Changing care systems for people with frailty John Young Geriatrician, Bradford Hospitals Trust, UK National Clinical Director for Integration & the Frail Elderly, NHS England (john.young@bthft.nhs.uk)
STRUCTURAL, RELATIONAL & CULTURAL FRAGMENTATION (SILOS OF PROVISION) HOSPITALS PRIMARY CARE SOCIAL CARE FALLS SERVICES COMMUNITY HEALTH SERVICES COMMUNITY NURSING (LG funded & means tested) AMBULANCE SERVICES NURSING & CARE HOMES MENTAL HEALTH SERVICES PHARMACY VOLUNTARY SECTOR HOSPITAL-AT-HOME; VIRTUAL WARDS; COMMUNITY HOSPITALS; HOME THERAPY TEAMS; COMMUNITY MATRONS; SPECIALIST NURSES; CRISIS RESPONSE REAMS; PALLIATIVE CARE; RE-ABLEMENT SERVICES, etc, etc
Financial Gearing 40 decrease or 20% Primary 200 Community & MH 500 Specialist 300 Acute 1000 4% increase or 40 The average health spend per citizen is 2,000 per year 27/11/2015
1990s Today Generalist- Specialist Care Gap A c t i v i t y GP CARE GAP Specialist Specialist Complexity 4
New Care Models (NHS England) Secondary care reaches into general practice Primary & Acute Care Systems Primary Care reaches into the hospital Multispecialty Community Providers RISK STRATIFICATION & POPULATION-BASED APPROACHES; OLDER PEOPLE; CLOSING THE SPECIALIST/GENERALIST GAP; PERSON-CENTRED/INTEGRATED CARE; OUTCOMES BASED COMMISSIONING; CAPITATED PAYMENT SYSTEMS
National Programmes Integrated care & support pioneers 14 CCGs (+11) Year of Care Commissioning Model Integrated Personal Commissioning 5 CCGs (+35 fast followers) 9 CCGs Vanguard Programmes: Urgent & Emerg Care 8 CCGs Acute Care 13 CCGs MCP 14 CCGs PACS 9 CCGs Care Homes 6 CCGs
Prevalence rate estimates for frailty (Systematic review of 21 cohort studies) 65-69 = 4% 70-74 = 7% 75-79 = 9% 80-84 = 16% Over 85 = 26% Collard et al. JAGS 2012: 60; 1487-92 Distinguishing fit from frail; and frail from fit: the most pressing clinical task of our age?
Frailty syndromes Instability (falls) Immobility Intellectual impairment Incontinence Prof Bernard Isaacs 1924-1995 Geriatricians are certain that they are specialists, but uncertain about what they are specialists in. (1981)
Frailty as an abnormal health state A state of vulnerability to poor resolution of homeostasis following a stressor event Resilience gap Clegg, Young, Iliffe, Olde-Rikkert, Rockwood. Frailty in elderly people. Lancet 2013
The new narrative: Frailty as a long-term condition? A LTC is: A condition that cannot, at present, be cured but is controlled by medication and/or other treatment/therapies (DH 2012) Frailty is: Common (25-50% of people over 80 years) Progressive (5 to 15 years) Episodic deteriorations (delirium; falls; immobility) Preventable components Potential to impact on quality of life Expensive (Harrison, Young, Clegg, Conroy Age & Ageing 2015)
Developing the frailty narrative
Making frailty visible: identification of frailty in routine practice 1 Comprehensive geriatric assessment (CGA) (Structured, multi-disciplinary assessment) 2. Simple assessments Gait speed/timed-up-and-go test Questionnaires (e.g. PRISMA 7) Brief clinical tools (e.g. Edmonton frail scale; Rockwood 9) 3. Routine data (electronic Frailty Index)
The 4m walking speed test detects frailty Taking more than 5 seconds to walk 4m predicts future: Disability Long-term care Falls Mortality 4M Van Kan et al JNHA 2009; 13:881 Systematic Review of 21 cohorts
Diagnostic Test Accuracy (DTA) for simple frailty instruments (Systematic Review) Sensitivity Specificity Gait Speed <0.8m/s 99% 64% Gait Speed <0.7m/s 93% 78% TUGT >10s 93% 62% PRISMA 7 83% 83% (wide CIs) Self-reported Health 83% 72% (wide CIs) Groningen Frailty Indicator 58% 72% Polypharmacy (>5 meds) 67% 72% GP clinical assessment 58% 72% (Frailty instruments assessed against a reference standard) (Clegg, Teale, Young. Age Ageing 2014)
Development of a primary care electronic Frailty Index (efi) Existing primary care EHR ( SystmOne ) Read Codes (>80,000 8,000 2,200) Read codes map onto 36 DEFICITS Tested in ResearchOne (n=454,711 65y) Internal Validation Process (n=227,063 65y) External Validation Process (n=500,000 65 y)
Primary care electronic Frailty Index (efi) survival plots Fit Mild frailty Proportion Primary care audit of frailty codes alive Enhanced Summary Care Record Moderate frailty Severe frailty Time 5 yrs
Y&H AHSN: National Spread of efi (Year 1) Clinical Commissioning Group (Pop approx. 250,000) Partners Engagement Count GP Practices 22 CCGs (n=211) 35 at risk populations De-prescribing EoLC/ACPs Supported-self management etc, etc.. CSU 1 SCN 1 CLAHRC 1 Public Health (regional) Industry Partners 3 2 (ACG Systems) VCS 1 (Age UK Y&H)
FIT 32% MILD 41% MOD 20% SEV 7%
Candidate Preventable Components for Frailty Alcohol excess Cognitive impairment Falls Functional impairment Hearing problems Mood problems Nutritional compromise Physical inactivity Polypharmacy Smoking Social isolation and loneliness Vision problems Stuck et al. Soc Sci Med. 1999 (Systematic review of 78 studies) Additional topics: Look after you feet Make your home safe Vaccinations Keep warm Get ready for winter Continence Preserving memory A Practical Guide to Healthy Ageing
The burden of multimorbidity Mrs Greenaway is a 78 yr old woman with previous myocardial infarction; type-2 diabetes; osteoarthritis; COPD; and depression.. 11 drugs (and possibly another 10) 9 lifestyle modifications 8-10 routine primary care appointments 8-30 psychosocial interventions Smoking cessation appointments Pulmonary rehabilitation (Hughes et al Age & Ageing 2013)
Another view of Mrs Greenaway What are the most important things you d like to discuss today? 1. The pain in my feet 2. Difficulty sleeping 3. Getting out for a chat 4. I don t like all these tablets; do I really need them all?
Enhanced (primary care) service specification: Avoiding unplanned admissions: proactive case finding and patient review for vulnerable people Use a risk stratification tool to identify people at risk of unplanned admission to hospital Establish a primary care register for a minimum of 2% of the practice list size Monthly review of register (consider new actions eg CGA/MDT review; ACP) The GP practice will implement proactive case management for all patients on the register... (to) include developing collaboratively with a patient and their carer (if applicable) a written/electronic personalised care plan,...
It s Care Planning Jim, but not as we know it!
Care Plan vs Care Planning Care plan: focus on disease or problem management Care planning: the focus on person management When I make a care plan: 1. I make an assessment of the patient True / False 2. I pass on lots of information to the patient True / False 3. I do most of the talking True / False 4. I follow a template very closely True / False
NHS England Older People & Frailty TODAY The Frail Elderly (i.e. a label) TOMORROW An older person living with frailty" (i.e. a long-term condition) Presentation late & in crisis (e.g. delirium, falls, immobility) Timely identification for preventative, proactive care by supported self-management & personalised care planning Hospital-based: episodic, disruptive & disjointed Community-based: personcentred & co-ordinated (Health + Social + Voluntary + Mental Health)