Welcome to the Routine frailty identification in the GP contract webinar presented by Dawn Moody

Transcription

1 Welcome to the Routine frailty identification in the GP contract webinar presented by Dawn Moody The presentation will begin at 12.00pm. Attendees will be muted during the presentation to avoid interference. Attendees will be free to ask questions at the end of the presentation. Please note this webinar is being recorded.

2 Routine frailty identification in the GP contract Webinar Dawn Moody GP and NHS England s Associate National Clinical Director for Older People 28 th April 2017

3 GMS Contract 2017/18 3

4 Webinar Agenda Recent developments in the identification and management of frailty Opportunities that now present to improve care and support for people living with frailty How the GP contract aims to help us to realise these benefits

5 What is frailty? Reduced resilience and increased vulnerability to decompensation after a stressor event The most problematic expression of human ageing (Clegg 2013) INEPENDENT DEPENDENT Unpredictable recovery 5

6 Frailty Syndromes Side effects of medication Falls Delirium Incontinence FRAILTY SYNDROMES Immobility 6

7 Supporting people living with frailty Needs addressed in isolation Holistic approach to care Fragmented system of care Integrated system of care Reducing inequalities and improving care for people living with frailty

8 Fit for Frailty The British Geriatric Society, 2014/2015 Part 1 June 2014 Advice and guidance on the recognition and management of frailty in community and outpatient settings Part 2 January 2015 Advice and guidance on the development, commissioning and management of services for people living with frailty in community settings 8

9 Fit for Frailty Identifying frailty Developing & commissioning services Managing frailty Managing services 9

10 Frailty as Long Term Condition 10

11 Identifying frailty Opportunistic assessment

12 Identifying frailty Opportunistic assessment Population based approaches

13 GMS GP Contract 2017/18 Practices will use an appropriate tool e.g. Electronic Frailty Index (efi) to identify patients aged 65 and over who are living with moderate and severe frailty For patients identified as living with severe frailty, practice will deliver a clinical review providing an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12/12 Where a patient does not already have a Summary Care Record (SCR) the practice will promote this seeking informed patient consent to activate the SCR Practices will code clinical interventions for this group 13

14 What is the electronic Frailty Index? Tool for measuring frailty Based on cumulative deficit model of frailty Uses coded data in electronic primary care record

15 Cumulative Deficit Model of Frailty The more things that go wrong, the greater the risk of adverse outcomes At some point the number of problems becomes more important than the individual problems themselves. Expressed as a Frailty Index (FI), calculated as the number of deficits present/the total number of deficits being assessed, e.g. if 9 deficits are present out of 36 assessed, FI = 0.25 Fried et al. J Gerontol A Biol Sci Med Sci (2001) 56 (3): M146-M157 15

16 Deficits that make up the efi 20 Disease states e.g., Hypertension Arthritis Chronic Kidney Disease Ischaemic Heart Disease Diabetes Thyroid Disease Urinary System Disease Respiratory System Disease 1 Abnormal Laboratory Value Anaemia and haematinic deficiency Source: Supplementary data from Development and validation of an electronic frailty index using routine primary care electronic health record 36 Frailty deficits of efi 8 Symptoms / signs Polypharmacy Dizziness Dyspnoea Falls Sleep Disturbance Urinary Incontinence Memory & cognitive problems Weight loss & anorexia 7 Disabilities Visual Impairment Hearing Impairment Housebound Social Vulnerability Requirement for care Mobility & transfer problems Activity limitation

17 Fit (50%) or 0 4 deficits Mild Frailty (35%) > or 5 8 deficits Moderate Frailty (12%) > or 9 13 deficits Severe Frailty (3%) > 0.36 or more than 13 deficits What do efi scores mean? Source: Development and validation of an electronic frailty index using routine primary care electronic health record data Increasing efi = Increasing Frailty

18 Validation of efi Emergency bed days per 1,000 person year 7,844 4,195 2, Fit Mild frailty Moderate frailty Severe frailty Validated against outcomes associated with frailty, e.g. Emergency admissions Emergency bed days Nursing home admission Mortality Source: Analysis of supplementary data from Development and validation of an electronic frailty index using routine primary care electronic health record data

19 Validation of efi Emergency bed days per 1,000 person year 7,844 4,195 2, Fit Mild frailty Moderate frailty Severe frailty Validated against outcomes associated with frailty, e.g. Emergency admissions Emergency bed days Nursing home admission Mortality Source: Analysis of supplementary data from Development and validation of an electronic frailty index using routine primary care electronic health record data % Increase in efi from least fatigued quartile 36% 53% 119% Validated against fatigue, a phenotypic characteristic of frailty (separate research) - Least fatigued (Q1) Q2 Q3 Most fatigued (Q4) Source: Unpublished research by Dr Dawn Moody

20 Outcomes by stage of frailty Time (days) 5 yrs Fit Reducing proportion alive Mild frailty Moderate frailty Severe frailty Source: Development and validation of an electronic frailty index using routine primary care electronic health record data

21 Outcomes by stage of frailty One year outcome (hazard ratio) Mild frailty Moderate frailty Severe frailty Mortality Hospitalisation Nursing home admission

22 Tools for Frailty Identification Gait Speed test Edmonton Frail Scale Tilburg Frailty Indicator TUG test PRISMA 7 Questionnaire efi Frailty Identification Clinical Frailty Scale (Rockwood 22

23 The Gait Speed Test 23

24 Tilburg Frailty Indicator 24

25 Clinical Frailty Scale 25

26 Managing Frailty One year outcome (hazard ratio) Mild frailty Moderate frailty Severe frailty Mortality Hospitalisation Nursing home admission

27 GMS GP Contract 2017/18 Practices will use an appropriate tool e.g. Electronic Frailty Index (efi) to identify patients aged 65 and over who are living with moderate and severe frailty For patients identified as living with severe frailty, practice will deliver a clinical review providing an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12/12 Where a patient does not already have a Summary Care Record (SCR) the practice will promote this seeking informed patient consent to activate the SCR Practices will code clinical interventions for this group 27

28 Falls and frailty 30% people aged 65+, 50% aged 80+ have at least 1 fall / year Falls associated with high mortality in adults 65+ Ground level admitted falls 65+, 1 year mortality 33% Cause pain, distress, injury, loss confidence and independence, decline in functional ability Multifactorial > consider a range of interventions 28

29 Medication and frailty Polypharmacy is extremely common Increased risk of toxicity and interactions Falls, sedation, constipation, cognitive impairment, delirium, electrolyte disturbance Anticholinergics, benzodiazepines, diuretics, SSRIs, antihypertensives are common offenders 29

30 Multimorbidity and frailty 30

31 Multimorbidity and frailty 31

32 GMS GP Contract 2017/18 Practices will use an appropriate tool e.g. Electronic Frailty Index (efi) to identify patients aged 65 and over who are living with moderate and severe frailty For patients identified as living with severe frailty, practice will deliver a clinical review providing an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12/12 Where a patient does not already have a Summary Care Record (SCR) the practice will promote this seeking informed patient consent to activate the SCR Practices will code clinical interventions for this group 32

33 Summary Care Record The SCR is created automatically through clinical systems in GP practices and uploaded to the Spine. It is then updated when further changes are made to the GP record. Additional information can be added to the SCR, with explicit patient consent, by the GP. The information can be included automatically by changing the patient's SCR consent status. Benefits - SCRs with additional information offer the opportunity to: Increase patient safety by providing timely access to information such as significant diagnoses Empower patients and increase satisfaction as patients can make their preferences known Empower health professionals by providing consistent, accurate, accessible information Increase efficiency and effectiveness through more integrated care and reduced time/effort. * For further guidance on patient consent, see 'patient consent and considerations for patients who lack capacity to consent'. (PDF, 345.5kB) 33

34 Severe Moderate Mild Fit Frailty as a Long Term Condition What does it mean? Managing Frailty as Long Term Condition

35 Severe Moderate Mild Fit Frailty as a Long Term Condition What does it mean? Managing Frailty as Long Term Condition

36 Severe Moderate Mild Fit Frailty as a Long Term Condition What does it mean? Healthy Ageing Supported self-management Managing Frailty as Long Term Condition

37 Severe Moderate Mild Fit Frailty as a Long Term Condition What does it mean? Multimorbidity (NG56) Managing Frailty as Long Term Condition

38 Severe Moderate Mild Fit Frailty as a Long Term Condition What does it mean? Comprehensive Geriatric Assessment Care & support planning Case management / EoL care Managing Frailty as Long Term Condition

39 Severe Moderate Mild Fit Frailty as a Long Term Condition What does it mean? Depression and/or anxiety Managing Frailty as Long Term Condition

40 Severe Moderate Mild Fit Frailty as a Long Term Condition What does it mean? Healthy Ageing NG56 Supported self-management Depression / anxiety Care & support planning CGA Case management / EoL care Managing Frailty as Long Term Condition

41 Caring with, and for, frailty 41

42 Fit for Frailty Identifying frailty Developing & commissioning services Managing frailty Managing services 42

43 GMS GP Contract 2017/18: Data number of patients recorded with a diagnosis of moderate & severe frailty number of severe frail patients with an annual medication review number of severe frail patients recorded as having fall in last 12/12 number of severe frail patients providing consent to activate enriched SCR 43

44 GMS GP Contract 2017/18: Data NHS England will use data to understand nature of the interventions made And prevalence of frailty by degree among practice populations & nationally Data will not be used for performance management purposes 44

45 Opportunities Identifies people whose care & support can be influenced by primary care services Help to better understand frailty trajectories and impacts of interventions for both individuals and populations Support service planning by enabling more sophisticated modeling than demographic data alone Promotes system capability to support increasing number of older people living with frailty 45

46 Next steps - what we plan to do Core contractual guidance Wider support package from LTC Unit to help practices introduce the contractual requirements smoothly Support for those practices that want to go further to take greater advantage of the opportunity that routine frailty identification offers for improved prevention and better care. 46

47 Next steps we need your help! Please give us your input to help shape the development of supporting resources. Please take this opportunity to ask any questions you have. Please tell us what you would most like to see in future resources - content and format. 47

48 Q&A Discussion 48