Integration; Frailty; and efi

Transcription

1 Integration; Frailty; and efi John Young Geriatrician, Bradford Hospitals Trust, UK National Clinical Director for Integration & the Frail Elderly, NHS England

2 NHS England Older People & Frailty TODAY The Frail Elderly (i.e. a label) TOMORROW An older person living with frailty" (i.e. a long-term condition) Presentation late & in crisis (e.g. delirium, falls, immobility) Timely identification for preventative, proactive care by supported self-management & personalised care planning Hospital-based: episodic, disruptive & disjointed Community-based: personcentred & co-ordinated (Health + Social + Voluntary + Mental Health)

3 STRUCTURAL, RELATIONAL & CULTURAL FRAGMENTATION (SILOS OF PROVISION) HOSPITALS PRIMARY CARE SOCIAL CARE (LG funded & means tested) COMMUNITY HEALTH SERVICES DEMENTIA SERVICES COMMUNITY NURSING AMBULANCE SERVICES NURSING & CARE HOMES MENTAL HEALTH SERVICES PHARMACY VOLUNTARY SECTOR HOSPITAL-AT-HOME; VIRTUAL WARDS; COMMUNITY HOSPITALS; HOME THERAPY TEAMS; COMMUNITY MATRONS; SPECIALIST NURSES; CRISIS RESPONSE REAMS; PALLIATIVE CARE; RE-ABLEMENT SERVICES, etc, etc

4 STRUCTURAL, RELATIONAL & CULTURAL FRAGMENTATION (SILOS OF PROVISION) HOSPITALS PRIMARY CARE SOCIAL CARE (LG funded & means tested) COMMUNITY HEALTH SERVICES DEMENTIA SERVICES COMMUNITY NURSING AMBULANCE SERVICES NURSING & CARE HOMES MENTAL HEALTH SERVICES VOLUNTARY SERVICES PHARMACY VOLUNTARY SECTOR HOSPITAL-AT-HOME; VIRTUAL WARDS; COMMUNITY HOSPITALS; HOME THERAPY TEAMS; COMMUNITY MATRONS; SPECIALIST NURSES; CRISIS RESPONSE REAMS; PALLIATIVE CARE; RE-ABLEMENT SERVICES, etc, etc

5 Access to mental health input from intermediate care 2014/15

6 National Evaluation of (16) Integrated Care Pilots RAND Europe; Ernst &Young 2012 Integrating activities included: Narrative/collective vision; strong leadership Process improvements: care planning; new roles; MDT working Locality based teams & co-location Shared IT/ care records Governance and performance management Financial systems and incentives

7 Integration is about (people) relationships!

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9 Our loaded guns Integrated care & support pioneers 14 CCGs (+11) Year of Care Commissioning Model Integrated Personal Commissioning 5 CCGs (+35 fast followers) 9 CCGs Vanguard Programmes: Urgent & Emerg Care 8 CCGs Acute Care 13 CCGs MCP 14 CCGs PACS 9 CCGs Care Homes 6 CCGs

10 The burden of multimorbidity Applying NICE guidelines to a 78 yr old woman with previous myocardial infarction; type-2 diabetes; osteoarthritis; COPD; and depression.. 11 drugs (and possibly another 10) 9 lifestyle modifications 8-10 routine primary care appointments 8-30 psychosocial interventions Smoking cessation appointments Pulmonary rehabilitation (Hughes et al Age & Ageing 2013)

11 Frailty: key issues Related to the ageing process (Clegg, Young et al Lancet 2013) Around 10% of over 65s have frailty (Collard et al. JAGS 2012: 60; ) Increases to 25-50% of over 85s (Collard et al. JAGS 2012: 60; ) Independently associated with adverse outcomes, which are expensive (Falls; dependency; hosp admission; care home admission) Best understood as a long-term condition (Harrison, Young, Clegg, Conroy Age & Ageing 2015)

12 Developing the frailty narrative

13 The new narrative: Frailty as a long-term condition? A LTC is: A condition that cannot, at present, be cured but is controlled by medication and/or other treatment/therapies (DH 2012) Frailty is: Common (25-50% of people over 80 years) Progressive (5 to 15 years) Episodic deteriorations (delirium; falls; immobility) Preventable components Potential to impact on quality of life Expensive (Harrison, Young, Clegg, Conroy Age & Ageing 2015)

14 Making frailty visible: identification of frailty in practice 1 Comprehensive geriatric assessment (CGA) (Structured, multi-disciplinary assessment) 2. Simple assessments Gait speed/timed-up-and-go test Questionnaires (e.g. PRISMA 7) Brief clinical tools (e.g. Edmonton frail scale; Rockwood 7) 3. Routine data (is this possible?)

15 Development of a primary care electronic Frailty Index (efi) Existing primary care EHR ( SystmOne ) Read Codes (>80,000 8,000 2,200) Read codes map onto 36 DEFICITS Tested in ResearchOne (n=454,711 65y) Internal Validation Process (n=227,063 65y) External Validation Process (n=500, y)

16 efi National Spread (Year 1) Partners Engagement Count GP Practices 22 CCGs (n=211) 35 Clinical Commissioning Group (Pop approx. 250,000) at risk populations De-prescribing EoLC/ACPs Supported-self management etc, etc.. CSU 1 SCN 1 CLAHRC 1 Public Health (regional) Industry Partners 3 2 (ACG Systems) VCS 1 (Age UK Y&H)

17 Distribution efi: Frailty Severity Grade PRIMARY CARE Offer MDT assessment Offer C&S Planning Offer ACP

18 Candidate Preventable Components for Frailty Alcohol excess Cognitive impairment Falls Functional impairment Hearing problems Mood problems Nutritional compromise Physical inactivity Polypharmacy Smoking Social isolation and loneliness Vision problems Stuck et al. Soc Sci Med (Systematic review of 78 studies) Additional topics: Look after you feet Make your home safe Vaccinations Keep warm Get ready for winter Continence Preserving memory A Practical Guide to Healthy Ageing

19 Supported selfmanagement for people with mild frailty 1st Oct 2015: Partnership with Fire & Rescue Services to incorporate into 670,000 Safety and Wellness home visits targeting homebound people

20 NHS England Older People & Frailty TODAY The Frail Elderly (i.e. a label) TOMORROW An older person living with frailty" (i.e. a long-term condition) Presentation late & in crisis (e.g. delirium, falls, immobility) Timely identification for preventative, proactive care by supported self-management & personalised care planning Hospital-based: episodic, disruptive & disjointed Community-based: personcentred & co-ordinated (Health + Social + Voluntary + Mental Health)