DRAFTv9 Appendix 1 SCHEDULE 2 THE SERVICES. A. Service Specifications (Short Form Contract)

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1 DRAFTv9 Appendix 1 SCHEDULE 2 THE SERVICES A. Service Specifications (Short Form Contract) Service Specification TO BE COMPLETED BY CONTRACTING No. Service Enhanced Frailty Service Commissioner Lead Dorset Clinical Commissioning Group Provider Lead PLEASE USE POST OR DIRECTORATE NOT INDIVIDUALS Period 1 st April st March 2020 Date of Review 31 st March 2018 (Mid-point review) 1. Population Needs 1.1 National/local context and evidence base Enhanced services require an enhanced level of provision above what is required under core GMS / PMS and APMS contracts. The specification of this service is designed to cover the enhanced aspects of clinical care for severe and moderately frail patients all of which are beyond the scope of essential services. In 2014/15 the NHS paper Everyone Counts stated that CCG s shall be expected to support practices in transforming the care of patients aged 75 and above with a view to reducing avoidable admissions by providing funding to practices to develop schemes to deliver this. The CCG acknowledges that hospital admission is dependent on a number of factors and that the previous over 75 schemes are just one interrelated scheme. In order to improve prevention and care for frail and older people the NHS Five Year Forward View calls for better integration of GP, community health, mental health and hospital services, as well as more joined up working with domiciliary care and care homes and closer working with the voluntary sector. 1

2 DRAFTv9 Appendix 1 General Practice has evolved since the design and implementation of the Over 75 schemes in 2014 and strategically there is a clear direction towards developing integrated community and primary services (ICPS) new models of care, of which this scheme is an integral part. Therefore, this specification should be read in conjunction with Appendix A (Integrated Primary and Community Services, Community Care Model: Key Features, Functions and Outcomes). This specification moves towards delivering a service based on need and not age alone, recognising that the current service does not support younger and frail people. It is not expected that individual general practices deliver all of the service model within the specification. The specification asks practices to work with each other and partners within their health community to form the multi-disciplinary, sustainable and resilient health and care teams needed to support their population, making the best of the resources available. The ICPS model developed is based on stratifying the local population needs. This then allows us to configure service delivery around individual levels of need in the most appropriate way. The five broad groupings of population need are outlined overleaf. Frailty defining terms can be found in Appendix B Frailty Framework. 2

3 DRAFTv9 Appendix 1 The CCG recognises that one size does not fit all and frailty schemes will need to be tailored to meet population need, for example support for care homes may be the main requirement for one area but not another. Clear rationale behind choices of service delivery must be demonstrated to be of relevance to the locality population. In order to develop a comprehensive and useful frailty register, patients can be identified through the efi score, ideally combined with the rockwood score and clinical judgement. Localities are expected to develop Frailty Profiles with support from The CCG Business Intelligence Team, and localities will be required to consistently monitor the effectiveness of the service and adapt it in order to meet the outcomes required. 3

4 DRAFTv9 Appendix 1 Practices should work together at scale in a networked way, and with partners to deliver a broad team approach. There is also an expectation that teams will work with the community, voluntary, acute and local authority providers increasingly as an Accountable Care System to ensure a cohesive service for all patients providing full population coverage. There is also recognition that the focus of this service is on individual patient need as opposed to age. The CCG has developed a Frailty Framework (Appendix B) to support practices in taking a common approach to the early recognition, identification and management of frailty. For many patients, the response needs to be a non-medical model and is more about maintaining social contact with their community. This specification builds on the core requirements as detailed below: GP CORE CONTRACT REQUIREMENTS: As of the 1 st July 2017 there have been some key changes within the GMS contract which coincides with the Avoiding Unplanned Admissions DES ceasing on 31 March The funding of million was transferred into the global sum, weighted and without the out-of-hours deduction applied, and used to support the new contractual requirement on Identification and Management of Patients with Frailty. The national contract states that practices shall: 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; Identify patients living with severe frailty, and deliver a clinical review providing: o An annual medication review; o Where clinically appropriate discuss whether the patient has fallen in the last 12 months and provide any other clinically relevant interventions; Promote the Summary Care Record (SCR) by seeking informed patient consent to activate the enriched SCR; Code clinical interventions for this group appropriately (N.B Read codes detailed in Appendix C (work in progress)) Collect data on the number of patients: o Recorded with a code of moderate frailty; o With severe frailty; 4

5 DRAFTv9 Appendix 1 o With severe frailty with an annual medication review; o With severe frailty who are recorded as having had a fall in the preceding 12 months; o Severely frail patients who provided explicit consent to activate their enriched SCR. NHS England will use this information to understand the nature of the interventions made and the prevalence of frailty by degree among practice populations and nationally. This data will not be used for performance management purposes or benchmarking purposes. 2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators Domain 1 Preventing people from dying prematurely Domain 2 Enhancing quality of life for people with longterm conditions Domain 3 Helping people to recover from episodes of illhealth or following injury Domain 4 Ensuring people have a positive experience of care Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm 2.2 Local defined outcomes Outcome: Build on the core contract to understand your frail population Measure: Evidence of a comprehensive and useful frailty profile developed from efi scores, combined with Rockwood and clinical knowledge see Appendix D. No. referred to Memory Gateway Dementia diagnosis recorded and Read coded 5

6 DRAFTv9 Appendix 1 Improving health of the moderately and severely frail; Collaborative working across practices and providers; Promote the Summary Care Record Engagement with the Dorset Care Plan (WORK IN PROGRESS) 3. Scope Reduction in unplanned admissions; Reduction in over 65 years hospital bed days per weighted population benchmark against Chenmed level (supported by Business Intelligence) Reduction in Ambulatory Care Sensitive Admissions; No. of face-to-face polypharmacy reviews for patients identified with moderate frailty (Read coded). Evidence of a locality integrated care board that demonstrates collaborative working between practices and health care partners. The scheme is part of a wider multi-dimensional, interdisciplinary skill mix 2% of complete Summary Care Records; 2% of the most complex frail population with a completed Dorset Care Plan 3.1 Aims and objectives of service To improve prevention and care for frail and older people and to reduce avoidable admissions for this cohort of patients, building on the core requirements of the contract. 6

7 DRAFTv9 Appendix Service description/care pathway This specification focuses on the contribution of General Practice working at scale, to provide frailty schemes, by means of allowing access to patient lists across localities and with partner providers, to cover the enhanced aspects of clinical care for patients living with moderate and severe frailty within the ICPS model. It is imperative that the Practices/Locality work in alliance with other providers to ensure there is a focus on the appropriate skills and expertise to deliver the new models of care and to demonstrate this. For many patients, the response needs to be a nonmedical model and is more about maintaining social contact with their community. A model based on stratifying the local population needs and configuring service delivery with a multi-dimensional, interdisciplinary skill mix which by working with other agencies could include: Clinical GP / Specialist (Geriatrics & other general medical specialities); Pharmacy (this could be by linking with an existing community pharmacy or a joint appointment); Nursing (practice, community and specialist); Therapy; Care Co-ordinator; Voluntary Sector; Care navigator. Collaborative options practices could work at may include: Collaborative model other practices and with community services / other providers (Preferred option); Locality or cluster working; A network of practices; Practices working on behalf of another practice(s); Individual practice with an integrated multidisciplinary team (if the practice is large enough to deliver an MDT and is at sufficient scale) The expectation is that this will be a team approach and not reliant on the GP only. Please note: With all options there is an expectation that frailty teams work with partners in the health community e.g.:- Community, Acute, Voluntary and Local Authority Partners. 7

8 DRAFTv9 Appendix 1 LOCAL ENHANCED REQUIREMENTS This specification sets out the requirements to be delivered by General Practice preferably at scale for the needs of the patient to enhance the core requirements for the moderately frail. Schemes need to build on the basis of the core contract by developing collaborative working / systems of care, including non-medical / nonphysical support. The practice/collaborative/locality shall: Provide on-going case finding and risk stratification methods to identify people requiring proactive care (recommended tools are efi and the Rockwood scale combined with knowledge of the patient, please see Appendix D Frailty Developing a meaningful and accurate register). Dependent on the frailty profile of the local population this may include proactive assessment and management of people in their own home and / or care home settings. Provide proactive holistic assessment which will include: o Proactive working within the multi-dimensional, interdisciplinary system to plan, assess and provide intervention; o Where appropriate, phone and liaison approach with the wider MDT to gain specialist opinions on complex cases; o Where appropriate, promotion of self-management (including apps/improved guidance), telehealth, telecare, education, signposting - including partnership working with the voluntary sector; o Access and referral where appropriate to specialist pharmacist or provide in house prescribing reviews to undertake medicines review and reconciliation including on discharge from hospital; o A face-to-face medication review appropriate to the needs of the patient are set out by Dorset CCG Medication Review Guidance. Please see Appendix E. o Develop and support enhanced care into care homes; o Signposting of carers and families to relevant support recognising need for advocacy where appropriate; o Cognitive assessment and referral to the Memory Support and Advisory Service (MSAS), where indicated; 8

9 DRAFTv9 Appendix 1 Complete The Dorset Care Plan which includes: o A core care plan o An admission avoidance care plan which summarises the individuals wishes in the event of a crisis with regards to their own health (i.e. do they want to go to hospital, under what circumstances would they want to stay at home, whether there is a DNACPR order in place) or in the health of the carer should this deteriorate; o An advance care plan or end of life care plan which could describe the individual s wishes with respect to their preferred place of dying and whether they have just in case medications in place; o Upload all the above to the Summary Care Record (SCR) Please see Appendix F (work in progress) The Dorset Care Plan toolkit 3.3 Population Covered Those identified with moderate and severe frailty registered with a GP in Dorset. 3.4 Any acceptance and exclusion criteria. 3.5 Interdependences GP Core Contract there is a contractual requirement on the identification and management of patients with severe frailty. System working in line with the ACS. 4. Applicable Service Standards 4.1 Applicable national standards (eg NICE) 4.2 Applicable standards set out in Guidance and/or issued by a competent body (eg Royal Colleges) Enhanced Care into Care Homes (NHS England) 9

10 DRAFTv9 Appendix Applicable local standards Appendix A Integrated Community and Primary Services, Community Care Model: Key Features, Functions and Outcomes; Appendix B Frailty Framework. Appendix C Read codes Appendix D Frailty Developing a meaningful and accurate register Appendix E Medication review information Appendix F - Dorset Care Plan Toolkit 5. Applicable quality requirements and CQUIN goals 5.1 Applicable quality requirements (See Schedule 4 Parts A-D) 5.2 Applicable CQUIN goals (See Schedule 4 Part E) 6. Location of Provider Premises The Provider s Premises are located at: 7. Individual Service User Placement N/A 10

11 NHS Dorset Clinical Commissioning Group Integrated Primary and Community Services Community Care Model: Key Features, Functions and Outcomes Supporting people in Dorset to lead healthier lives February 2017

12 Contents Introduction... 3 Key Features and Functions of Integrated Community and Primary Care Services... 7 Very High Need... 9 High Need Moderate Need Routine Care Urgent and Unplanned Care Urgent Care Centres Urgent Primary Care Urgent Care visiting service Integrated Urgent Care Access, Advice, Assessment and Treatment Service (NHS 111 / GP OOH / Clinical Hub) Ambulance Service Integrated Community and Primary Care Services Community Care Model Outcomes Generic Community Care Model Outcomes: Admission Avoidance End of Life Care outcomes based on national ambitions for EOLC Generic Community Care Model Outcomes: Person Centred Care Generic Community Care Model Outcomes: Risk Stratification, Identification & Assessment and Care Planning Bibliography Page 2

13 Introduction Sustainability and Transformation Plan for local health and care Our Dorset (Sustainability and Transformation Plan) sets out the vision for Dorset s health and social care systems. It describes three programmes of work: 1. The Prevention at Scale programme will help people to stay healthy and avoid getting unwell 2. The Integrated Community Services programme will support individuals who are unwell, by providing high quality care at home and in community settings. 3. The One Acute Network programme will help those who need the most specialist health and care support, through a single acute care system across the whole country. Supported by two enabling programmes: The Leading and Working Differently programme focuses on giving the health and care workforce the skills and expertise needed to deliver new models of care in an integrated health and care system The Digitally Enabled Dorset programme will increase the use of technology in the health and care system, to support new approaches to service delivery. Dorset s health and care system is working together to deliver this five year plan in order to meet national priorities in line with the scale of change required and to close the gaps in health and wellbeing, care and quality, and finance and efficiency. A needs based approach to our interconnected programmes of work has been taken and is being supported by two enabling programmes: Leading and working differently focusing on giving the health and care workforce the skills and expertise needed to deliver new models of care. Digitally enabled Dorset to harness the power of technology and support digital innovation to support new approaches to service delivery. Page 3

14 Figure 1: Diagram showing the three tiers of care in the new model. ICS forms tier 2. What do we mean by Integrated Community Services (ICS)? Integrated community services from the middle tier of our plan (fig 1 diagram middle tier). This programme will transform general practice, primary and community health and care services in Dorset so that they are truly integrated and based on the needs of the local populations. Community based services will be led by multidisciplinary teams of health and care professionals, working together to meet the needs of people who have short term health needs, individuals with long term conditions and those requiring specialist care for severe or complex health needs. We will deliver all of these services in a way that makes it easier for people to access care when and where they need to, with a consistent and high quality experience for patients as they move between different parts of the integrated system. Our priorities are to: Support people to better manage their own health, with access to appropriate information and support we expect a 10% reduction in new outpatient attendances and a 25% reduction in follow ups. Provide care that is based on the needs of our local population, with services delivered at the times and places people need them. Enable more people to receive care at home and in the community, and to self manage long term conditions, to avoid having to visit hospital or being admitted as an inpatient we expect to reduce 25% unplanned emergency medical admissions and unplanned surgical admissions by 20%. Make sure our community services are able to support frail older people with long term conditions so that more care can be delivered closer to home. Improve personalised care for people with complex needs, including individuals with learning disabilities. Page 4

15 Adopt new technologies that will support a high quality, consistent patient experience throughout the health system, with standardised working practices and seamless communication between health professionals. Create integrated teams of professionals with the right skill mix (including students) in improved working environments, to support the delivery of the model of care as well as enhance skills acquisition and personal development opportunities. Make sure that our NHS buildings, resources and finances are used in a cost efficient way, including by planning care on a larger scale to achieve cost savings. (Sustainability and Transformation Plan) What are our aims? The model of care we propose aims to: Increase the number of people supported in community settings, such as their own homes or through community hubs, as an alternative to being admitted to major hospitals Increase the range of services on offer in the community Support health and social care staff working together across traditional organisational boundaries Provide a seven day service that is available for longer during the day Improve use of community hospitals as community hubs by consolidation of some or increased use of others Ensure that the mental health and wellbeing of patients is an integral part of local services. Creating a network of community service hubs We will establish a network of community service hubs each providing a range of health and care services which will provide the following: ROUTINE CARE RAPID SAME DAY ACCESS SELF MANAGEMENT SUPPORT OUTPATIENT APPOINTMENTS URGENT AND UNPLANNED CARE SECONDARY CARE CONSULTATIONS REHABILITATION SPECIALIST CARE AND SUPPORT To deliver our priorities we intend to create a network of community hubs throughout Dorset. These hubs will enable people to access a wider range of health services, from routine care to urgent and specialist care, closer to their homes. Page 5

16 Mixed teams of health and care professionals, will staff the hubs providing assessment and care for people who have physical and mental health needs. They will offer services for children, adults and our growing older population. The health and care system will address a wide range of different needs of our local population, including: People who are mostly healthy but with some episodic health needs, such as young children, pregnant women and people with short term illnesses People at moderate risk of requiring higher sudden levels of care need, or sudden care needs, including those with long term conditions, learning or physical disabilities, and frail older people People with a very high risk of deterioration in their health, which require regular supervision and support, including people at the end of life and those with multiple health and social care needs. The services will include: Routine care including traditional primary care, screening, baby clinics and checks, contraception services and prevention advice Rapid same day access to GP led urgent care, with on site diagnostic testing including imaging and x rays Self management support for patients with long term conditions Outpatient appointments Urgent and unplanned care Secondary care consultations and minor procedures Rehabilitation and services to support recovery after periods of ill health Specialist care and support for people with complex needs, including 24/7 crisis support to help people receive the urgent care they need without going into hospital. Page 6

17 Key Features and Functions of Integrated Community and Primary Care Services The integrated community services new model of care illustrated below has been developed to meet the different levels of need of our local population. It is recognized that people may move up and down the levels of need depending on their stage of health and wellbeing. Page 7

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19 Very High Need Definition Those people with a very high risk of deterioration, requiring case management, regular supervision and support, e.g. people in the final phase of life, people with multiple health and social care needs. Individuals will have comprehensive care plans in place that are regularly reviewed to include an escalation plan, urgent care plan and advance care plan. Response will include rapid access to assessment and multidisciplinary care if the service user shows signs of deterioration/crisis. Workforce requirements Extended integrated primary care teams including GP, Consultant, GP with specialist interest, nurses, pharmacist, support workers, mental health professionals, Allied Health Professionals (AHP s therapists) community and voluntary sector and social care with access to specialist advice and support e.g. geriatrician, Mental health professional, rheumatologist, cardiologist, specialist nurses, dieticians, podiatrists, Emergency Care Practitioner, specialist palliative care. Location Initial assessment at home or usual place of residence. Access to step up beds within a community hub close to home may be required. More specialist assessment may be required within the day assessment/ facility of a community hub. Page 9

20 High Need Definition Those people in a stable condition but at high risk of escalating to higher levels of need and requiring more intense levels of care, e.g. frail people and those with multiple long term conditions, severe learning and physical disabilities. Care, support, planning and provision for people with high intensity needs, who have complex care needs, such as those people with Long Term Conditions (LTCs). The provision of this element of the service will focus on personalised plans to reduce the risk of patients becoming unstable, preempting escalation requirements and to reduce the need for unplanned care. Workforce Requirements Extended integrated primary care teams including GP, Consultant, GP with specialist interest, integrated community teams, pharmacist, mental health professionals, AHPs, support workers, community and voluntary sector and social care with access to specialist advice and support e.g. geriatrician, Mental health professional, rheumatologist, cardiologist, specialist nurses, dieticians, podiatrists, Emergency Care Practitioner, specialist palliative care. Location Home or usual place of residence. More specialist assessment may be required within the day assessment/ facility of a community hub. Page 10

21 Key features and functions for ICPS to support those with very high or high needs Identification system in place e.g. Electronic Frailty Index (efi) Case management approach to proactively managing the very high/ high need population identified through risk stratification processes Home based provision of care and rehabilitation Response will include rapid access to the MDT for assessment and care if the service user shows signs of deterioration/crisis. Additional support if required from the rapid response service based in a hub 7/7 from 8.00 am 8.00 pm, responds to request from senior clinical decision maker. The health and social care coordinator/case manager is informed and care plan updated by the relevant health or social care professional The MDT consists of GP/ GP extensivist or advanced nurse practitioner with medical prescriber role, community nurse, community matron, therapists, social care worker and dedicated administration. Access to specialist advice and support e.g. geriatrician, psychiatrist, rheumatologist, cardiologist, specialist nurses, dieticians, podiatrists, Emergency Care Practitioner, specialist palliative care Access to diagnostics Holistic assessment, planning and coordination of care from key health and social care worker with trusted and shared assessments e.g. Comprehensive Geriatric Assessment A completed Dorset Care Plan including o An escalation plan what an individual and their carer might need to look out for; when and who to call or what to do if there is a problem o An urgent care plan which summarises the individuals wishes in the event of a crisis with regards to their own health (i.e. do they want to go to hospital, under what circumstances would they want to stay at home, whether there is a DNACPR order in place) or in the health of the carer should this deteriorate o An advance care plan or end of life care plan which could describe the individual s wishes with respect to their preferred place of dying and whether they have just in case medications in place Support for carers/family Voluntary sector support social isolation, wellbeing and support Proactive and coordinated input to care homes / supplement the care to high risk patients in care homes Access to step up/step down beds within a community bedded hub Community Pharmacy providing and sharing medicine reviews including on discharge from hospital Identification of high risk individuals in the community, coming to the end of their life, working to support them to die at home care home, in a community hospital or as close to home as possible for those, who are unable or do not wish to remain in their own home. Seamless working with the patient s GP and primary health care team to ensure seamless communication and high quality care. Working in an i t t d ith i li t lli ti id h i d Page 11

22 Moderate Need Proactive ongoing care for people with moderate needs Definition Proactive and targeted ongoing care For those people in a stable condition but at moderate risk of requiring higher levels of care, e.g. frail people and those with multiple long term conditions By providing input in community settings to help manage care needs, support self care, prevent exacerbations and need for tertiary care emergency intervention and help join up clinical care across primary and secondary settings, cutting down unnecessary appointments and hospital attendances. Workforce requirements Primary care/extended Primary Care teams; Locality Integrated health and social care teams; Early help/third sector support; Access to specialist support/advice Location It is expected that people will be supported to remain at home or their usual place of residence by accessing coordinated services as close to home as possible e.g. within locality/cluster area Early help support, education, and signposting will be offered within local communities Page 12

23 Key features and functions for ICPS to support those with moderate needs Case finding and risk stratification methods required to identify people requiring proactive care Named care coordinator approach to proactive assessment, care planning, intervention and review Person centred, coordinated care with personalised care and support plan documenting optimal maintenance of health and function goal orientated rather than disease focused (support people to thrive, not just survive) Integrated MDT approach to proactive planned assessment and intervention Longer primary care consultations for individuals with multiple long term conditions Named care coordinator from extended primary care team Trusted and shared assessments More focus on: Self management (including apps/improved guidance), Telehealth, education, signposting including partnership working with the voluntary sector Support for carers and families Proactive input and support for care homes Access to diagnostics All individuals with frailty have at least an annual holistic review by their GP based on the principles of the Comprehensive Geriatric Assessment (medical, functional, psychological and social needs) with specialist support when needed. Includes identification of cognitive impairment and dementia Phone and liaison approach for Primary care and MDTs to gain specialist opinions on complex cases Specialist presence on select MDTs (e.g. LD, mental health, diabetes specialist) People are able to access specialist opinions and services in the community, rather than having to go to the acute hospital for an outpatient appointment and receive care support, self care and prevention advice Community Pharmacy providing medicine reviews including on discharge from hospital Safe and well visits Dorset & Wiltshire Fire and Rescue Page 13

24 Routine Care Definition Fast and effective, high quality, accessible planned services incorporating: Routine primary care delivered by GPs, nurse practitioners, wellbeing practitioners but also using technology to provide advice at home Primary care practitioner focused rather than GP focused Delivering a focus on prevention activities with treatment advice and support. Promotion of selfmanagement and self care Primary care or community based diagnostics Workforce requirements Increasingly nurse focused and incorporating voluntary and third/independent sector support Better utilisation of GP s with Special Interest Social Care coordinators to be available across localities, networks and hubs, providing an interface for patients and service Early help services Location Routine care predominantly community based Page 14

25 Key features and functions for ICPS to support those with routine care needs Services responding to the holistic needs of people to include consideration of social and psychological needs as well as their physical needs A significant focus on prevention through delivery of education, screening and the promotion of self care and self help activities. Focus is on primary care nurse delivered care, rather than GP delivered care, with the voluntary and Third Sector embedded in delivery of services Safe and well visits Dorset & Wiltshire Fire and Rescue Education and group classes delivered through community based facilities such as community health centres Clear and accessible sign posting of services, prevention activities, education and group classes available through digital technology Diagnostics available closer to home and through community facilities such as integrated community hubs More planned care services, including low risk procedures, taking place in community settings closer to people s homes or in their communities Rehabilitation services available to people on their return from hospital to their normal place of residence Annual health checks and routine care services for those who require monitoring of their health and social care needs o Integrated IT and innovative use of technology to drive improvements in access to and sharing of information. Better utilisation of Telehealth, Tele Care and digital technologies Clinical assessments and treatment taking place during same visit where possible and including diagnostics and pharmacy Access to other services co located in a single location where appropriate Initial assessments taking place in primary care and only with GP if required Page 15

26 Urgent and Unplanned Care Urgent Care Centres Urgent Care Centres are community and primary care facilities providing access to urgent care for minor injuries and illness to a local population. Urgent Care Centres should normally have a medical or non medical prescriber present throughout their hours of operation. They will support the local community and provide quick competent assessment and treatment, linking to Rapid Response services. Urgent Care Centre to be co located within the Planned Acute Site or within community hubs. In non co located units use of telemedicine should be considered to develop and enhance services to prevent the need for transfer to the Emergency Department where clinically safe. Urgent Primary Care Future blueprints are being discussed locally within Primary Care. There is the potential to stream off urgent primary care, providing it differently, perhaps at scale as part of a multidisciplinary approach as part of an urgent care system. The urgent primary care offer may include a range of options for patients to access same day care including telephone consultations, e consultations, walk in clinics and face to face appointments. A clear mechanism is in place to ensure primary care takes part in the discharge planning of frail and vulnerable patients following an urgent / unplanned presentation. Urgent Care visiting service Provide an immediate response to people in the community, the aim of the service is to prevent patients, in their own home and under the care of their GP, from being admitted into hospital if they become unwell and are safe to remain at home. Senior nurses, mental health nurses, therapists, rehabilitation assistants and social workers make up the teams. A person in need can be rapidly assessed by a senior nurse or therapist and a care plan and care package put in place to help the person remain at home. The community urgent care response team can also help in rehabilitation of people once home from hospital ensuring that people return to their daily routine as soon as possible. An urgent care response here would result in rapid assessments by either health or social care either in the home or in a unit, and the right level of intervention undertaken. This way of working will ensure people access the services quickly and are assessed and enabled effectively. Page 16

27 Integrated Urgent Care Access, Advice, Assessment and Treatment Service (NHS 111 / GP OOH / Clinical Hub) An enhanced 111 will act as a Single Point of Access (SPoA) working in an integrated way with GP OOH, which will be required to use a visiting model which interfaces with Community Hubs and integrated locality teams. Primary care out of hours services need to have arrangements in place with NHS111 to enable call handlers to directly book appointments where appropriate. Additional clinical expertise will be available in/via NHS 111 call centre (e.g. Pharmacy, dental, MH and GPs, Dorset labour line). Special Patient Notes (SPNs), end of life and anticipatory care plans are available at the point in the patient pathway which ensures appropriate care. A Local Directory of Services that holds updated accurate information across all acute, primary care, community, and social care services including third sector organisations. Clear protocols to direct patients to community pharmacies where these can appropriately respond to patients needs. Ambulance Service Maximising appropriate non conveyance rates to ED is an important enabler to keeping patients out of hospital. By developing integrated community and primary care services, the ambulance service can become a mobile urgent treatment service (NHSE, 2014). Page 17

28 Key features and functions of Urgent Care Access, Advice, Assessment and Treatment Service Provides access to a broad range of physical and mental illness and injury care for both adults and children for which clear pathways of care are present UCC open and staffed consistently for a minimum of 16 hours daily (365 days per year) e.g midnight) Where appropriate, provision of health and wellbeing advice and sign posting to local community and social care services where self referral is accepted (for example, smoking cessation services and sexual health, alcohol and drug services). Provision of psychiatric liaison interventions in areas where need identified. Agreed working protocols with ambulance service to convey patients to UCC where patient s condition is suitable for primary care management. Agreed working protocols with ambulance service to facilitate rapid transfer to an Emergency Department Agreed escalation protocols that ensure seriously ill/high risk patients presenting to an UCC are assessed immediately and rapidly transferred to emergency centres where appropriate. Access to real time support and advice from experienced doctors in primary and secondary care without necessarily requiring patients to be transferred to another service Agreed pathways to facilitate smooth transfer/access into other community based and primary care services Integrated diagnostic facilities. Urgent Care Centres should normally have on site plain film x ray and blood testing, reporting and analysis. Immediate access to the following equipment at all Urgent Care Centres: a full resuscitation trolley; a defibrillator (this may be an automated external defibrillator); oxygen; suction; emergency drugs. Adopts a see & treat approach (triage deemed inappropriate in UCC settings) with the aim of managing most patients within 2 hours of presentation Access to up to date electronic patient records Dorset Care Record Page 18

29 Integrated Community and Primary Care Services Community Care Model Outcomes End of Life Care outcomes based on national ambitions for EOLC Each person is seen as an individual personalised care planning, mechanism for a person to review and update their wishes and preferences Each person gets fair access to care Each person and their family/ those close to them receive maximum comfort and wellbeing Care is coordinated and information is shared e.g. advance care plan Staff feel skilled and competent in the assessment and management of EOLC symptoms and to have honest conversations Families and communities feel supported and able to support those people approaching the end of life Outcomes measures developed by DHUFT in EOLC Vision and NICE Quality Assessment tool Satisfaction survey Primary care audit Generic Community Care Model Outcomes: Admission Avoidance Decrease or maintain avoidable hospital admissions for individuals with very high and high needs Decrease in readmissions for individuals with very high and high needs Staff groups are able to access the Summary Care Record and view the patients care plan where in place Reduction in time spent in hospital (bed days) acute and community Safe transfer of individuals between acute care and community services Decrease in ED attendances Increase in number of polypharmacy interventions Page 19

30 Generic Community Care Model Outcomes: Risk Stratification, Identification & Assessment and Care Planning System to identify frailty/vulnerable/deprived individuals in place e.g. efi, encounter screening, triggers System in place to risk stratify the identified cohort of patients Agreed common approach to CGA in place and in use Universal agreement to and use of Dorset Care Plan across extended teams for high intensity users Generic Community Care Model Outcomes: Person Centred Care Individuals are engaged in decisions about their care and have a single care plan which can be shared AND is reviewed on an agreed basis Care is coordinated through a single point of access Each individual has a proactive care and support plan based on their needs, preferences and goals A named accountable GP has overall responsibility for their care Community health and social care staff work together to provide joined up care A named care coordinator will make sure an individual s care is proactive and joined up Individuals and their Carers are satisfied with the quality of service received Individuals are less dependent on support from health and social care following an episode of reablement or rehabilitation Individuals and their Carers have an improved quality of life as a result of the service received Individuals experience improved function and well being following intervention Individuals are given choice about how they manage their needs now and in the future. Individuals feel able to self manage Prevention advice, early diagnosis and intervention is available utilising technology eg Skype where available Emotional, psychological and practical support is available when required access to local community support and signposting Dorset Anticipatory Care Plan completed Quality reporting Satisfaction survey Number people accessing social prescription services Page 20

31 Bibliography Dorset Healthcare NHS Foundation Trust. (2016). End of Life Care: Vision. Our Dorset. (n.d.). Sustainability and Transformation Plan. Retrieved from transformation plan/: %20WATERMARK.pdf NHS England Safer, Faster, Better: Good practice in delivering urgent and emergency care (2015) NHS England Guidance for commissioners regarding Urgent Care Centres, Emergency Centre and Emergency Care Centres with specialist services (Developmental guidance, 2015) NHS England NHS 111 Commissioning Standards (2014) Page 21

32 NHS Dorset Clinical Commissioning Group Helping People Thrive Not Just Survive A Framework for Frailty in Dorset March 2017 Supporting people in Dorset to lead healthier lives

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34 Contents Introduction... 5 The Vision... 6 The Framework... 6 Key Actions for the Recognition and Management of Frailty in Primary Care... 6 Recognising & Identifying Frailty... 7 How to Case Find?... 7 Assessing Frailty... 8 Frailty Read Codes... 9 Frailty as a Long Term Condition... 9 Key Features and Priorities... 9 Comprehensive Geriatric Assessment (CGA) Care & Support Planning Managing Specific Frailty Syndromes across the Primary/Community/ Acute Care Divide Monitoring for Polypharmacy Acute and Emergency Care Management Integrated Community Services Education and Training Principles of Care in Nursing and Residential Homes Early Help and Third Sector Support Conclusion References Appendix 1: Features of Frailty Appendix 2: Recommended Identification Tools Primary care Electronic Frailty Index: Page 3

35 The Electronic Frailty Index Guidance Notes Tools to Identify Frailty in Community & Hospital Settings PRISMA Gait Speed Test Rockwood Frailty Scale Groningen Frailty Indicator Questionnaire ISAR Screening Tool Page 4

36 Introduction The Dorset Framework for Frailty has been developed by Dorset Clinical Commissioning Group (CCG) through multi sectorial collaboration with health and social care providers, voluntary and third sector organisations, patients and their representatives. It is endorsed by the Dorset Frailty and End of Life Care Reference Group. The development of the framework is a response to the request for a common approach to the early recognition and identification of frailty as a long term condition, promoting early detection through case finding, appropriate assessment, risk stratification; and backed up by planned and coordinated care and support. The British Geriatric Society (BGS) defines frailty as: A distinctive health state related to the ageing process in which multiple body systems gradually lose their in built reserves. (BGS 2014:2) The BGS definition goes on to state that around 10% of people aged over 65 years will be living with frailty and for those people a minor event can frequently trigger major health changes or deterioration and therefore it is important to recognise and identify these changes early. Frailty is not an inevitable part of ageing; it is seen as a long term condition in the same way as diabetes or Alzheimer s disease For people living with frailty the state for an individual is not static; it can be made better and worse. Frailty is a spectrum condition that spans from mild to severe In Dorset about 17,000 people would fall within this definition. Of Dorset s estimated population of 765,700 some 173,000 are aged 65 and over. Of these around 6,200 are 85 or over; a figure which is said to rise to 9,300 in the next 25 years. (ONS 2015 Office of National Statistics accessed online March 2016) See Appendix 1: Features of Frailty Page 5

37 The Vision The vision for NHS Dorset CCG is that all people living with frailty have their condition recognised early and proactively managed within an integrated coordinated care pathway which meets the needs and expectations of the individual, their carers and advocates. Coordinated care defined by National Voices states: I can plan my care with people who work together to understand me and my carer(s), allow me control, and bring together services to achieve the outcomes important to me. The Framework This Framework aims to provide all health and social care providers across Dorset with a model designed to support those living with frailty to not just survive but to thrive. It is designed for use by clinicians, in conjunction with the person, their carers / advocates and all members of the multi disciplinary team to develop a co ordinated plan of care that supports the person living with frailty to proactively manage their condition. The Framework supports the following questions: How do we identify frailty as a trigger to ensure people are supported appropriately within the health and social care system? How do we recognise that frailty is a long term condition living WITH frailty rather than BEING frail? How do we do this in a way that is acceptable for older people and enables them to work in partnership? Key Actions for the Recognition and Management of Frailty in Primary Care Assess older people for frailty during all healthcare encounters Provide clear links to the voluntary sector and early help Identify the needs of carers/families and signpost to support as appropriate Encourage advance care planning discussions at the earliest opportunity, including conversations regarding potential transitions such as care at home or moving to a formal care setting Record frailty, and frailty severity, using Read codes Page 6

38 Record known diagnosis of dementia using Read codes In people with moderate or severe frailty, carry out a Comprehensive Geriatric Assessment (CGA) to: Diagnose medical illnesses and optimise treatment Conduct a medication review Generate the Dorset Anticipatory Care Plan in collaboration with the integrated community services team Refer for specialist assistance in complex or uncertain diagnoses Share Enhanced Summary Care Record between primary care, emergency services, secondary care and social services In people with very severe frailty, support with end of life planning Recognising & Identifying Frailty ALL encounters between health and social care staff and older people should promote a discussion that includes an assessment of frailty Frailty should be identified with a view to maintaining and restoring control, preserving dignity and facilitating person centred care for the person and those close to them, improving outcomes and avoiding unnecessary harm. Many people with multiple long term conditions will also be living with frailty which may be overlooked if the focus is on disease based, longterm conditions such as diabetes or heart failure. How to Case Find? To provide the appropriate care and support, we need to engage proactively; the first step is to identify that a person is living with frailty. Primary Care and all services engaged with the care of older people need to be able to case find and identify those at risk and act upon that knowledge. Identification that the person is experiencing any of the following problems may trigger recognition of frailty: Falls (e.g. collapse, legs gave way, found lying on floor ) Immobility (e.g. sudden change in mobility, gone off legs, stuck in toilet ) Delirium (e.g. acute confusion, sudden worsening of confusion in someone with dementia or known memory loss) Page 7

39 Incontinence (e.g. change in continence new onset or worsening of urine or faecal incontinence) Susceptibility to side effects of medication Those housebound or known to community nurses this data could be obtained from those community nurses who visit for flu vaccines, if not Read coded Those with mild cognitive impairment Those on the dementia register Those on a LD register Those with serious mental illness Those on end of life care register or cancer care registers Those on community matron or district nursing caseload Those on >7 medications Those with neurological conditions, e.g. stroke, MS, Parkinson s disease Those with rheumatological conditions Those with respiratory and cardiovascular conditions e.g. COPD, heart failure Those known to Adult Social Care and Support Services Social isolation (can be a cause and a result of frailty) Key Actions Once Frailty Is Identified and Recognised Assessing Frailty There are a number of assessment tools currently available; these are outlined in detail in Appendix 2 and include: Electronic Frailty index PRISMA 7 Gait Speed Test Rockwood Frailty Scale Groningen Frailty Indicator Questionnaire ISAR Screening tool Page 8

40 Once recognized as a syndrome and a long term condition frailty can be classified as a continuum from mild frailty to severe frailty and should be coded as shown in the table below: Frailty Read Codes CTV3 Read V2 X76Ao Frailty 2Jd. Frailty XabdY Mild frailty 2Jd0. Mild frailty Xabdb Moderate frailty 2Jd1. Moderate frailty Xabdd Severe frailty 2Jd2. Severe frailty Frailty as a Long Term Condition Mild frailty: Self management advice, signpost to external agencies, exercise Moderate frailty: Assessment and development of a care plan in which Comprehensive Geriatric Assessment (CGA) becomes an integral part of the plan, Dorset Anticipatory Care Plan completed Severe frailty: Anticipatory care planning and end of life care planning is undertaken with the person and carer. If it has not occurred before CGA is offered. End of Life Recognition and Care: Recognise the end of life and support the person with end of life issues [The blocks below represent amount of need/work. Numbers will be inversely proportional] Severe Frailty Moderate Frailty Case management Anticipatory care planning Page 9 Mild Frailty Self-management Exercise Signposting CGA Proactive case management Use of external agencies to support individual and carer/family Admission avoidance Treatment escalation planning EOLC planning

41 Key Features and Priorities The assessment will define the level of frailty experienced; ensuring that the appropriate care, support & proactive management can be planned, agreed and shared. Every area will follow the framework as a system to identify people at risk of frailty Once frailty is identified as moderate a Comprehensive Geriatric assessment (CGA) will be undertaken by the multidisciplinary team (MDT) in collaboration with Primary Care and community services (including older people s mental health services) and a Dorset Anticipatory Care Plan completed with the individual and their family, carers or advocate Every person living with severe frailty will have an agreed and shared Dorset Anticipatory Care Plan and appropriate Treatment Escalation Plan (TEP) in place. Comprehensive Geriatric Assessment (CGA) This is a multidimensional assessment, treatment plan and regular review delivered by a multidisciplinary team (MDT). Evidence from cases where a comprehensive assessment has been useful suggests that the team should consist of: A competent specialist physician in medical care of frail and older people A coordinating specialist nurse with experience of frail and older people A social worker or a specialist nurse who is also a care manager with direct access to care services Dedicated appropriate therapists Access to mental health team The patient, and their family, carers, friends or advocates Although CGA is commonly conducted in hospital settings, there is evidence that provision of CGA to older people with frailty in community settings could reduce hospital admissions, admissions to nursing homes and increase the chance of continuing to live at home (Berwick et al. 2010). Other circumstances which warrant a comprehensive assessment include: Acute illness associated with significant change in functional ability Transfers of care for rehabilitation/reablement or continuing care A person prior to surgery or experiencing two or more geriatric syndromes or falls, delirium, incontinence or immobility Page 10

42 Care & Support Planning The CGA and Dorset Anticipatory Care Plan should be created in collaboration with the person, their carers or advocates and the MDT to outline goals, roles and responsibilities for the proactive management of the condition. This will be agreed and made accessible to those involved in that individual s care. This will ensure the person living with frailty defines what is important to them, their family, carers and advocates, in terms of their future care. The Dorset Anticipatory Care Plan includes a Self Care Management plan, an Advance Care Plan and a Treatment Escalation Plan (TEP). Managing Specific Frailty Syndromes across the Primary/Community/ Acute Care Divide Specific Symptoms: Delirium Falls Dementia with Frailty Incontinence Immobility Polypharmacy Delirium Delirium (sometimes called an acute confusional state) is a common clinical condition characterized by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually lasts 1 2 days (NICE, 2010). As we age, the risk of Delirium increases and 15 26% of these persons will die (Fox et al., 2012). The older person who presents with delirium offers a challenge to the practitioner that will often lead to the person being admitted. Frail older persons are at higher risk of Delirium and subsequent admission than those who are not frail (Verloo et al., 2016). Up to 31% of all admissions are due to delirium (Siddiqi et al., 2006) and many who are frail will die. In 90% of all cases causes can be determined and treated within a few hours therefore avoiding admission. Falls Frailty has been identified as an independent factor for falls (Rockwood, 2005) and falling should be recognised as a macro state indicator of complex system failure rather than a specific disorder of particular organs (such as the brain or heart). Existing clinical guidelines and risk assessments agree that falls require multifaceted assessment and holistic management (Nowak and Hubbard, 2009). Less than one in four people over 75 report receiving any support or advice in preventing further falls or progression of osteoarthritis (Melzer et al 2012 as cited in Oliver et al., 2014) Page 11

43 Every person who has been seen to require a falls risk assessment should be considered as potentially having frailty and equally every person identified as having frailty should be considered to be at risk of falls. Falls prevention is an important consideration in this group of persons. Dementia Although it is possible to have dementia in the absence of frailty and frailty in the absence of dementia, there is a large area of overlap between the two conditions. Dementia contributes to frailty and physical frailty contributes to cognitive impairment and dementia. It is important to identify cognitive frailty since there may be a component of reversibility within the multi dimensional approach. Joint working is particularly important for those with frailty and dementia and their carers. Improved information, advocacy and training will be required for all involved. It should also be recognised that a person with frailty is associated with risk of mild cognitive impairment. Continence Issues Urinary incontinence and lower urinary tract symptoms are highly prevalent in older adults, and are strongly associated with frailty. Despite this, frail older persons are underrepresented in the research evidence and much of the management of lower urinary tract symptoms. (Gibson, W. and Wagg, A., 2014). As in other frailty syndromes the causes are seldom one factor. There are often complex inter related issues that lead to incontinence and these issues need to be taken into account when considering management options. It is advised a continence assessment be conducted once a person is identified as living with frailty as many will not voluntarily admit to continence problems. Immobility Frailty can present in crisis as a sudden loss of mobility and functional independence. The common presentation of immobility should prompt the possible presence of frailty. Polypharmacy Older people have a higher risk of multiple diseases and illnesses and the physiological changes of ageing can masquerade as illness. They are more likely to be prescribed medication by their doctors and to take multiple medications. The risk of adverse drug reactions and adherence is high in this group of individuals particularly in those who are identified as living with frailty and people in this group are also likely to be receiving several medicines. Anticholinergics have long been linked to impaired cognition and falls risk, but (more recently) have also been linked to increased morbidity and mortality. Anticholinergics may also be a cause of constipation and urinary retention. Page 12

44 Many symptoms can be caused by medication which may include: Falls Confusion or altered cognition Decrease in functional ability Dizziness Constipation Incontinence Fatigue Depression Tremor Monitoring for Polypharmacy Monitoring for problems requires consideration of the increased risk of doing harm in elderly people from altered pharmacokinetics, comorbidity and polypharmacy. Some drugs, when used in elderly people, are more likely to be associated with an increased risk of adverse events. Assessing each individual person for problems will generally mean knowing age, weight, general well being, cognitive function, use of over the counter and complementary medications, specific renal and hepatic function, likely compliance, and an accurate understanding of the person s other conditions and medications (Best Practice Journal, 2013) The key principle when prescribing for older people (Best Practice Journal, 2013) is to consider quality of life as the most relevant outcome and: Treat the disease process rather than symptoms, be cautious about adding new medication Start low, go slow Monitor closely for adverse effects Manage the whole of the person s treatment regimen, including medication used for the treatment of dementia and other mental health conditions Medication reviews are therefore recommended with a pharmacist: Annually for persons who are taking a large number of medications (polypharmacy) this may include over the counter remedies with new medication after discharge from hospital after any change in condition of the person (both exacerbations and improvements) Acute and Emergency Care Management Using the principles set out by the Acute Frailty Network and Silver Book, ensure there is a Frailty Pathway from emergency care across the hospital with a view to preventing deconditioning by adhering to principles of facilitated early discharge to the usual place of residence as soon as possible. Key principles must include the following: All persons to be recognised as having frailty within all front door areas (e.g. ED, AMU, etc.) Page 13

45 Start a Comprehensive Geriatric Assessment (CGA) within 2 hours of attendance/admission. Complete the CGA and have had a plan documented with an expected date of discharge within 24 hours of admission. Plan for the Expected Date of Discharge and undertake an MDT review of the person daily. Consider whether all the tests have to be in hospital can the person be discharged and return rather than stay in hospital to decondition: Discharge to Assess Where people who are clinically optimised and do not require an acute hospital bed, but may still require care services are provided with short term, funded support to be discharged to their own home (where appropriate) or another community setting. Assessment for longer term care and support needs is then undertaken in the most appropriate setting and at the right time for the person. (NHS England Publications Gateway Reference 05871) Every day in hospital will have a meaningful active task completed to return the person home in as short a time as possible. There will be no wasted time for the person waiting unnecessarily due to delays e.g. Consider the use of Red/Green days as shown in the table below. Page 14

46 Integrated Community Services Many of the acute crises affecting people with frailty might be more safely managed in ways other than admission to an acute hospital, whilst remembering that a clinical assessment to identify the cause or combination of causes that precipitated the acute decline is of core importance. This has led to a need to ensure appropriate staff skills and competency in the care of older people, specifically in appreciating the complexity of care, when older people have multiple long term conditions, including dementia. Integrated Community Services Teams (ICST s) are developing methods to monitor and maintain a knowledge and intelligence around understanding who in their communities are at risk of frailty. MDTs (within Primary Care and integrated locality hubs) are utilised to discuss the management for these people and individual case managers are assigned to support those with moderate to severe frailty. In some cases, when integrated care cannot be carried out in the person s home, a short term step up/step down bed may be required for the purpose of providing rehabilitation, reablement or end of life care. Education and Training Every integrated community services team should have an identified Frailty Champion/Lead trained in how best to facilitate support for people identified as living with frailty. Training in the recognition and response to frailty will be offered to staff engaged with people who are at risk of frailty. These skills and knowledge will include the ability to: Define frailty Recognise and respond to frailty conditions Develop an understanding of when to manage the acutely frail person within their setting and when to seek specialist advice and support Recognise and respond to early signs of deterioration in acutely frail adults Have a knowledge and understanding of the pathophysiology of ageing Recognise deteriorating memory and dementia presentation Differentiate and respond swiftly to delirium and other frailty syndromes aiming for a reduction in acute hospital admission or where admission is required to have a minimum number of bed days as a result Understand mental capacity and safeguarding guidelines Principles of Care in Nursing and Residential Homes Prior to a person becoming a resident in a care home (with nursing or residential) the home manager, senior staff member or a trusted assessor is required to carry out a pre admission assessment to identify and agree that this person s needs can be met. Once in the home a number of assessments are carried out, including (but not exclusively) MUST, Waterlow, falls Page 15

47 risk, continence, medication review, etc., to generate a care or support plan, that includes input from the people involved in that person s care: including the integrated community services team, the home staff, the resident, their family, carers or advocate if that person lacks mental capacity. Through the development of Frailty Champions and the involvement of the multi disciplinary team the anticipated benefits would be improved health outcomes, enhanced satisfaction for residents and a more efficient use of resources (NHS Confederation, 2016). Early Help and Third Sector Support Prevention at scale, including self management, early help and third sector support is key to delivering the sustainability and transformation plan for local health and social care. Supported self management considers the needs and personal goals of the person then considers what support is required and how this can best be achieved, empowering individuals, their family, carers or advocates, to promote proactive care, meaningful activity and actively manage their condition/s. There are various early help schemes within Dorset at present, many of which support those individuals who are frail. Services responding to the holistic needs of people to include consideration of social and psychological needs as well as physical needs e.g. isolation A significant focus on prevention through delivery of education, screening and the promotion of self care and self help activities Safe and well home visits Dorset Fire and Rescue Education and group classes delivered through community based facilities such as community health centres Clear and accessible sign posting of services, prevention activities, lunch opportunities, education and group classes available through digital technology Conclusion The development of the Dorset Framework for Frailty is a response to the request for a common approach to case finding, assessment, care planning and case management for those who are frail. It enables a move away from disease based systems of care towards a more appropriate integrated, person centred approach to supporting those living with frailty. It has been shaped by local clinicians and supports the Sustainability and Transformation Plan for local health and care focusing on prevention and early help, integrated community services working in collaboration with acute services. Respect for the autonomy and dignity of the older or frail person must underpin our approach and practice at all times. As Dorset s vision develops and new ways of working emerge it is likely that innovative ways of addressing the needs of those who are frail will evolve. A whole systems approach with integrated health and social care services, providing a person centred approach provides the only means to achieve the best outcomes for older or frail individuals. Page 16

48 References Abel J, Pring A, Rich A, Malik T, Verne J (2013). The impact of advance care planning of place of death, a hospice retrospective cohort study. BMJ Supportive & Palliative Care, vol 3, no 2, pp Best Practice Journal (2008) Dilemmas: Principles of prescribing for elderly people Beswick AD, et al. (2008) Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta analysis. Lancet. 371: Beswick AD et al., (2010) Maintaining independence in older people. Reviews in Clinical Gerontology. 2010; 20(02): BGS, British Geriatric Society (2014) Fit for Frailty 1: Consensus best practice guidance for the care of older people living with frailty in community and outpatient settings. BGS, RCGP & Age UK. June 2014 BMJ (2004) Primary Care: 10 minute Consultation: Using the NO TEARS tool for medication review. BMJ; 329:434 Bridges J, Flatley M, Meyer J, Nicholson C (2009). Best practice for older people in acute care settings (BPOP): guidance for nurses (2009). London: RCN Publishing Company/City University. Budnitz DS, et al., (2011) Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med.; 365: College of Occupational Therapists (2013). Living well through activity in care homes: the toolkit. London: College of Occupational Therapy, London College of Occupational Therapists (2015) Occupational Therapy in the Prevention and Management of Falls in Adults, College Occupational Therapy, London. Clegg A, Young J, Iliffe S, Rikkert M, Rockwood K. (2013) Frailty in elderly people. The Lancet 2013; 381: Fonda, D., et al., (2015) Incontinence in Frail Elderly people, In: GMC (2013) Good practice in prescribing and managing medicines and devices Garfinkel D, Mangin D. (2010) Feasibility study of a systematic approach for discontinuation of multiple medications in older adults. Ann Intern Med. 170: Page 17

49 Gibson, W and Wagg, A., (2014) Urinary incontinence in the frail elderly: what do we still need to learn? Clinical Practice, July 2014, Vol. 11, No. 4, Pages Goulding M. (2004) Inappropriate medication prescribing for elderly ambulatory care persons. Arch Intern Med; 164(3): Imison C, Poteliakhoff E, Thompson J. (2012) Older people and emergency bed use. Exploring variation. Ideas that change healthcare. London: The King's Fund. Ipsos/Mori (2014) Understanding the Lives of Older People Living with Frailty: A qualitative investigation, Age UK, March Naylor, C. Mundle, C. Weaks, L. Buck, D. (2013) Volunteering in Health and Care Securing a Sustainable Future. The Kings Fund accessed on line: inhealth and social care kingsfund mar13.pdf 2014 NHS Confederation (2016) Growing Old Together: Sharing new ways to support older people accessed on line: 20old%20together%20 %20report.pdf Gateway Reference 04251/2016 NHS Confederation, Local Government Association, Age UK (2013). Delivering dignity: securing dignity in care for older people in hospitals and care homes. Commission on Dignity in Care for Older People NICE (2010) Delirium: Diagnosis, prevention and management Nowak, A., and Hubbard, R., (2009) Falls and frailty: lessons from complex systems, Journal of Royal Society Medicine, Mar 1; 102(3): Rockwood K. (2005) Frailty and its definition: a worthy challenge. J Am Geriatric Soc. 53: Oliver, D, Foot, K., and Humphries, R., (2014) Making our health and care systems fit for an ageing population, Kings Fund, London ONS 2015 Office of National Statistics accessed online March Statistics and census information Kings Fund (2012) The care of frail older people with complex needs: Time for a revolution. London, Kings Fund. Tadd W, Hillman A, Calnan S et al (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. Southampton: NIHR SDO Page 18

50 Sari AB, Cracknell A, Sheldon TA (2008). Incidence, preventability and consequences of adverse events in older people: results of a retrospective case note review. Age Ageing 2008; 37(3): Tsilimingras D, Rosen AK, Berlowitz DR (2003). Person safety in geriatrics: a call for action. J Gerontol A Biol Sci Med Sci; 58(9):M Verloo, H., et al., (2016) Association between frailty and delirium in older adult persons discharged from hospital Welsh TJ, Gordon AL, Gladman JR (2013) Comprehensive geriatric assessment a guide for the non specialist. Int J Clin Practice.68: Page 19

51 Appendix 1: Features of Frailty There are two models proposed for frailty by the British Geriatric Society. 1. The Phenotype model This describes a group of person characteristics (unintentional weight loss, reduced muscle strength, reduced gait speed, self reported exhaustion and low energy expenditure) which, if present, can predict poorer outcomes. Generally, individuals with three or more of the characteristics are said to have frailty (although this model also allows for the possibility of fewer characteristics being present and thus pre frailty is possible). 2. The Cumulative Deficit model. Described by Rockwood in Canada, it assumes an accumulation of deficits (ranging from symptoms e.g. loss of hearing or low mood, through signs such as tremor, through to various diseases such as dementia) which can occur with ageing and which combine to increase the frailty index which in turn will increase the risk of an adverse outcome. Rockwood also proposed a clinical frailty scale for use after a comprehensive assessment of an older person; this implies an increasing level of frailty which is more in keeping with experience of clinical practice. The British Geriatric Society states that: A central feature of physical frailty, as defined by the phenotype model is loss of skeletal muscle function (sarcopenia) and there is a growing body of evidence documenting the major causes of this process. The strongest risk factor is age and prevalence clearly rises with age. There is also an effect of gender where the prevalence in community dwelling older people is usually higher in women. Appendix 2: Recommended Identification Tools Primary care Electronic Frailty Index: The EFI uses a cumulative deficit model, which measures frailty on the basis of the accumulation of a range of deficits, which can be clinical signs (e.g. tremor), symptoms (e.g. vision problems), diseases, disabilities and abnormal test values. It is made up of 36 deficits comprising around 2,000 Read codes. The score is strongly predictive of adverse outcomes and has been validated in large international studies. The score can be used to define frailty categories. Page 20

52 The Electronic Frailty Index Guidance Notes The electronic frailty index (efi) helps identify and predict adverse outcomes for older patients in primary care. It is therefore useful to plan at an individual and whole systems level. Information for the efi is collected using existing electronic health record information at no extra cost The efi uses a cumulative deficit model, which measures frailty on the basis of the accumulation of a range of deficits, which can be clinical signs (e.g. tremor), symptoms (e.g. vision problems), diseases, disabilities and abnormal test values The efi is made up of 36 deficits comprising around 2,000 Read codes (follow link for map and table 1 in appendix for list of 36 deficits 1 ). The score is strongly predictive of adverse outcomes and has been validated in large international studies The efi is presented as a score (e.g. if 9 deficits are present out of a possible total of 36 the FI score = 0.25) higher scores indicate increasing frailty Higher scores indicate increasing frailty and greater risk of adverse outcomes (e.g. on average, those with an efi > 0.36 have a six fold increased risk of admission to a care home in the next 12 months and a five fold increased mortality risk, compared to fit older people). The efi can be used to score to define frailty categories: 1. Fit (efi score ) People who have no or few long term conditions that are usually well controlled. This group would mainly be independent in day to day living activities. 2. Mild frailty (efi score ) People who are slowing up in older age and may need help with personal activities of daily living such as finances, shopping, transportation. 1. Moderate Frailty (efi score ) People who have difficulties with outdoor activities and may have mobility problems or require help with activities such as washing and dressing. 3. Severe Frailty (efi score > 0.36) People who are often dependent for personal cares and have a range of long term conditions/multi morbidity. Some of this group may be medically stable but others can be unstable and at risk of dying within 6 12 months Notes%20for%20HAC%20Partners.pdf 2 Authored by: Sarah De Biase, Improvement Programme Manager, Healthy Ageing Collaborative Improvement Academy part of the AHSN Yorkshire and Humber Page 21

53 Tools to Identify Frailty in Community & Hospital Settings PRISMA 7 A score of three or more indicates frailty 1. Are you more than 85 years old? 2. Male? 3. In general, do you have any health problems that require you to limit your activities? 4. Do you need someone to help you on a regular basis? 5. In general do you have any health problems that require you to stay at home? 6. In case of need, can you count on someone close to you? 7. Do you regularly use a stick, walker or wheelchair to get about? PRISMA 7 has been used as an annual postal questionnaire to people aged over 75. Gait Speed Test Average gait speed of longer than 5 seconds to walk 4 meters is an indication of frailty. The test can be performed with any patient able to walk 4 meters using the guidelines below. 1. Accompany the patient to the designated area, which should be well lit, unobstructed, and contain clearly indicated markings at 0 and 4 meters. 2. Position the patient with his/her feet behind and just touching the 0 metre start line. Instruct the patient to Walk at your comfortable pace until a few steps past the 4 metre mark (the patient should not start to slow down before the 4 metre mark). 3. Begin each trial on the word Go. 4. Start the timer with the first footfall after the 0 metre line. Stop the timer with the first footfall after the 4 metre line. 5. Repeat three times, allowing sufficient time for recuperation between trials. Page 22

54 Rockwood Frailty Scale Page 23

55 Groningen Frailty Indicator Questionnaire For Patients to Use and Report The GFI is a validated, 15 item questionnaire with a score range from zero to fifteen that assesses the physical, cognitive, social, and psychological domains. A GFI score of four or greater is considered the cut off point for frailty. It is suitable for postal completion. Circle the appropriate answer and add scores Mobility Can the patient perform the following tasks without assistance from another person (walking aids such as a cane or a wheelchair are allowed) YES NO 1. Grocery shopping Walk outside house ( around house or to neighbour) Getting (un)dressed Visiting restroom 0 1 Vision 5. Does the patient encounter problems in daily life because of impaired vision? 1 0 Hearing 6. Does the patient encounter problems in daily life because of impaired hearing? 1 0 Nutrition 7. Has the patient unintentionally lost a lot of weight in the past 6 months (6kg in 6 months or 3kg in 3 months)? 1 0 Co morbidity 8. Does the patient use 4 or more different types of medication? 1 0 Cognition Page 24

56 YES NO SOMETIMES 9. Does the patient have any complaints on his/her memory (or diagnosed with dementia)? Psychosocial 10. Does the patient ever experience emptiness around him? E.g. You feel so sad that you have no interest in your surroundings. Or if someone you love no longer loves you, how do you feel? 11. Does the patient ever miss the presence of other people around him? Or do you miss anyone you love? 12. Does the patient ever feel left alone? E.g. You wish there is someone to go with you for something important. 13. Has the patient been feeling down or depressed lately? 14. Has the patient felt nervous or anxious lately? Physical Fitness 15. How would the patient rate his/her own physical fitness? (0 10 ; 0 is very bad, 10 is very good) 0 6 = 1, 7 10 = 0 TOTAL SCORE GFI = Page 25

57 ISAR Screening Tool The ISAR Screening tool can be used with a person who attend the Emergency Department, and is a self reporting tool to identify older people at risk who could benefit from early assessment and CGA. Page 26

58 Appendix C Read Codes Using the electronic frailty index (efi) Some GP EPRS are configured to convert the efi index result into a diagnostic (Read) code for the electronic health record (EHR). Batch-coding is where this process is undertaken for cohorts of people, effectively automating clinical diagnosis without clinical judgement. To support appropriate follow up action, it is important that the efi index result is subject to clinical review before entry into the EHR. It is recommended that this is not done for the following reasons: efi is not a clinical diagnostic tool: it is a population risk stratification tool; Automated diagnostic coding without clinical judgement will lead to inappropriate diagnosis of frailty with direct consequences for patient care; Such practice does not meet the core contractual requirement which includes clinician judgement to diagnose sever or moderate frailty; Patients incorrectly diagnosed may be subject to inappropriate clinical interventions or future care planning based on wrong diagnosis. Identification and management of frailty Read Codes Read v2 Read CTV3 Frailty Index 38QI. XabYS Mild frailty 2Jd0. XabdY Moderate frailty 2Jd1. Xabdb Severe frailty 2Jd2. Xabdd Express consent for core and additional Summary Care record dataset upload XaXbZ 9Ndn. Dementia data collection Read codes Read v2 Read CTV3 Assessment for dementia 38C10 XaaBD Dem Tect scale 38Qj. XabVK Everyday Cognition questionnaire 38Qv. Xabp1

59 Appendix C Read Codes Mini-mental state examination 388m. XM0fo Six item cognitive impairment test 3AD3. XaJLG GPCOG general practitioner assessment of cognition 38Dv. XaQJP Dementia screening declined 8IEu. XaaTn Dementia screening questionnaire declined 8IEu0 XaabA At risk of dementia 14Od. XaQyJ Initial memory assessment 38C15 Xaahy Initial memory assessment declined 8IEu0 Xaahx Referral to memory clinic 8HTY XaJua Referral to memory clinic declined 8IEn. Xaa9t Dementia care plan 8CMZ. XaaBZ Dementia advance care plan agreed 8CSA. XabEk Review of dementia advance care plan 8CMG2 XabEI Dementia care plan reviewed 8CMZ1 Xacly Dementia advance care plan declined 8IAe0 XabEi Dementia care plan declined 8CMZ2 Xaclz Dementia advance care plan review declined 8IAe2 XacM2 Dementia care plan review declined 8CMZ3 XacJ0 Medication review Read codes Read v2 Read CTV3 Medication review 8B314 8B314

60 Appendix C Read Codes Polypharmacy medication review B831B XaaCQ Medication review 8B3S. N/A Medication review done 8B3V. XaF8d Medication review done with patient 8B3x. XaJCO Medication review done by pharmacist 8BIC. XaloW Medication review done by doctor 8BIH. XaJHq Medication review additional 8BT.. N/A Medication review by practice nurse 8BT2. XaYO4 Medication review without patient N/A XaIVI Medication review done by nurse N/A XaJf4 Medication review done by medicines management pharmacist N/A XaXBe Medication review declined codes 8I3V. XaJf5 Summary Care Record Consent Preference The patient wants a core Summary Care Record (Express consent for medication, allergies and adverse reactions only) The patient wants a Summary Care Record with core and additional information (Express consent for medication, allergies, adverse reactions and additional information) The patient does not want to have a Summary Care Record (Express dissent for Summary Care Record (opt out) Read v2 9Ndm. 9Ndn. 9Ndo. Read CTV3 XaXbY XaXbZ XaXj6