Ageing Well. Frailty: why is it important? Martin Vernon NCD Older People. Find Recognise Assess Intervene Long-term.

Transcription

1 Ageing Well Frailty: why is it important? Martin Vernon NCD Older People 22 th March

2 Its not how old we are, but how we are old 2

3 UK Ageing Population Source: Office for National Statistics, National Records of Scotland, Northern Ireland Statistics and Research Agency

4 Where we re heading 4

5 Projected UK age structure Foresight,

6 Ageing population Older population expansion in England will accelerate next 20 years Over 65s will from 17% (2010) to 23% by 2035 England in 2014: 9.5 million aged 65+; 471K aged 90+ By 2035 there will be 14.5 million 65+ and 1.1 million 90+ 6

7 Ageing impacts 15 million live with a long term condition (LTC) 58% people with a LTC are over 60 (14% under 40) A&E attendances by people aged 60+ by two thirds 2007 to : 18% emergency hospital older people admissions 7

8 Acute bed numbers 8% reduction in general and acute beds since 2010: NHSB 2017

9 Spend on adult social care

10 Health and unpaid care Over 65s report poorer health and provide a growing amount of unpaid care 73% people >65 with disability receive care from a family member Verticalised families: more generations are alive simultaneously 2007 to 2032 people >65 who require unpaid care is projected to have grown by >1 million For people >70 the primary challenge will be maintaining physical connectivity 2011 Census & Foresight Report

11 Health and unpaid care Over 65s report poorer health and provide a growing amount of unpaid care 73% people >65 with disability receive care from a family member Verticalised families: more generations are alive simultaneously 2007 to 2032 people >65 who require unpaid care is projected to have grown by >1 million For people >70 the primary challenge will be maintaining physical connectivity 2011 Census & Foresight Report

12 Health and unpaid care Over 65s report poorer health and provide a growing amount of unpaid care 73% people >65 with disability receive care from a family member Verticalised families: more generations are alive simultaneously 2007 to 2032 people >65 who require unpaid care is projected to have grown by >1 million For people >70 the primary challenge will be maintaining physical connectivity 2011 Census & Foresight Report

13 Health and unpaid care Over 65s report poorer health and provide a growing amount of unpaid care 73% people >65 with disability receive care from a family member Verticalised families: more generations are alive simultaneously 2007 to 2032 people >65 who require unpaid care is projected to have grown by >1 million For people >70 the primary challenge will be maintaining physical connectivity 2011 Census & Foresight Report

14 Health and unpaid care Over 65s report poorer health and provide a growing amount of unpaid care 73% people >65 with disability receive care from a family member Verticalised families: more generations are alive simultaneously 2007 to 2032 people >65 who require unpaid care is projected to have grown by >1 million For people >70 the primary challenge will be maintaining physical connectivity 2011 Census & Foresight Report

15 Connectedness? Use of the Internet by seniors as a communication technology Online questionnaire to survey 222 Australians over 55 years of age* Internet primarily used for communication, seeking information, and e-commerce Negative correlation between loneliness and well-being. Greater use of Internet as a communication tool associated with lower social loneliness Greater use of Internet to find new people associated with greater emotional loneliness Its important not to make assumptions about what people want *Sum S et al. CyberPsychology & Behavior. April 2008, Vol. 11, No. 2:

16 This is not just about now The demand of care for older people will continue to increase Many of these will have frailty, multi-morbidity, and/or disability Care systems must be equipped for complexity to manage flow The only feasible approaches to this are: Reduce demand through prevention (attenuation) Optimise current care systems to keep them effective 16

17 Ageing population: key outcomes Foresight,

18 Ageing population: key outcomes KEEP THESE PEOPLE HEALTHY AND WORKING Foresight,

19 Ageing population: key outcomes KEEP THESE PEOPLE AGEING WELL KEEP THESE PEOPLE HEALTHY AND WORKING Foresight,

20 5YFV: Older People Focus on prevention Stronger community services Integration of care Lead role of GPs Prevent modifiable aspects of unhealthy ageing & unnecessary hospital admission Enabling people greater control of their care: shared health & social care budgets Support unpaid carers with partnerships: NHS, voluntary organisations, communities Break down barriers to support people with multiple health conditions: older people living with frailty Support communities to choose effective new care delivery options which integrate out of hospital care, primary care & other community based providers Improve support to older people in care homes

21 GPFV: Older People Greater focus on prevention Better integrated Stronger community services Lead role of GPs Contractual measures: improve hospital/gp interface Support people living with long term conditions to self care: early frailty Care planning Local community pharmacy pathways to promote self care Voluntary sector organisation support to GP through social prescribing: call off services Develop digital interoperability to give access to a shared primary care record Summary care records access in community pharmacies Accelerated access to patient records across different services Permit healthcare professionals in different settings to update & inform practices

22 Policy: increase disability free life expectancy 22

23 Policy: increase disability free life expectancy 23

24 Age Well PREVENTION TAILORED CARE SUPPORTIVE CARE LIVE WELL AGE WELL DIE WELL NEEDS, PREFERENCES, CHOICES 24

25 Of key importance Ways of keeping people connected (socially, to health care) Ways of activating people to manage their conditions Identification of people at risk (of unwarranted outcomes) Outcomes measurement to drive improvement & assure value Efficient & effective recording & sharing information 25

26 Why is frailty important? 26

27 FUNCTIONAL ABILITY Find Recognise Assess Intervene Long-term What is frailty? A long-term condition characterised by lost biological reserves across multiple systems and vulnerability to decompensation after a stressor event The most problematic expression of human ageing facing the NHS today (Clegg) MINOR ILLNESS INDEPENDENT DEPENDENT Unpredictable recovery 27

28 The Frailty phenotype People aged >60: 14% & those >90: 65% More common in women (16% v 12%) In England1.8m people >60 and 0.8M people>80 live with frailty 93% frail people have mobility problems 63% need a walking aid 71% frail people receive help Fried et al. J Gerontol (2001) 56(3): M146-M157 Gale et al. Age Ageing 2015;44:

29 PREVENTION Find Recognise Assess Intervene Long-term Frailty as a Long Term Condition A long term condition can be diagnosed, is not curable but can be managed and persists As resilience is lost, care and support planning assumes greater importance through to the end of life RESILIENCE CARE & SUPPORT PLANNING END OF LIFE INCREASING FRAILTY 29

30 PREVENTION Find Recognise Assess Intervene Long-term Frailty through a different lens? Economic, social, emotional, cognitive resilience As resilience is lost, care and support planning assumes greater importance through to the end of life RESILIENCE CARE & SUPPORT PLANNING END OF LIFE INCREASING FRAILTY 30

31 Frailty as a Long Term Condition NOW FUTURE The frail Elderly An Older Person living with frailty A long-term condition Late Crisis presentation Fall, delirium, immobility Timely identification preventative, proactive care supported self management & personalised care planning Hospital-based episodic care Disruptive & disjointed Community based person centred & coordinated Health + Social +Voluntary+ Mental Health 31

32 Person Centred Care 32

33 Prevention..upstream 33

34 Address frailty systematically Prevention up stream in the life course: Effective management of LTCs Healthy ageing Delay onset of, or attenuate, pre or mild frailty Manage optimally to attenuate, where feasible, the effects of: Pre/mild Frailty Multi-morbidity Disability Manage optimally to achieve best care for people living (& dying) with: Moderate and severe frailty Irremediable medical conditions 34

35 Routine frailty identification Routine frailty identification in primary care has 2 potential merits: 1. Population risk stratification 2. Targeted individualised interventions for optimal outcomes 35

36 Frailty identification Distinguishing fit from frail & frail from fit is the most pressing clinical task of our age Frailty is linked to acquisition of multiple Long Term Conditions Can be achieved for individuals or populations Can therefore help target interventions more effectively 36

37 Electronic Frailty Index (efi) Clegg et al: Age Ageing2016: 45:

38 Electronic Frailty Index (efi) Depression? Clegg et al: Age Ageing2016: 45:

39 Electronic Frailty Index (efi) The efi has robust predictive validity for predicting outcomes (age 65-95) 1,3 5 year risk mortality, hospitalisation, nursing home admission The prevalence of people who were fit, had mild, moderate or severe frailty was 50%, 35%, 12% and 3% respectively Severe frail had on average 2.2 comorbidities and were taking 8 medications One year risk almost doubles for mild frailty and quadruples for severe frailty Routine implementation of the efi will support delivery of evidence-based interventions to modify frailty trajectories One year outcome (hazard ratio) Mild frailty Moderate frailty Severe frailty Mortality Hospitalisation Nursing home admission

40 Population Risk Stratification Primary care electronic Frailty Index (efi) Survival plots (n=227,648; >65y) (Clegg et al) 40

41 GMS GP Contract 2017/18 Practices will use an appropriate tool e.g. Electronic Frailty Index (efi) to identify patients aged 65 and over who are living with moderate and severe frailty For patients identified as living with severe frailty, practice will deliver a clinical review providing an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12/12 Where a patient does not already have a Summary Care Record (SCR) the practice will promote this seeking informed patient consent to activate the SCR Practices will code clinical interventions for this group 41

42 GMS GP Contract 2017/18: Data number of patients recorded with a diagnosis of moderate & severe frailty number of severe frail patients with an annual medication review number of severe frail patients recorded as having fall in last 12/12 number of severe frail patients providing consent to activate enriched SCR NHS England will use data to understand nature of the interventions made And prevalence of frailty by degree among practice populations & nationally Data will not be used for performance management purposes 42

43 Why Falls? 43

44 Falls and older people Older people have highest risk of falling* 30% people aged 65+ fall at least once/year 50% of people aged 80+ Globally 37 million falls/year need medical attention worldwide deaths/year: 80% in low/middle income countries *NICE CG161

45 Falls impacts Causes pain, distress, injury, lost confidence/independence NWAS (2013): 10.5% all ambulance call outs were falls related 1 in 2 women, 1 in 5 men in UK will suffer fracture after age 50 Most fractures in older people follow a fall: 10% falls result in fracture Causes mortality: adults 65+ suffer greater number of fatal falls *NICECG161

46 Falls mortality Falls associated with mortality in adults 65+ Ground level admitted falls +65: only 33% went home without assistance* 1 year mortality 33% for all admissions 1 year mortality for those discharge alive 24% Those discharged to nursing facility had 3X risk of death in 1 year (HR=2.82) *Ayoung-Chee et al (2014) Long term outcomes of ground level falls in elderly. J Trauma & Acute Care Surgery: 76 (2)

47 Why medications? Multimorbidity NG56 Tailoring care to the needs of individuals 47

48 Multimorbidity: what matters to you? 48

49 Multimorbidity: pain 49

50 Multimorbidity: depression 50

51 How does urgent care respond? 51

52 Acute care admission Age split of emergency admissions: 0 to 64 56% 65 to 74 14% 75 to 84 17% % 44% of elective admissions are aged 65 and over (13% age 85 plus) Length of stay for emergency admissions All ages = 5.7 days = 7.2 days = 9.1 days 85+ = 11.3 days (1 day increase since 2015) Age profile at different stages in the pathway NHS benchmarking Older People Acute Care Audit 2016

53 Acute care admission Emergency admissions discharged same day (%) Emergency admissions discharged following day (%) NHS benchmarking Older People Acute Care Audit 2016

54 Impact of long stays on OBDs Total number of spells Total number of OBDs Spells with LoS >21 days=7% Spells with LoS >21 days=41% Spells with LoS <=2 days=9% of OBD Spells with LoS 3-21 days=37% Spells with LoS 3-21 days=50% of OBD Spells with LoS <=2 days=56% NHS benchmarking Older People Acute Care Audit 2016

55 Small numbers BUT high occupancy NHS Benchmarking 2016 DTOCs average 3.1% of all occupied bed days in Trusts Range from 0.2% %

56 DToC bed days 76% total increase since % increase from Nov 2015 Nov 2016: NHSB 2017

57 Complex reasons for DToC? NHS benchmarking Older People Acute Care Audit 2016

58 Discharge destination Discharge destination 58% discharged to own home (76% admitted from own home) 9% discharged to residential home, 13% to nursing home 7% discharged to transitional arrangements 8% of cohort died NHS benchmarking Older People Acute Care Audit 2016

59 Older people Pathway Small numbers of people (7%) with LOS>21 days use 41% occupied beds High numbers of people (56%) with LOS<2 days use 9% occupied beds 46% emergency admission are 65 and over 83% DTOCs are aged 65 and over 13% emergency admission are aged 85 and over 39% DTOCs are aged 85 and over Acute care systems must gear up to these realities Is the investment in key steps right? NHS benchmarking Older People Acute Care Audit data

60 Improving delivery & experience of care 60

61 RightCare scenario: The variation between standard and optimal pathways Janet s story: Frailty

62 The RightCare approach

63 Rightcarehttps:///rightcare/intel/cfv 63

64 Janet s story Her experience of a frailty care pathway, & how it could be so much better Scenario examines a frailty care pathway, comparing a sub-optimal but typical scenario against an ideal pathway 1 2 At each stage we have modelled the costs of care, both financial to the commissioner, and also the impact on the person and their family s outcomes and experience. It shows how the RightCare methodology can help clinicians and commissioners improve the value and outcomes of the care pathway. 4 3 Document is intended to help commissioners and providers to understand the implications both in terms of quality of life and costs of shifting the care pathway

65 Janet and the standard pathway No prevention Pillar to post Too late Reactive No education No third sector No risk profiling and identification Traditional treatment Many wards Too much time in bed Inappropriate acute care Damage done Too much reliance on acute care Insufficient home care support

66 Questions for GPs & commissioners In the local population, who has overall responsibility for: Promoting frailty as a condition for which targeted interventions must be planned and delivered? Identifying individuals living with frailty? Planning care models to address key stages of frailty (pre/early, moderate or severe)? Identifying and reporting on measurable positive and negative frailty associated outcomes? Quality assurance and value for money of frailty care? Getting best value for money from the investment by caring agencies re frailty? 7 How do we do the right thing for the patient and at the same time recognise that costs shift from health to social care?

67 Janet and the optimal pathway Prevention Focus Prevention focus Fast Appropriate Proactive Education Third sector Risk profiling and identification Bespoke treatment Little time in bed Greater understanding of need Great acute care Support mechanisms in place Trusted system Happier and healthier experience Great home care support

68 Care Homes 68

69 Care homes High prevalence of people with multi-morbidity and frailty Frailty varies between 19 and 76% Minority engage in advance care planning* Missed opportunity to plan for care to avoid unwanted outcomes Systematic approaches utilising frailty can help *De Gendt C,Bilsen J,Stichele RV,Deliens L. Advance Care Planning and Dying in Nursing Homes in Flanders, Belgium

70 Structured Care Homes Support Key attributes Proactive optimised resident-centred LTC assessment, management Proactive resident centred care planning Coordinated: all system parts work together and talk to each other Capability for 24/7 response to unplanned changes in resident condition 70

71 Key Elements Primary care Alignment to General Practice and proactivity Medication review Hydration and nutrition Urgent care Multi-disciplinary team support Expert advice & care for those with complex needs Care navigation (people and professionals) Reablement & rehabilitation End of life care Advance care planning Palliative care skills and knowledge Dementia care Joined up commissioning & collaboration: health & social care Workforce & skills development Data and technology EPaCCS Telemedicine 71

72 Frailty identification & Prevention 72

73 Can we use frailty for prevention? Potentially modifiable risk factors Alcohol excess Cognitive impairment Falls Functional impairment Hearing problems Mood problems Nutritional compromise Physical inactivity Polypharmacy Smoking Social isolation and loneliness Vision problems Targeted interventions for those at most risk : Good foot care Home safety checks Vaccinations Keeping warm Readiness for winter Stuck et al. Soc Sci Med. 1999(Systematic review of 78 studies) 73

74 What we ve also done so far Read codes for mild, moderate and severe frailty Healthy Aging and Caring Guides Handbooks for Care & Support Planning, Risk Stratification and Multi-Disciplinary Team Working Discharge to Assess Quick Guide Safe and well visits by Fire Service Commitments to Carers Frailty toolkit for primary care Frailty CQUIN Integrated pathway of care Commitments to end of life care Standard outcomes set for older people Rightcare Frailty Scenario Falls consensus statement 74

75 What we re doing GP GMS Contract implementation Promotion of electronic frailty index and additional information within summary care record Economic modelling of impact of frailty Care homes commissioning guidance NICE multi-morbidity clinical guideline (and QS) Serious illness care programme Rightcare LTC Commissioning for Value Age Well and Healthy Ageing 75

76 What next? 76

77 Where we re heading Best value health care for all What do we mean by Value? Return on investment for the taxpayer Experience and outcomes of care for people What do we mean by All? Multi-morbidity Disability Frailty 77

78 Key areas for development (1) Prevention Delayed onset of MM, disability and frailty Attenuation of progression To prevent unwarranted outcomes at key stages Care delivery To maintain functional ability To achieve ROI 78

79 Key areas for development (2) Understanding the nature and scale of the problem Identification of populations and needs Trajectories Monitoring and tracking: use of data Outcomes Process Person centred Delivery Optimal interventions (how, where, when to achieve outcomes) Optimal systems and mechanisms of delivery Use of technology 79

80 Key areas for development (3) Workforce development Education and training Skills development and maintenance Resilience and diversification Patients and carers Self care and management Education, learning and understanding Activation Occupation Communication Public: traditional and social media Patients and carers Workforce Environment The built environment: housing, roads, infrastructure Technologies 80

81 Key points These issues are everyone s business Frailty and multi-morbidity are here to stay We must align care systems accordingly: use frailty as a common currency We can only address this sustainably if we collaborate effectively together We must ensure that everyone is playing to their strengths We must coordinate efforts to achieve best return on investment We must focus on the things most likely to benefit at scale We must be aware of our blind spots What are you doing (or plan to do) in these spaces now? 81

82 Thank you 82