGPsurgery.IfnotimprovingasusualoryoursymptomsareworsethanusualthenmakeanemergencyappointmentwithGP/requestvisit/outofhourscall111.
Foranyotherurgenthealthproblems-makeanemergencyappointmentwithGP/requestvisit/outofhourscall111
Forroutinehealthproblems–makearoutineappointmentwithyourGP
Ifyouhaveaseveresymptomandfeelyourlifemaybeatriskfromit,thencall999orpressyourCarelinebuzzer
Ifyoufallandcan’tgetup,thencall999orpressyourCarelinebuzzer.
Whatistheirpreferredplaceofcare?(dropdownbox)
Page|21
ComprehensiveGeriatricAssessmentThegoldstandardforthemanagementforfrailtyinolderpeopleistheprocessofcareknownasComprehensiveGeriatricAssessment(CGA).Itinvolvesaholistic,multidimensional,interdisciplinaryassessmentofanindividualbyanumberofspecialistsofmanydisciplinesinolderpeople’shealthandhasbeendemonstratedtobeassociatedwithimprovedoutcomesinavarietyofsettings(BGSJune2014)
Notallpatientsrequireassessmentsfromeverymemberofthemultidisciplinaryteamandonwardreferralsmayberequiredfollowingtheprocess.TheassessmentiscommonlybuiltupoveraperiodoftimewithinputfromdifferentmembersofthemultidisciplinaryteamandthisiswhyasharedtemplateacrossthevariousHealthCareservicesisidealtoachievethisandtoreduceduplication.
TheoutcomeoftheCGAprocessistheformulationofapatient-centredlistofneedsandissuestotackle(anactionplan)andanindividualisedcareandsupportplan(e.gtheDorsetCarePlan)andarecommendationforfrequencyofreview.
ComponentsofaCGA
� PhysicalSymptoms� MentalHealthsymptoms� Leveloffunctionindailyactivityforpersonalcareandlifefunctions� Socialsupportnetworkscurrentlyavailable(formalandinformal)� Livingenvironment� Levelofparticipationandindividualconcerns/anxieties–whatisimportanttothem� Compensatory mechanisms and resourcefulness the individual uses to respond to
havingfrailty.
OutcomesofaCGA
� Formulation of a patient-centred list of needs and issues to tackle includingmedicationreview(anactionplan)
� Individualisedcareandsupportplan(e.gtheDorsetCarePlan)� Recommendationforfrequencyofreview.
FitforFrailty(BGS2014)recognisesthatresourceswouldnotallowallpatientswithfrailtytohaveafullCGAassessment,butsuggeststhatallpatientswithfrailtyshouldatleasthaveaholisticmedicalreviewbytheirGPbasedontheprinciplesofCGAwiththesameoutcomesasafullCGA(actionplanandDorsetCarePlaninthismodel).
Page|20
PleasenoteontheDHCversiontherewillbeanadditionalboxtoticktostateconsenthasbeen
gainedforthepatient’srecordstobesharedontheenhancedsummarycarerecord.Therewill
alsobeanautomatedtasksenttotheGPwhentheDCPhasbeenamendedorcompletedinthe
communitysettingastheGPistheonlyprofessionalwhocanchangeapatientsconsentsettings
Throughoutthecareplantemplatethereareoptionstoopenupadditionalformsforcompletionwhenrelevantandextraguidance
e.gSAILform,STOPPSTARTtool
*PleaseseeAppendix3forfurtherexamplesonhowtocompletetheDorsetCarePlan
PAGE8:Problems,medication
Anopportunitytoreviewmedicationandproblemlist–medicationscanbealteredfromthisscreenandproblemlistcanbeeditedifsomeproblemsneedtobemovede.gmajoractivetomajorinactive
Recorddetailsaboutabilitytomanagemedication
PAGE9:ConsenttoShare
Codingpageforconsenttoshareandconsent(ordissent)forcoreandenhancedsummarycarerecord
PAGE10:PrintCarePlan&FinalSteps
FinalpagetoallowcreationofapersonalisedDorsetCarePlandocument(bytickingthebox)
Page|23
MildFrailty/E-Learning
AlthoughtheBritishGeriatricSocietyadvisesagainstpopulationscreeningforfrailtyduetolackofevidenceofpositiveoutcomes,weneedtobemindfuloftheearlywarningsignsofdevelopingfrailtyandbeabletoachievethegoalof'assessingindividualsforfrailtyateveryHealthCareencounter.'DorsetHealthCarehasafrailtymodulethatisrecommendedtobecompletedbyallstaffandcanbeaccessedbytheE-hub.Itprovidesabasiclevelofinformationtoincreasetheknowledgeofallstaffmemberswhocomeintocontactwithpatientswhoarepotentiallyincreasinginfrailty.
ThismodulehasnowalsobeenmadeavailableontheCCGintranet,GPpracticesareencouragedtopromotethecompletionofthismodulebyallreception/adminandclinicalstaff.Thiscanbeaccessedbyhttps://intranet.dorsetccg.nhs.uk/localities/frailty-elearning.htm.
Wehaveprovidedaseriesofleafletsonlivingwithfrailty,assessingforfrailty(usingavalidatedtoolcalledPRISMA7)advancecareplanningandearlyself-help.Thesepatientscanbewellsupportedbythirdsectorearlyhelpandofcourseexerciseandbalanceclassesaretheonlyinterventionthathasshownadefiniteabilitytopartiallyreverseorslowtheprogressionoffrailty.Wehopethatthesetoolswillgiveyousomeadditionalresourcestohelpdeveloppracticeandlocalityspecificsupportandidentificationofthemildlyfrail.*PleaseseeAppendix4
Page|22
OutcomeMeasures
Aim
Theaimofthisworkistoreduceunplannedadmissionsforpatientsover65identifiedasbeingmoderateorseverelyfrail
ProcessMeasures–Thesemeasuresdefinetheprocessimplementedtoachievetheintendedoutcome
• Patientsidentifiedasmild/moderateandseverelyfrail• Rockwoodscore• CGA• DorsetCarePlan
Outcomemeasure–TheseoutcomemeasurescanbecollectedbyrunningreportsontheGPsystemorfromdailyacuteadmissiondatefromsecondarycare
• Numberofunplannedadmissions• Lengthofstay• Preferredplaceofcareachieved• GP/OOHContacts• Toallowforquantitativedatafriendandfamilyauditscanalsobeincluded
Page|25
Appendix1–eFIformulaeIfthereiseveraproblemwithanyofyourformulapleasecheckthissheetsoyoucancorrectanyerrorsthatmayhaveoccurred.
PleasenotethathighlightedcellnumbermaynotalwaysbeA2–itwillbewhichevercellcontainsthefirstNHSnumberinyourlist
Ifyouneedtoamendformulamakesureyoudragtheformuladownsoitamendsallcellsnecessary
PrevMDTscore=IFERROR(VLOOKUP(A2,'PreviousmonthEFIlist'!A:E,5,FALSE),"Notonlist")
Diff=IFERROR(SUM(E2-F2),"-")
Page|24
CaseStudy
NHSEngland.“Nowwehavehelp”https://www.youtube.com/watch?v=Y9hYaD201rI
Acknowledgements
Authors
DrLauraGodfrey–WeymouthElderlyCareService
EmmaWinterburn–CommunityMatron/ProjectLead
KatieScourfield–Health&SocialCareCo-ordinator
WewouldliketoextendourthankstoDorsetHealthCareUniversityFoundationTrust,DorsetClinicalCommissioningGroup,TwoHarboursHealthCare,theWeymouth&PortlandFrailtyProjectTeamandHealthEducationWessexfortheirsupportandcontribution.
References
BritishGeriatricsSociety.Fitforfrailty-consensusbestpracticeguidanceforthecareofolderpeoplelivingincommunityandoutpatientsettings.www.bgs.org.uk/press-3/resources/campaigns/fit-for-frailty/fff-guidance-downloadOxfordacademic.Developmentandvalidationofanelectronicfrailtyindexusingroutineprimarycareelectronichealthrecorddata.https://academic.oup.com/ageing/article/45/3/353/1739750/Development-andvalidation-of-an-electronicNHSEmployers.Technicalrequirementsfor2017/18GMScontractchanges.www.nhsemployers.org/gms201718NHSEngland.FiveYearForwardView.www.england.nhs.uk/five-year-forward-view
To download Frailty Tool Kit please visit: www.dorsetccg.nhs.uk/frailty
Page|26
Appendix2–Paretochart
0
50
100
150
200
250
300
350
400
450
500
RespiratorySystem
CardiacSurgeryandPrimaryCardiac
Conditions
MusculoskeletalSystem
UrinaryTractandMale
ReproductiveSystem
DigestiveSystem NervousSystem Immunology,Infectious
DiseasesandothercontactswithHealth
MouthHeadNeckandEars
Skin,BreastandBurns
EndocrineandMetabolicSystem
HepatobiliaryandPancreaticSystem
Haematology,Chemotherapy,Radiotherapyand
SpecialistPalliative
MultipleTrauma,Emergency
MedicineandRehabilitation
VascularSystem EyesandPeriorbita
RadiologyandNuclearMedicine
Acuteadmissiondata2016/2017ApriltoMarchOver75s
Page|28
Appendix4–FrailtyLeaflets
1 Are you more than 85 years?
Yes No
2 Male?
Yes No
4 Do you need someone to help you on a regular basis?
Yes No
3 In general do you have any health problems that require you to limit your activities?
Yes No
5 In general do you have any health problems that require you to stay at home?
Yes No
6In case of need, can you count on someone close to you?
Yes No
7Do you regularly use a stick, walker or wheelchair to get about?
Yes No
IDENTIFYINGFRAILTY
We would like to extend our thanks to Health Education Wessex for funding the project and providing support throughout and to Dorset Healthcare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.
Acknowledgments
To download this leaflet please visit:www.dorsetccg.nhs.uk/frailty
AcknowledgmentsWe would like to extend our thanks toHealth Education Wessex for funding the project and providing support throughout and to Dorset HealthCare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.
We want to ensure all our patients receive the best possible health care. Part of this includes looking for problems early before they develop into something more serious. As we get older, we become at risk of developing a health condition called ‘frailty.’ This is not just a description, but a condition where you start to lose your bodies inbuilt reserves. This can show itself in different ways and is not always easy to recognise. This can often be mistakenly put down to an inevitable part of getting older, whereas there are sometimes things we can suggest to slow this process down or improve the symptoms.
There is a brief questionnaire that can help us tell if you are developing this health condition. Please can you complete it and hand it back to reception. If you score 3 or more on this questionnaire, we can arrange for one of the healthcare team to review you (either in the surgery or in your own home if you struggle to get to the surgery). This will allow us to work out if there are things that we can suggest which will help to slow down this process and help you remain healthy for longer.
Page|27
Appendix3–DCPadditionalexamplesPatients/carersperspective
e.g.Jillhasadvanceddementiaandsheneverwantedtobecomeasunwellasshenowisandwouldhavebeenveryupsettohavebeenunabletomanageherownhygieneneeds.Shestronglydislikeshospitalsandtakingmedication.Thepriorityismaintaininghercomfortanddignityinthefamiliarsurroundingsofhercarehomeandensuringthathospitaladmissionisavoided.
HealthProfessionalssummary
e.g.JillhasadvanceddementiaandmovedintoanursinghomeinJanuary2017whenitbecametoodifficulttomeethercareneedsathome.Sheneedsallnursingcare.Shecanbecomeagitatedandaggressivewithinter-currentinfectionandsheexperiencesrecurrentUTI.Ifsheneedsanymedicationthenitshouldbeliquidordispersibleformulationduetoswallowingdifficulties.
FunctionalStatus
e.g.Jillhasnoactivemobilityandneedshoistingfortransfers.Sheisdoublyincontinentandneeds2carerstomanagepersonalcare,washinganddressing.Sheneedstobefedandneedsstage1thickenedfluidsandapureeddiet.Sheisatriskofpressuresoresandneedsregularchangesofpositiontoavoidthis.
Clinicalescalationplan
e.g.Jillhasadvanceddementiaandingeneralhercareneedsarebestmetinafamiliarsettingwithfamiliarcarers.AbestinterestsdecisionindiscussionwithhernextofkinhasagreedthatwheneverpossiblehercareshouldbemanagedinthenursinghomewithsupportfromherGPsurgeryoroutofhoursservice.Theonlyexceptionwouldbetraumaorifsymptomaticcontrolcouldnotbeachievedinthecommunity.
SheisatriskofUTIandchestinfections.Theseusuallyrespondtooralantibiotics(liquidformulation).Anyinfectionsshouldbetreatedinthenursinghomesettingonlywithoralantibioticswhensheisabletoswallow.Ifshebecomesunabletoswallowthenmanagementshouldbepalliative.
Dementia–shehasadvanceddementiaandcandisplaysomebehavioursthatchallengerelatingtoaggressivebehaviourwithinterventions.Thesecanbemanagedwithbehaviouralstrategiesgenerally.Ifthereisachangetobehaviourthenconsiderreversiblecausese.g.pain,infection,constipation.Managedeteriorationrelatedtodementiainthenursinghomewiththeprioritybeingsymptomcontrol.NocurrentCMHTinvolvement.
Fallsriskislowduetoherimmobility.IfthereistraumathenassessinA&Eonlyforsuspectedfractureorunmanageablewoundsandreturntonursinghomeassoonaspossible.
Heartfailure–symptomscurrentlycontrolledwithdiuretics,thesemayneedadjustmentifshedevelopsworseningperipheraloedemaorshortnessofbreath.
Intheeventofanysuddendeteriorationinhealthe.g.CVA–manageinthenursinghomesymptomaticallywithsupportofGPsurgery/outofhoursservice.
Self-managementplan
e.g.Jill-Theaimisformanagementinthenursinghome,soforanyunexpecteddeteriorationinhealththencontactGPsurgery/outofhoursservicetoadvise/review.
Foranynon-urgentproblemthenawaitroutineweeklyGPsurgeryvisit
999onlyfortraumaoraseveredistressingsymptomthatcannotawaitGPadvice/assessment.
Page|29
Appendix5–FrailtyPoster
To download this leaflet please visit:www.dorsetccg.nhs.uk/frailty
AcknowledgmentsWe would like to extend our thanks to Health Education Wessex for funding the project and providing support throughout and to Dorset HealthCare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.
For certain of our frailer patients or patients at
high risk of hospital admission, we can complete a
Dorset Care Plan. This not only gives you a chance
to tell your GP what your wishes are, but allows a
record of these wishes and plans to be available to
the out of hours services and paramedics too.
These are in addition to the documents listed
below, but could contain information from any or
all of them. If you feel that you should have a care
plan and do not yet have one, then don’t hesitate
to let your GP know.
For an overview of advance care planning and all it
entails please visit
DorsetCare Plan
http://www.nhs.uk/planners/end-of-life-care/
documents/planning-for-your-future-care.pdf
AdvanceCare PlanThis is a booklet that you can fill in to let other
people know what your wishes are in certain
situations e.g. if you got very poorly, whether you
would want to go into hospital or be cared for
at home.
We have copies of these available in the surgery, or
you can download a copy at:
http://www.dorsetccg.nhs.uk/Downloads/
aboutus/CCP/Cancer%20and%20end%20of%20
life/201309_Dorset_Advance_Care_Planning_
Guide.pdf
What wouldhappen if...Have you ever thought about what would happen if you or
a relative became seriously ill or disabled?
Regrettably we often fail to address these issues until it is
too late to do anything about them.
For example, if you (or a relative) lost the ability to make
decisions about your finances or health – do you know
what would happen?
Another situation is resuscitation – lots of people have
quite clear views that, when the time comes, they want to
be allowed ‘to go naturally’ – however if this not clearly
documented then resuscitation will always be attempted.
These are difficult subjects to think and talk about for
many people, and that is both completely understandably
and acceptable.
If however you do want to think about this, then we’ve
listed some areas to consider, and some helpful links too.
LastingPower of AttorneyThis is a legal document that lets you nominate
one (or more) people to make financial or health
decisions for you, if you loose the ability to
do so. This is particularly relevant for people
who develop dementia, but can apply in other
situations too.
This has to be completed whilst you still have the
‘capacity’ to do so. So it’s never too early to think
about it. And remember, no matter how early you
make this, the people you nominate can only make
decisions for you if you no longer can.
https://www.gov.uk/power-of-attorney/
overview
If you have a clear view that you would not want
resuscitation to be attempted, then you can discuss this
with your GP, who can complete the relevant form.
Please remember that making a decision to allow a natural
death does NOT mean that your regular medical treatment
will stop. Your healthcare team will continue to ensure
that you get the highest level of care regardless of
this decision.
‘Allow aNatural Death’
Advance decisionto refuse treatmentIt is possible to make an advance decision to refuse a
specific treatment, in specific circumstances e.g. if you had
a stroke and were unable to eat/drink – you could refuse to
have a feeding tube fitted.
http://www.ageuk.org.uk/money-matters/
legal-issues/living-wills/advance-decision/
Appendix 4 - Frailty Leaflets
Page I 29
Page|29
Appendix5–FrailtyPoster
My Life My Care‘visit Age UK for help, information and advice’.
They are able to provide advice, enable independence e.g. exercise classes, and combat loneliness e.g. befriending services
0800 678 1174 www.ageuk.org.uk
Citizens Advice Bureau‘Information, advice and support to help you find a way forward whatever the problem’ Includes benefits, income maximization, debt, housing, employment. Health & care, family & relationships, legal, immigration, consumer, education, tax.
0344 2541219 (any queries)
0845 4900042 (Macmillan support – living with cancer)
01929 775500 (energy advice)
www.citizensadvice.org.uk
To download this leaflet please visit:www.dorsetccg.nhs.uk/frailty
Acknowledgments
We would like to extend our thanks to Health Education Wessex for funding the project and providing support throughout and to Dorset HealthCare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.
Appendix 4 - Frailty Leaflets
Page I 30
There are many different options available to help maintain your independence and allow you to live in your own home for as long as possible. However it is sometimes difficult to know what options are available, whether there is a cost, if help with costs is available and where to go for advice.
This leaflet includes a list of local and national options available to help you to work out what you need. Some of this information you can find yourself online, some services can be contacted by telephone or email to access advice that way or to arrange face to face meetings. All of these services are free to contact and access, although some of the services they may be able to guide you to may have a cost.
Dorset Popp Wayfinders‘Wayfinders are individuals who live and work locally who are able to meet you and provide information and signposting to support and services for adults in their local community’
‘They work primarily with any adults who have an identified need or a concern that is reducing their ability to maintain their independence or quality of life whilst living in their own homes for as long as they wish to’
01305 548111 www.helpandcare.org.uk
My Life My Care‘if you find it difficult to live safely and independently in your own home, you can find help here. Our solutions offer information and advice to help you make informed choices about living the life you want’
01305 221016 www.mylifemycare.com
My Health My Way‘access free support with your health...helping you cope and feel more confident living with a health condition’
0303 303 1053 [email protected] www.myhealthdorset.org.uk
SAIL - Safe And Independent Living‘SAIL offers Dorset residents a wide range of free support, services or information to help keep people safe and independent in their own homes’
Health professional to complete 0800 0382323 ‘Safe and Well’ advice line
Complete online www.mylifemycare.com/Safe-and-independent-living
Page|29
Appendix5–FrailtyPoster
We would like to extend our thanks to Health Education Wessex for funding the project and providing support throughout and to Dorset HealthCare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.
Use of Dorset Care Plan has remained consistent but there has been a marked improvement in the detail recorded and the template is now also available to community health services.
Use of both the Rockwood score and the frailty readcodes has continued to rise throughout the project. Note that significant increase in use of frailty readcodes between April and August will have in part been due to the GP contract requirements of July 2017.
No results recorded on the use of CGA as this is still in development.
RESULTS
DEC
EMB
ERA
PRIL
AU
GU
ST
123715031811
RO
CK
WO
OD
SCO
RE
DEC
EMB
ERA
PRIL
AU
GU
ST
7149321854
FRA
ILTYR
EAD
CO
DES
We would like to extend our thanks to Health Education Wessex for funding the project and providing support throughout and to Dorset Healthcare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.
British Geriatrics Society. Fit for frailty - consensus best practice guidance for the care of older people living in community and outpatient settings. www.bgs.org.uk/press-3/resources/campaigns/fit-for-frailty/fff-guidance-download
Oxford academic. Development and validation of an electronic frailty index using routine primary care electronic health record data. https://academic.oup.com/ageing/article/45/3/353/1739750/Development-andvalidation-of-an-electronic
NHS Employers. Technical requirements for 2017/18 GMS contract changes. www.nhsemployers.org/gms201718
NHS England. Five year forward view. www.england.nhs.uk/five-year-forward-view
ACKNOWLEDGMENTS
REFERENCES
The Dorset Care Plan was developed in Weymouth & Portland in primary care to encompass the patient’s priorities for care, admission avoidance including treatment escalation and advanced care planning.
The DCP links with the enhanced summary care record providing OOH/Paramedics with this valuable information. As part of the frailty project Dorset Health Care have developed an equivalent version enabling Community and Primary care to input into a shared document ensuring the patients records are up to date and accurate and completed by the most appropriate clinician at the time.
The Dorset Care Plan (DCP)
In October 2016 Weymouth & Portland received funding from Health Education Wessex to focus on developing services for frailty.
The aim was to support the goals of Integrated Primary and Community Services ensuring a joined-up approach, reducing duplication and enhancing patient care.
OBJECTIVES
INTRODUCTION ABOUT FRAILTY
For people living with frailty the state for an individual is not static; it can be made better and worse.
Frailty is a spectrum condition that spans from mild to severe.
In Dorset about 17,000 people would fall within this definition. Of Dorset’s estimated population of 765,700 some 173,000 are aged 65 and over. Of these around 6,200 are 85 or over; a figure which is said to rise to 9,300 in the next 25 years.
The pilot for this project focused on Weymouth and Portland and developed an integrated model with excellent GP and Community services engagement. A toolkit
was designed to enable the model to be rolled out to other localities
TOOL KIT INCLUDES
Whilst the rollout of the Dorset Frailty Toolkit provides the bulk of the projects education, other developments have been made. Dorset Healthcare had a pre-existing frailty e-learning module that has now, through the work of the frailty project, been made available to the Dorset CCG providing a basic level of information to increase the knowledge of all staff members who come into contact with patients who are potentially increasing in frailty. A series of leaflets on living with frailty, assessing for frailty & advance care planning and early self-help were also developed during the project.
Education
MULTI-DISCIPLINARY MEETINGS IN GP PRACTICES
LOCAL CONTEXT
Population of Dorset Are 85+ and are frail
Frailty is not an inevitable part of ageing; it is seen as a long term condition in the same way as diabetes or Alzheimer’s disease
Fit the definition of frail
For patients identified as frail - to develop a frailty framework, underpinned by a standardized assessment approach
To agree a standardized approach to the identification and stratification of frailty across health and social care services within Weymouth and Portland Locality
To develop a training and education package to enablel the above to be consistently delivered, reviewed and monitored across Dorset.
DEVELOPING FRAILTY SERVICES IN DORSET
Recommended structure for MDTs
Terms of Reference
MDT discussion tool example
Instruction on how to risk profile using the Efi, Admissions and hub data
Detailed instructions on completing a Dorset Care Plan
Introduction to CGA
Recommended outcome measures
Information on the E-Learning frailty Module
Patient leaflets – Planning future care, self & early help resources and Prisma 7 questionnaire/mild frailty
The Toolkit provides a step by step guidance on how to get the best value out of a GP MDT.
Risk profiling of frail patients using the Electronic Frailty Index and admission data is analysed prior to MDTs to ensure the patients who are in most need are discussed. The MDT discussion tool is used in the meeting to help guide the discussion and formulate a clear action plan.
PATIENTS IDENTIFIED AS MILD/ MODERATE AND SEVERELY FRAIL
COMPLETED ROCKWOOD SCORE
COMPLETED CGA
COMPLETED DORSET CARE PLAN
To monitor the engagement and uptake of the model the following process measures have been implemented:-
THE ROLL OUTThe model and toolkit has been adopted by Dorset health Care and the Dorset Clinical Commissioning Group. It is being rolled out as the gold standard of frailty work to be implemented in all localities over the next year
What next?
We plan to create a shared Comprehensive Geriatric Assessment (CGA) template between primary and community services to reflect and enable the following:-
The gold standard for the management for frailty in older people is the process of care known as Comprehensive Geriatric Assessment (CGA)
Holistic, multidimensional, interdisciplinery assesment of a individual by a number of specialists of many disciplines in older peoples health
The CGA has been demonstrated to be associated with improved outcomes in a variety of settings (BGS June 2014)
Number of unplanned admissions
Length of stay
Preferred place of care
GP / OOH contact
The following Outcome Measures will be used to measure the impact of this project:-
8 / 7 days prior to meeting.... the risk profiling team•Run eFI and Hub referrals report •Provide clinical translation of data•Produce manageable list of patients who would benefit from MDT discussion or more detailed review & assessment
1 week prior to meeting.... Link Workers Review data sent by risk profiling team & highlight any patients they wish to discuss
MDT CoordinatorForward data to GPs / relevant Practice staffCollate list of patients identified for discussion by other MDT members
MDT Meeting•Use MDT discussion tool template to guide and record discussion
•Make use of the broadest range of professionals as appropriate
•Discuss identified patients•Each patient discussed must have a clear outcome with a named person responisible for the action
•MDT Coordinator to follow up actions 2 weeks after meeting
Send identified
patients to named GPs for any prep
work
Send data to Surgery MDT Coordinator
& link workers
A1 version.indd 1 31/10/2017 12:23:05
Use of Dorset Care Plan has remained consistent but there has been a marked improvement in the detail recorded and the template is now also available to community health services.
Use of both the Rockwood score and the frailty readcodes has continued to rise throughout the project. Note that significant increase in use of frailty readcodes between April and August will have in part been due to the GP contract requirements of July 2017.
No results recorded on the use of CGA as this is still in development.
RESULTS
DEC
EMB
ERA
PRIL
AU
GU
ST
123715031811
RO
CK
WO
OD
SCO
RE
DEC
EMB
ERA
PRIL
AU
GU
ST
7149321854
FRA
ILTYR
EAD
CO
DES
We would like to extend our thanks to Health Education Wessex for funding the project and providing support throughout and to Dorset Healthcare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.
British Geriatrics Society. Fit for frailty - consensus best practice guidance for the care of older people living in community and outpatient settings. www.bgs.org.uk/press-3/resources/campaigns/fit-for-frailty/fff-guidance-download
Oxford academic. Development and validation of an electronic frailty index using routine primary care electronic health record data. https://academic.oup.com/ageing/article/45/3/353/1739750/Development-andvalidation-of-an-electronic
NHS Employers. Technical requirements for 2017/18 GMS contract changes. www.nhsemployers.org/gms201718
NHS England. Five year forward view. www.england.nhs.uk/five-year-forward-view
ACKNOWLEDGMENTS
REFERENCES
The Dorset Care Plan was developed in Weymouth & Portland in primary care to encompass the patient’s priorities for care, admission avoidance including treatment escalation and advanced care planning.
The DCP links with the enhanced summary care record providing OOH/Paramedics with this valuable information. As part of the frailty project Dorset Health Care have developed an equivalent version enabling Community and Primary care to input into a shared document ensuring the patients records are up to date and accurate and completed by the most appropriate clinician at the time.
The Dorset Care Plan (DCP)
In October 2016 Weymouth & Portland received funding from Health Education Wessex to focus on developing services for frailty.
The aim was to support the goals of Integrated Primary and Community Services ensuring a joined-up approach, reducing duplication and enhancing patient care.
OBJECTIVES
INTRODUCTION ABOUT FRAILTY
For people living with frailty the state for an individual is not static; it can be made better and worse.
Frailty is a spectrum condition that spans from mild to severe.
In Dorset about 17,000 people would fall within this definition. Of Dorset’s estimated population of 765,700 some 173,000 are aged 65 and over. Of these around 6,200 are 85 or over; a figure which is said to rise to 9,300 in the next 25 years.
The pilot for this project focused on Weymouth and Portland and developed an integrated model with excellent GP and Community services engagement. A toolkit
was designed to enable the model to be rolled out to other localities
TOOL KIT INCLUDES
Whilst the rollout of the Dorset Frailty Toolkit provides the bulk of the projects education, other developments have been made. Dorset Healthcare had a pre-existing frailty e-learning module that has now, through the work of the frailty project, been made available to the Dorset CCG providing a basic level of information to increase the knowledge of all staff members who come into contact with patients who are potentially increasing in frailty. A series of leaflets on living with frailty, assessing for frailty & advance care planning and early self-help were also developed during the project.
Education
MULTI-DISCIPLINARY MEETINGS IN GP PRACTICES
LOCAL CONTEXT
Population of Dorset Are 85+ and are frail
Frailty is not an inevitable part of ageing; it is seen as a long term condition in the same way as diabetes or Alzheimer’s disease
Fit the definition of frail
For patients identified as frail - to develop a frailty framework, underpinned by a standardized assessment approach
To agree a standardized approach to the identification and stratification of frailty across health and social care services within Weymouth and Portland Locality
To develop a training and education package to enablel the above to be consistently delivered, reviewed and monitored across Dorset.
DEVELOPING FRAILTY SERVICES IN DORSET
Recommended structure for MDTs
Terms of Reference
MDT discussion tool example
Instruction on how to risk profile using the Efi, Admissions and hub data
Detailed instructions on completing a Dorset Care Plan
Introduction to CGA
Recommended outcome measures
Information on the E-Learning frailty Module
Patient leaflets – Planning future care, self & early help resources and Prisma 7 questionnaire/mild frailty
The Toolkit provides a step by step guidance on how to get the best value out of a GP MDT.
Risk profiling of frail patients using the Electronic Frailty Index and admission data is analysed prior to MDTs to ensure the patients who are in most need are discussed. The MDT discussion tool is used in the meeting to help guide the discussion and formulate a clear action plan.
PATIENTS IDENTIFIED AS MILD/ MODERATE AND SEVERELY FRAIL
COMPLETED ROCKWOOD SCORE
COMPLETED CGA
COMPLETED DORSET CARE PLAN
To monitor the engagement and uptake of the model the following process measures have been implemented:-
THE ROLL OUTThe model and toolkit has been adopted by Dorset health Care and the Dorset Clinical Commissioning Group. It is being rolled out as the gold standard of frailty work to be implemented in all localities over the next year
What next?
We plan to create a shared Comprehensive Geriatric Assessment (CGA) template between primary and community services to reflect and enable the following:-
The gold standard for the management for frailty in older people is the process of care known as Comprehensive Geriatric Assessment (CGA)
Holistic, multidimensional, interdisciplinery assesment of a individual by a number of specialists of many disciplines in older peoples health
The CGA has been demonstrated to be associated with improved outcomes in a variety of settings (BGS June 2014)
Number of unplanned admissions
Length of stay
Preferred place of care
GP / OOH contact
The following Outcome Measures will be used to measure the impact of this project:-
8 / 7 days prior to meeting.... the risk profiling team•Run eFI and Hub referrals report •Provide clinical translation of data•Produce manageable list of patients who would benefit from MDT discussion or more detailed review & assessment
1 week prior to meeting.... Link Workers Review data sent by risk profiling team & highlight any patients they wish to discuss
MDT CoordinatorForward data to GPs / relevant Practice staffCollate list of patients identified for discussion by other MDT members
MDT Meeting•Use MDT discussion tool template to guide and record discussion
•Make use of the broadest range of professionals as appropriate
•Discuss identified patients•Each patient discussed must have a clear outcome with a named person responisible for the action
•MDT Coordinator to follow up actions 2 weeks after meeting
Send identified
patients to named GPs for any prep
work
Send data to Surgery MDT Coordinator
& link workers
A1 version.indd 1 31/10/2017 12:23:05
Page I 31