Frailty pathway

Latana A. Munang Consultant Physician and Geriatrician St John’s Hospital

Outline

The status quo Frailty Comprehensive Geriatric Assessment The Frailty Pathway Summary & Discussion

Projected population change West Lothian

General Register Office for Scotland

MEDICAL ADMISSIONS BY AGE <65 65-75 >75 7 14 12 7 12 8 9 MONDAY 8 4 15 9 6 TUESDAY WEDNESDAY THURSDAY 4 8 6 FRIDAY 4 8 10 4 3 16 SATURDAY SUNDAY

FRAILTY SCREENING FOR >65 IN MAU Frail Screen positive, but not frail Not frail 5 4 7 5 2 4 10 11 6 6 7 5 2 3 7 MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY 5 1 6 SATURDAY 3 2 2 SUNDAY

n Age, years Mean (SD) Range Length of stay, days Mean (SD) Median (IQR) Range Readmission (%) 7 day 30 day 60 day Mortality (%) Inpatient 7 day 30 day 60 day Frail 47 79.3 (8.1) 68 - 101 18.2 (20.7)* 11 (4.25 – 22.75)* 1 – 85* 2 (4.3) 8 (17) 8 (17) 7 (14.9) 3 (6.4) 7 (14.9) 8 (17) Non-frail 56 75.8 (6.3) 65 - 90 7.6 (12.1) 3 (1 – 6) 1 - 57 6 (10.7) 12 (21.4) 15 (26.8) 5 (8.9) 1 (1.8) 2 (3.6) 7 (12.5) p-value <0.05

<0.05

NS NS NS NS NS <0.05

NS * 2 patients are still inpatients

Frailty

‘A biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative decline across multiple physiologic systems, and causing vulnerability to adverse outcomes' Walston et al. Research Agenda for Frailty in Older Adults: Toward a Better Understanding of Physiology and Etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. JAGS 2006; 54: 991-1001

Vulnerability of frail elderly people to a sudden change in health status after an illness Clegg, Young, Iliffe, Rikkert, Rockwood Frailty in elderly people Lancet 2013; 381: 752 - 762

Survival curve estimates by frailty status at baseline

Fried L P et al. J Gerontol A Biol Sci Med Sci 2001;56:M146-M157

Comprehensive Geriatric Assessment

Multidimensional diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person in order to develop a coordinated plan to maximize overall health with aging

Domain Medical Mental health Functional capacity Social circumstances Environment Assessment Co-morbidity & disease severity Medication review Nutritional status & dentition Continence Vision & hearing Advance care preferences Cognition Mood & anxiety Fears Spirituality Basic activities of daily living Gait & balance Activity / Exercise status Instrumental activities of daily living Support from family & friends Social network eg. Visitors, daytime activities Finances Eligibility for care resources Home facilities, comfort & safety Potential use of telehealth technology Transport facilities Access to local resources

Geriatrician GP Pharmacist Social Worker Dietician

Case Manager

Physiotherapist Occupational Therapist Speech & Language Therapist Nurse

Assessment Intervention

CG A

Problem list Goals

CGA vs. usual care

Outcome Living at home Up to 6 months End of follow up Mortality Up to 6 months End of follow up Institutionalisation Up to 6 months End of follow up Death or deterioration No. of studies 14 18 19 23 14 19 5 No. of participants 5117 7062 6786 9963 4925 7137 2622 Effect size 1.25 [1.11, 1.42] 1.16 [1.05, 1.28] 0.91 [0.80, 1.05] 0.99 [0.90, 1.09] 0.76 [0.66, 0.89] 0.78 [0.69, 0.88] 0.76 [0.64, 0.90] Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011, Issue 7

CURRENT MODEL Unwell frail older person SJH Front door Gen Med Ward GP A&E PAA MAU Refer PT OT MoE Boarding ward Rehab ward OPD Templar Day Hospital REACT GP

Principles

Right to medical diagnosis and equal access to specialists Patient-centred Home is best The right patient looked after by the right team in the right setting Planned care better than emergency care Simple Sustainable Focus on quality and quality improvement

Case-finding for targeted intervention

Frail patients identified as soon as possible to enable timely assessment and management Specialist nurse supported by Consultant Geriatrician Systematic MDT on all medical wards Robust referral system from other parts of the system

Health Improvement Scotland: Think Frailty

MAU SJH

MAU SJH

MAU SJH

MAU SJH

Right patient, right team, right setting

Prompt decision on care trajectory and transfer to most appropriate setting Complex frail patients managed by consultant geriatricians Tracking of less complex frail through liaison Effective MDT in each ward with regular discussions for goal setting and discharge planning

Home is best

Admission avoidance

Hospital at Home Rehab at Home

Templar Rapid Access Frailty Clinic

Rapid access CGA in a specialist multidisciplinary ambulatory setting A ‘one-stop’ clinic offering specialist assessment and same-day diagnostics with real time decision-making led by a geriatrician Referrals via telephone to the MoE Single Point of Contact (SPOC) with appointments for the same or the next working day given in the same conversation Aim to reduce avoidable admissions and facilitate timely discharge when acute hospital care no longer necessary Close working with REACT, MAU/PAA, Reablement, Crisis care, Primary Care, Social Work, Mental Health and other specialties

Home is best

Admission avoidance REACT Templar Rapid Access Frailty Clinic Discharge to assess

Improving Flow

Patient Admitted D2A Assessment Seen by Doctor Seen by nurse Physio Assessment Rehabilitation OT and PT assessment Care at home Discharge Home Care at Home Discharge Home Discharge Planning Rehab in hospital OT Assessment

Home is best

Admission avoidance REACT Templar Rapid Access Frailty Clinic Discharge to assess “Medically stable” vs. “No longer in need of acute hospital care” Rehab at home Closer working with community services

Simple

Single point of contact Telephone or electronic contact Reproducible and scalable

Good post-acute care

CGA initiated and completed Reassessment Identify patients with highest risk of readmissions, deterioration Advance care plans

FRAILTY PATHWAY ST JOHN’S HOSPITAL Unwell frail older person SJH Front door A&E Frailty nurse Discharge hub PAA GP MAU Inpatient admission required Rehab ward Rest of SJH Referral or MDT pick up Medical ward under a geriatrician Consultant Geriatrician Single Point of Contact REACT OPD Templar Day Hospital GP care + agreed plan Subacute care

Summary

Frailty is our core business Early identification allows targeted CGA CGA is multidimensional, multidisciplinary and iterative Evidence-based changes to system to allow great frailty care everywhere

Discussion