frailty target event · highest cost. reduce and delay need here reduce or delay need here...
TRANSCRIPT
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© 2018 Herts Valley Clinical Commissioning Group
FRAILTY TARGET EVENT
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Welcome and Housekeeping
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HVCCG continues to deliver ‘Your Care, Your Future’ plans in line with the STP strategy ‘Healthier Future’ Aspirations to move care close to home and develop new and innovative pathways that benefit patient care During 2018/19 HVCCG has commissioned the following services:
•Integrated MSK, rheumatology, pain and postural stability (Jan 18) •Integrated diabetes (April 18) •Enhanced community gynaecology (April 18) •Community vasectomy (June 18) •CHC fast track pilot with hospices (Sept 18) •Respiratory referral management (Oct 18) •Community nutrition and dietetics (Nov 18)
Herts Valleys Transformation Plan
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During 2019 HVCCG will launch the following new services:
•Community ENT and Ophthalmology (Jan 19) •Adult community health services (Oct 19)
We are currently procuring the following services •Direct access ultrasound scanning services •Primary care enhanced community dermatology pilot
Herts Valleys Transformation Plan
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Significant work taking place across the planned care pathways. For 2019/20, HVCCG will be working to develop and transform these in the following areas: •Transformation of Adult Community Services •Cancer •Living with and beyond Cancer •Direct Access to Diagnostics •Faecal Immunochemical Testing •Frailty •End of Life •Urology •Gastroenterology •Cardiology •Pathology
Herts Valleys Transformation PlanPlanned Care
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Frailty for TARGET Events 2018
Dr Ros Kings, Geriatrician WGH
Dr Clifford Lisk, Geriatrician BGH
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Frailty
• Context
• What is frailty?
• Why is it important?
• How do we recognise it?
• What do we need to do about it?
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The Ageing Population
• NHS founded in 1948
• 48% died before the age of 65• Now 14% (ONS)
• By 2030, one in 5 people in England will be over 65 (House of Lords)
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Ageing with more complexity
• Success story for society and modern medicine
• BUT as you get older more likely to live with complex co-morbidities, disability and frailty
• Increasing cost to the NHS
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Problem…
• NHS hasn’t kept up with the demographic shift
• In general, services are designed around single organ diseases
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Solution…?
• A focus on frailty
• Not organ/disease specific
• Looks at a person as a whole
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WHAT IS FRAILTY?
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Three terms are commonly used interchangeably to identify vulnerable older adults...
Disability Frailty
Multimorbidity
Loss of resiliance:
High vulnerability for
adverse health
outcomes
Difficulty or
dependency in
carrying out activities
essential to
independent living
The concurrent
presence of two or
more medically
diagnosed diseases
Fried et al 2004
But what about
physiological
ageing...?
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What is frailty?
• “A clinically recognised state of increased vulnerability that results from aging, associated with a decline in the body’s physical and psychological reserves.”BGS definition
• But what does this actually mean?
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“Frailty” means different things to different people
Frailty: Language and Perceptions (BGS, Age UK) June 2015
Older People
Non-Specialist Health Care Professionals
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What is frailty?
• State of vulnerability
• Living close to a line of decompensation
• Minor trauma has a major impact
• Tip over the edge with minor illness
• Independent Dependent
Clegg et al (2013)
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Frailty as a long-term condition
• Frailty is best understood as a long-term condition
• eg diabetes, dementia, heart failure
• Varies in severity across a spectrum
• Some more severely affected than others
British Geriatrics Society (2014)
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WHY IS FRAILTY IMPORTANT?
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Frailty
• Associated with increased risk of:• Falls
• Disability
• Hospitalisation
• Death
Clegg et al, 2013
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Frail patients in hospital
• Increased risk of:• Delirium
• Length of stay
• Discharge to a care home
• Death
Winogred et al, 1991, Eeles et al, 2002
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Illness Trajectories
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HOW DO WE RECOGNISE FRAILTY?
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Two international models of frailty
• Frailty phenotype (Fried et al, 2001)
• 3 or more of• unintentional weight loss (10 lbs in past year)
• self-reported exhaustion
• weakness (grip strength)
• slow walking speed
• low physical activity
• Cumulative deficit model (Rockwood et al, 2005)
• eFI
• maps well onto Clinical Frailty Score
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eFI
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Recognition of frailty (primary care)
• eFI• Based on a cumulative deficit model
• 36 deficits
• Population risk stratification tool
• GP contract 2017/18
• Mild/Moderate/Severe
• Clinical review/medication review/history of falls
• Activate enriched summary care record
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Identification of frailty (secondary care)
• Screening at the front door >65
• Clinical Frailty Score (Rockwood)
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Importance of Rockwood
• Gives objectivity
• Reproducible
• Predicts outcome
• Addresses complexity • without “single organ” preoccupation
• Helps identify patients that need discussion • eg expectations of treatment
• 2 weeks before admission
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Other ways of recognising frailty
• Timed up and go (TUG) test
• PRISMA 7 questionnaire
• Gait (walking) speed test
• Presenting with the frailty syndromes
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TUG test
>14 seconds = high risk of falls, and frailty
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PRISMA 7 Questionnaire
If the respondent had 3 or more “yes” answers, this indicates an increased risk of frailty and the need for further clinical review.
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Frailty Syndromes = The Geriatric Giants
polypharmacy
“It was a fall waiting to
happen…”
“She’s just gradually got
more confused…”
Can we recognise these before people hit
crisis point?
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WHAT DO WE NEED TO DO ABOUT FRAILTY?
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What do we need to do about frailty?
• Recognise it• Before crisis point
• Recognise the risks associated with it
• Remember it’s not static
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Comprehensive Geriatric Assessment (CGA)
• Evidence-based approach to the care of older people
• Helps clinicians form a holistic, patient-centred management plan
• Addresses what matters to the patient more than what is the matter with the patient
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Different Domains of CGA
• Medical
• Psychological
• Functional
• Social circumstances
• Environment
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Cochrane Review 2017
• CGA works!
• Review of 29 studies
• More likely to be living at home and less likely to be in a care home up to 1 year after hospital admission (compared to standard medical care)
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Summary
• Frailty is important
• Not disease-specific
• Early recognition helps to shape plan
• Think of frailty when a patient presents with a frailty syndrome
• Proactively look for frailty
• CGA works
• Everyone should be involved
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Frailty in Practice MDT working
Dr Elizabeth Kendrick
GPwSI Geriatrics
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The Triple Aim - What
Better care for
Individuals
Better health for
PopulationsLower Cost
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STP Frailty Pathways
• Frailty Pathways – mild/ moderate/severe
• Falls pathways
• End of Life
• Lower limb
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Reducing the need and spend curve: Preventing avoidable spend in public service
Highest cost.
Reduce and delay
Need here
Reduce or delay need here
Intervene here before need
escalates
Volume of
spend
Severity of need
Existing curve
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The Aim from reducing the spend curve
Volume of
spend and
cost
Severity
Existing curve
The Achievable
curve?
Healthy Diagnosed ConditionIn treatment
Complex
Place based, social prescribing, social marketing
Pathway
Wrap round care co-ordinated approach
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How do we diagnose?
• EFI
• Rockwood
• Clinical judgement
• Prisma 7
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Prisma 7• 1. Are you more than 85 years?• 2. Male?• 3. In general do you have any health problems thatrequire you to limit your activities?• 4. Do you need someone to help you on a regularbasis?• 5. In general do you have any health problems thatrequire you to stay at home?• 6. In case of need can you count on someone closeto you?• 7. Do you regularly use a stick, walker or wheelchairto get about
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MILD Frailty
• Volunteering
• Exercise
• Reducing social isolation
• Self Management
• Guide to healthy aging
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Moderate Frailty
• Comprehensive Geriatric Assessment
• Prevention of admission
• Discharge home to assess
• Single Care plan
• Guide to healthy aging
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Severe Frailty
• End of Life
• GSF meetings
• Single care plan
• Rehabilitation potential
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Case 1
• Mrs D. W.
• 76 year old lady admitted to discharge home to assess following a fall.
• Lives alone
• Admitted from A and E
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Size of the Problem
• 30% of over 65s will fall per year
• 40-60% of falls lead to injury
• 14,000 deaths per year due to falls
• 50% will lose ability to live independently
• 60% of people in care homes fall each year
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Case Study continues
• Tripped when bringing bin in from outside. 2 other falls both inside.
• Takes atenolol 100mg, aspirin 75mg, and temazepam 10mg at night
• BP 146/76 dropping to 120/60 on standing
• Lives alone. No carers
• Socially isolated
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Multi-disciplinary team
• OT
• Physio
• Social worker
• Nurse
• CPN
• Medical input
• Voluntary sector
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Access to:
• Optician
• Dietician
• Chiropody
• Specialist services
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GP MDTs
• Relationship building
• Continuity of care
• Educational opportunities
• Advice re different services
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GP MDTs Markers of success
• Dedicated time to complete
• Updated in real time in records
• Right Membership
• What can we learn from GSF?
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GP MDTs Practical Advice
• Who to discuss?
• Who to include?
• Timings
• Preparation
• Template
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Community CGA
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Making CGA work
• Single patient held documentation
• Information sharing systems
• Regular MDT review meetings to share knowledge and develop team working
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WCL
Hub 2
(34,212)
Cassio surgeries MeadowellSuthergrey The Elms
Upton Road
Hub 3
(62,048)
Abbottswood
Callowland
Garston
Sheepcot
Tudor
Meriden
Vine House
Hub 4
(48,513)
Attenborough
Manor View
Pathfinder
South Oxhey
The Consulting Rooms
Hub 5
(64,398)
Baldwin’s Lane
Bridgewater surgeries
Chorleywood
Gade
New Road
The Colne
Primary Care Networks Clair Moring
Nicky Kemp
Marie-Anne Essam
Asif Faizy
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Primary Care Networks
Primary Care Networks (PCN) are likely to be formed around natural communities based on GP registered lists, often serving populations of around 30,000 –50,000 and involving primary care providers including general practice, pharmacy and some community services.They will enable services to deliver better integrated primary and community care for patients and will provide a platform for providers of care being sustainable into the longer term.
This definition of Primary Care Networks was taken from the 18/19 planning guidance
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Developing networks in Watford
Historically
• Watford practices were in clusters from PCT days • Neighbourhoods evolved our from the QoF work, • We have been building those relationships slowly in
the background with our LPF & by sitting practices in neighbourhoods at the Local Management
• Group meetings (PM & GP reps from each of our 25 practices)
What we have done to facilitate this:
• Needed to resurrect groups for Extended Access -we created the groups of practices renamed hubs -geographically and approx. similar list size 30-50k
• We have continued to have breakout time in these groups at our locality meetings for LPF and also ERM
• The groups for the place based care at our Target this week appeared to work well with community teams joining – they have been seeking to align their teams with our hubs we shall now call PCN.
Reflection & Learning
• Practices move in to groups more easily when they have a purpose , project
• Geographically makes sense and similar demographic
• Look for existing relationships between GP /PMs• Practices seemed to have benefited from sharing
best practice, (ERM) and learning from sharing projects
• but also let them choose their neighbourhoods semi-organically
• Also look to community teams and how they are configured
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1. What can we do differently for our frail patients, working more collaboratively?
2. How would your ideal multidisciplinary team function in the future? What would be different?
3. How could a primary care network better care for patients in a more proactive and preventative way?
Group Discussion