People at the centre of health and care

Transcription

1 People at the centre of health and care

2 Improving Care for Older People in Acute Care F is for Frailty F is for Frailty Identification and co-ordination of care for frail older people

3 Starting point - April Improve older people s acute care

4 Tools being tested: Locally adapted frailty triage tools and criteria Aim: 95% of frail patients (within test sites) have access to comprehensive geriatric assessment within 24 hours of admission, by March 2014 Impact: Comprehensive Geriatric Assessment carried out within 24 hours of admission Reduction in length of stay in hospital Reduction in boarding/hospital moves Improved patient experience

5 Test Site Visits Ayrshire and Arran (frailty& Delirium) Borders (Delirium) Greater Glasgow and Clyde (Delirium) Tayside (Delirium) Lothian (Frailty) Highland (Delirium) Grampian (Delirium) IslandBoard Session Date (2013) 17May 6 June 7 June 11 July 12 July 24 July 29 July 10Sep

6 An overview of frailty Dr Graeme Ellis, NHS Lanarkshire

7 Development of front door Comprehensive Geriatric Assessment model Geriatric Assessment Unit, Aberdeen Royal Infirmary Graeme Hoyle Consultant Geriatrician

8 What Geriatric Medicine is all about Age related decline leads to Impairment of individual organ function Breakdown of the complex interplay between organ systems (dyshomeostasis) This leads to Increased susceptibility to environmental stress = FRAILTY

9 Frailty Increased risk of death or debility following exposure to an environmental stressor A reduced ability to withstand illness without loss of function

10 Geriatric syndromes of presentation Dyshomeostasis leads to multiple body systems being involved in one 'illness' Disruption in multiple 'health domains' Typical 'syndromes of presentation' Falls Immobility ('off legs') Functional decline ('not coping') Delirium

11 Disruption of multiple health domains Complexity Medical Psychological Societal Social Functional Behavioural Environmental Nutritional Spiritual

12 Modes of dying

13 Illness trajectory -frailty Triggering event Functional ability Decline Crisis Reablement Admission Time

14 Frailty opportunities for intervention Triggering event Functional ability ACP Decline Crisis Reablement Admission Time

15 Intervention = Comprehensive Geriatric Assessment (CGA) Process to assess and manage illness in older people Determine what the problems are Multiple medical problems present at once Multiple health domains affected Determine what we can reverse and what we can make better Produce a management plan

16 Principles of effective Geriatric Medical care Early identification of need Early Comprehensive Geriatric Assessment Early streaming to appropriate care setting Home +/- follow up, Intermediate Care, inpatient care

17 Benefits of hospital Diagnosis access to expertise and complex investigations Access to specific therapies Access to greater intensity of therapy 24hr nursing care/observation

18 Risks of hospital Unfamiliar environment -risk of falls/ disorientation/ delirium Dependency / Institutionalisation Loss of familiarity with own home environment Hospital Acquired Infection Latrogenic harm - eg oversedation/medical mishap

19 Discharge window discharge window risks benefit time

20 How things used to be (2008) Woodend Hospital as the Geriatric Hospital ARI takes overspill when Woodend full Woodend: Disorganised, unhurried process of CGA ARI: No real process of CGA

21 Progress towards front door CGA Woodend ARI Acute beds 2008 Direct ward admission Geriatric liaison only 152 Mar 2009 Triage Unit ecga on AMAU 121 Geriatric Dec 2012 Rehab only 90 Assessment Unit

22 Geriatric Assessment Unit Right patient Right place Right people Right time

23 Process of care Admissions via A&E or AMIA both have 4 hour targets Transferred to GAU (Think Frailty criteria) Assessed by Consultant Geriatrician, Nurses, OT, PT Core team availability 8-8 weekdays, Twice daily MDT huddle Patient discussed Management plan agreed on EDD set (discharge focus) Outlets: Home; Acute inpatient bed; Rehab ward/community Hospital

24 Results Appropriateness of Placement 84% patients on GAU meet Think Frailty Criteria 20% of over 75s on Gen Med wards meet criteria ( = 1 patient every 3 rd day) Workload Projected annual patient numbers admitted to Geriatric Medicine = 4200 Previously = 3400

25 Outcomes Health Intelligence data comparing Geriatric Medical activity ARI 6 th Dec 2012 to 6 th Mar 2013 (first 3 months of GAU) Woodend 6 th Dec 2011 to 6 th Mar 2012 Caveat Discharges not admissions during this time Trends likely accurate, definitive figures may not be

26 Woodend GAU p value Mean LoS <0.001 Median LoS 11 3 <0.001 Discharge within 24hr 3% 17% Discharge within 48hr 9% 36% Readmit within 1wk 3.9% 5.6% 0.15 Mortality 15.4% 10.3% 0.04 Care Home discharge 13.1% 8.8% Mean Age

27 How are these benefits achieved? Early intervention of multidisciplinary team Better MDT communication Better information gathering and synthesis Communication with patients/families/other agencies Individualised patient-centred care Clear focus from day 1 on: goals of treatment discharge planning

28 Take Home messages Re-organisation of admission process Better for patient Better for system Importance of focussing experienced professionals at the front door What is the potential for pushing this beyond the front door? Alternative to Admission schemes Anticipatory Care Planning

29 Think Frailty Criteria Aged 75 and over. Yes No Complex multiple conditions Falls in the last 3 months Resident in a care home Acute or chronic confusion Impaired mobility or self care Likely to need complex support for discharge Are any of the above criteria met Indicator for care by another acute specialty Yes Need for HDU / ITU (including non-invasive ventilation Suspected new stroke or TIA Trauma with suspected fracture Head injury with loss of consciousness Acute abdominal pain with collapse Chest pain with suspected MI No Clear need for other specialty input Are any of the above criteria met

30 Questions?

31 Discussion What experience do you have of early identification and proactive care of frail older people in the community eg anticipatory care planning? 2. Do you have any examples of crisis intervention/hospital at Home schemes affect the frail older person s journey of care? 3. What s your experience of the best way to identify, assess and manage care for the frail older person who is admitted to hospital? 4. Could this model (described by Graeme) or elements of it work in your system? 5. What do you see as the benefits of this approach to managing frailty for patients and families? 6. Thinking of winter bed pressures how do you think this work focusing on frailty can influence capacity and flow within your organization? 7. How do we demonstrate the impact of a coordinated approach to care for frail older people?

32 @opachis