Vision for quality: A framework for action - technical document

Transcription

1 3. Frailty Vision for quality: A framework for action - technical document

2 Contents 1.0 Introduction The current situation in Warwickshire North The case for change Views and opinions The future direction What will change for our patients? Timeframes for action 10 This document is part of the Warwickshire North Clinical Commissioning Group s Vision for Quality clinical strategy. The Vision for Quality clinical strategy is formed of a series of chapters: Vision for Quality - provides a general overview of the strategy This is supported by a series of chapters that provide more detailed information on the individual health service areas: Urgent, emergency care and emergency general surgery Cardiovascular disease, stroke, transient ischaemic attack and heart failure Frailty End of life Mental health Dementia 3

3 1.0 Introduction One of the successes of the NHS and new treatments is that we have more people living well for longer and to support this the NHS needs to change. there is a body of evidence to suggest that it is a collection of biomedical factors that affect an individual s psychological state in a way that reduces their capacity to withstand environmental factors. Frailty is likely to be correlated with disability and co-morbidity and should identify a group that is vulnerable to adverse outcomes. Frailty is often associated with old age however, only a subset of elderly people, circa 6%, is at risk of becoming frail. There is also a cohort of younger people who are deemed clinically to be frail due to multiple morbidity and lifestyle. In this review the term frailty is used to describe a range of conditions in people, including general physical debility and cognitive impairment. Frail people are vulnerable to illness, social isolation, loss of independence and admission to hospital and nursing or residential home. The diagram below shows the stages of frailty: Stages of Frailty Healthy Aging Chronic Vulnerability Acute Illness Recovery Health stage Chronic loss of capacity Acute loss of capacity Illness stage 1

4 2.0 The current situation in Warwickshire North There is no register of people who are frail, however we can estimate that there are around 2,000 In addition there is a cohort of patients under the age of 65 who will be frail as a consequence of multiple long term conditions (LTCs.) Conditions people are living with that can be indicators of frailty The diagram below shows the number of people living in Warwickshire North with conditions or factors that can be indicators of frailty: 2,925 over 65 living with depression 2,138 over 65 living with dementia 1,653 over 65 living with a longstanding health problem following a heart attack 765 over 65 living with a longstanding health problem following a stroke Psychological Health Biological Sociological Patients returning home from hospital with some social care support This table shows the number of WNCCG patients discharged from George Eliot Hospital with social care support for the calendar year December 2011/November 2012: Discharges with social care packages are shown below: 12,193 over 65 live alone 873 over 65 live in a care home 13,337 over 65 unable to manage at least 1 domestic task unaided 5,934 over 65 with impaired mobility 572 over 65 living with a longstanding health problem from bronchitis or emphysema 2

5 There are 10 nursing homes across Warwickshire North with a total of 498 beds. Emergency Admissions for Frail Elderly Frail Elderly Admissions from home Frail Elderly Admissions from nursing homes 0 Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 The data demonstrates the activity and cost of emergency admissions for patients in WNCCG who have frail elderly conditions: defined as patients aged over 65 who are admitted under clinical codes of Falls, UTI, Dehydration or Dementia. The graph shows the data split by those admitted from home versus those from a care home. Emergency admissions from residential homes over the last 4 years / / / /13 There has been a 65% increase in emergency admissions from residential homes during this period. 3

6 3.0 The case for change There are a number of reasons why we need to make changes to how we care for those people who are frail. Some of these are stated below and grouped into local and national evidence: 3.1 Local evidence r There are currently around 34,000 people over 65 (20% of population) in Warwickshire North and it is anticipated that 2,000 (6%) will be frail. r There is a cohort of patients under the age of 65 who will be frail as a consequence of their lifestyle or multiple long term conditions. r The Warwickshire Director of Public Health 4GRQTV KFGPVKƂGU VJCV OWNVKRNG OQTDKFKV[ is associated with more hospital admissions and higher mortality. This in turn leads to an increase in costs. r Of all 10,547 emergency admissions to GEH over a 12 month period, there were 5,191 admissions for patients aged over 65 and 3,504 of those admissions were in the speciality of general medicine. r 6JGTG JCU DGGP C UKIPKƂECPV ITQYVJ KP emergency admissions to GEH from residential homes between 2009/2010 and 2012/2013 of 65%; that is 321 in 2009/2010 to 530 in 2012/2013. r Voluntary agency representatives told us that information, awareness and transport are priorities for this group, with community transport being important, as well as reaching harder to reach groups and providing information on available services. r Evidence in the Warwickshire Joint Director of 2WDNKE *GCNVJ #PPWCN 4GRQTV KFGPVKƂGU that more than 42% of the population could have one or more long term conditions and JCXG VYQ QT OQTG +V CNUQ KFGPVKƂGU VJTGG key opportunities for improvement in care for those with long term conditions. 4

7 3.2 National evidence The Geriatric Society and other national bodies such as the Kings Fund identify that change is required; most of the factors below align with local evidence for change: There is a pressing need to change how we care for older people with urgent care needs to Older people are admitted to hospital more frequently, have longer lengths of stay and occupy more bed days in acute hospitals compared to other individual groups. There are an increasing number of people who are frail attending emergency departments and accessing urgent health and social care services. Over the next 20 years, the number of people aged 85 and over is set to increase by twothirds, compared with a 10 per cent growth in the overall population. What matters most is clinical service-level integrated health and social care targeted at everyone. (The Kings Fund 2011). Emergency departments need to be supported to deliver the right care for those who are frail, as no one component of the health and social care system can manage this challenge in isolation; implementation of improved care for people requires a whole system approach. Attendance at the Emergency Department is associated with a high likelihood of admission for older people, and the nature of the service and the environment in which it is provided of healthcare in the 21st century, the bulk of which relates to increasingly frail people. Commissioning evidence-based integrated health and social care systems that address care across the continuum will help deliver holistic care for frail people in the years to come. failings in care for older and vulnerable patients which illustrate the need to improve how older people are cared for and assessed in A&E and on hospital wards. to focus support on those with the highest risks along with support for self care and shared decision-making to support and care for those with LTCs. Several recent national reports, including from organisations such as Patient UK, the Care Enquiry into Patient Outcome and Death (NCEPOD) and the Health Service Ombudsman, of people in acute hospitals ranging from issues around privacy and dignity to improving perioperative care. 5

8 4.0 Views and opinions 4.1 Local GP opinion GPs in Warwickshire North considered frailty in a workshop on 9 May 2013 with a range of evidence and information from the British Geriatric Society, the Kings Fund, the Francis report, local evidence of service usage and a presentation from South Warwickshire Foundation Trust on the community services currently in place. Feedback was also received from a number of GP practices about how services were operating based on their experience of seeing patients on a daily basis. Key improvements suggested were: To ensure nursing homes are providing services for patients in line with their contracted responsibilities ensuring quality, as well as activity metrics are being met. Where residents need community health services such as district nurses and therapy services, we provide this in recognition that if we support people this provides better care for our patients and may prevent an inappropriate admission. A need for community geriatricians to treat more patients outside of hospital, especially in nursing homes, and support to GPs who undertake home visits. Ability for GPs to access urgent advice from a geriatrician, either through a clinic appointment or a telephone call. Integrated teams between health and social approach. Geriatric Assessment Team at acute providers to better manage patients and improve outcomes. Increase in carer respite for those caring for their frail relatives. 4.2 Voluntary sector opinion At the voluntary sector workshop on 19 June 2013 the Frailty group considered what is important for the future?. Information, awareness and transport were the priority themes, with community transport being important, as well as reaching harder to reach groups and providing information on available services. There were also a number of comments and concerns around nutrition including: Ensure nutrition screening is carried out to identify malnutrition early and treatment is put in place. Increased dietetic provision in the community. Improve nutrition in care homes. Improve focus on food in hospitals. 6

9 5.0 The future direction The table below outlines the: issues we need to address, actions we will take, outcomes we will expect. What issues do we need to address? What actions are we going to take? Outcomes Poorly integrated services. Lack of geriontologist input at GEH. surgeries to proactively manage and co-ordinate care of the people at risk outside of hospital. Closely aligned health, social care and community teams working with acute providers to ensure a seamless admission into hospital and discharge from inpatient stay. Some admissions and length of stays will be avoidable with more appropriate non-hospital services and workable pathways. Ensuring that all opportunities for joint commissioning of integrated services are exploited. Exploring ways to appropriately address the rising admissions from residential homes where care is best provided in the community. GPs improving quality of care and life for patients and to help them to avoid emergency admissions to hospitals where possible (Direct Enhanced Service). Development of a specialist medical assessment unit (Frailty) at GEH site with geriontologist support in the community to prevent admissions and better treat patients outside of hospital. This is part of the Model for Urgent and Emergency Care. Increased number patients referred to community care teams as an alternative to hospital admission from agreed baseline. Agree integrated working model for health and social care teams across primary care, secondary care, social care and the voluntary sector. Increase in the number of people living well in the community with long term conditions as a result of the enhanced service in primary care. Reduce inappropriate admissions of over 65s to hospital. Decrease length of stay for patients over the age of 65. 7

10 What issues do we need to address? What actions are we going to take? Outcomes GPs inability to access urgent specialist opinion. Access to urgent specialist opinion for GPs to prevent patients being admitted unnecessarily. Patient has quicker diagnosis and treatment in the most appropriate place and reduction in unnecessary admissions. nutrition. Scrutiny of quality measures in care providers on offering good nutrition and hydration for our frail patients. Improved achievement of measures of good nutrition and hydration in hospital, and reduced complaints/incidents related to nutrition. between community services and nursing homes. Provide an enhanced service (Nursing Home Local Enhanced Service) to ensure admission to a nursing home and support to prevent unnecessary hospital admissions. Uptake and delivery against nursing home local enhanced service delivered by GPs, and a reduction in the number of inappropriate admissions to acute hospitals. Lack of support for carers. Work with Warwickshire County Council to implement the Carers Strategy Carers will have clear options for respite. Lack of outcomes information on care for our frail patients for commissioners and the public. Agree an Annual Plan from GEH outlining achievement against standards outlined in the Silver Book (The Geriatrics Society) as well as participating fully in all relevant national audits (e.g. stroke, hip fracture, dementia, falls, bone health and continence.) Annual plan for frailty by pathway and organisation patients. 8

11 6.0 What will change for our patients? There are times when the system does not work for our patients and we aim to improve on this. The following scenario provides an insight into what can happen now (when the system does not work well) and what would happen in the future following the proposed changes. Now Future John is 79 years old. He has had cancer twice in the past and has a series of long term conditions including diabetes. He has been feeling progressively more poorly over the last week and eventually his daughter is so concerned she takes him into A&E. He sees a junior doctor and it is not clear what is wrong with him so he is admitted for investigations. John sees the consultant on Monday as he was admitted during the night on Saturday. The consultant arranges a series of tests which are normal. The consultant asks the nursing teams to involve the community teams and social care but this takes some time to arrange. John is still in hospital two weeks later. John is 79 years old. He has had cancer twice in the past and has a series of long term conditions including diabetes. He has been feeling progressively more poorly over the last week and eventually his daughter is so concerned she takes him into A&E. He is seen by the geriatrician in the Specialist Medical Assessment Unit (Frailty) within an hour of presentation. there are no immediate reasons for concern. The geriatrician involves the community and social care team who are also based in the Urgent Care Centre and they arrange a package of care for John, rather than admitting him into hospital. John and, importantly his daughter, are clear about the package of care that has been arranged and have telephone numbers to contact. The geriatrician sends an immediate discharge letter to the GP who contacts John the next day to ensure everything is in place. 9

12 7.0 Timeframes for action Warwickshire North CCG believes that the changes we have proposed will benefit patient safety and improve quality of care. We anticipate that within the next three years all of these changes will have been implemented. A more detailed schedule of action is shown below. 2014/ / /17 Year 1 Year 2 Year 3 Implementation of integrated working between health, social care and voluntary sector. Training plan for nursing homes, linking with community team training. Implementation of Specialist Medical Assessment Team (Frailty) in Urgent Care Centre. Appointment of Geriatricians. Receive inaugural Annual Plan for Frailty. Geriatricians working in the community and linking directly with primary care. Teams working as a cohesive unit around the patient and across primary and secondary care. 10

13 Address: NHS Warwickshire North CCG Room 1 Lewes House College Street Nuneaton CV10 Tel: contactus@warwickshirenorthccg.nhs.uk Web: