Post on 29-Jan-2017
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Outline The status quo Frailty Comprehensive Geriatric Assessment The Frailty Pathway Summary & Discussion
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9 6
159 6
1016
88
7
4 8
83
14
12
7
124
4 4
Medical Admissions by Age<65 65-75 >75
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
10 116 5 7 6
2
7 5
6 7 31
2
54
2 42
5
3
Frailty screening For >65 in MAU
Frail Screen positive, but not frailNot frail
Frail Non-frail p-valuen 47 56Age, years Mean (SD) Range
79.3 (8.1)68 - 101
75.8 (6.3)65 - 90
<0.05
Length of stay, days Mean (SD) Median (IQR) Range
18.2 (20.7)*11 (4.25 –
22.75)*1 – 85*
7.6 (12.1)3 (1 – 6)1 - 57
<0.05
Readmission (%) 7 day 30 day 60 day
2 (4.3)8 (17)8 (17)
6 (10.7)12 (21.4)15 (26.8)
NSNSNS
Mortality (%) Inpatient 7 day 30 day 60 day
7 (14.9)3 (6.4)7 (14.9)8 (17)
5 (8.9)1 (1.8)2 (3.6)
7 (12.5)
NSNS
<0.05NS* 2 patients are still
inpatients
Frailty‘A biologic syndrome of decreased reserve and resistance to stressors,
resulting from cumulative decline across multiple physiologic systems,
and causing vulnerability to adverse outcomes' Walston et al.
Research Agenda for Frailty in Older Adults: Toward a Better Understanding of Physiology and Etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults.
JAGS 2006; 54: 991-1001
Vulnerability of frail elderly people to a sudden change in health status after an illness
Clegg, Young, Iliffe, Rikkert, Rockwood Frailty in elderly people
Lancet 2013; 381: 752 - 762
Survival curve estimates by frailty status at baseline
Fried L P et al. J Gerontol A Biol Sci Med Sci 2001;56:M146-M157
Comprehensive Geriatric Assessment
Multidimensional diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person in order to develop a coordinated plan to maximize overall health with aging
Domain AssessmentMedical Co-morbidity & disease severity
Medication reviewNutritional status & dentitionContinenceVision & hearingAdvance care preferences
Mental health CognitionMood & anxietyFearsSpirituality
Functional capacity
Basic activities of daily livingGait & balanceActivity / Exercise statusInstrumental activities of daily living
Social circumstances
Support from family & friendsSocial network eg. Visitors, daytime activitiesFinancesEligibility for care resources
Environment Home facilities, comfort & safetyPotential use of telehealth technologyTransport facilitiesAccess to local resources
GeriatricianGP
Physiotherapist
Occupational Therapist
NurseSpeech & Language Therapist
Dietician
Social Worker
Pharmacist
Case Manager
CGA vs. usual careOutcome No. of
studiesNo. of
participantsEffect size
Living at home Up to 6 months End of follow up
1418
51177062
1.25 [1.11, 1.42]
1.16 [1.05, 1.28]
Mortality Up to 6 months End of follow up
1923
67869963
0.91 [0.80, 1.05]
0.99 [0.90, 1.09]
Institutionalisation Up to 6 months End of follow up
1419
49257137
0.76 [0.66, 0.89]
0.78 [0.69, 0.88]
Death or deterioration
5 2622 0.76 [0.64, 0.90]
Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital.
Cochrane Database of Systematic Reviews 2011, Issue 7
GP
A&E
SJHFront door
PAA
MAU
OPD
Templar Day
Hospital
REACT
GP
CURRENT MODEL
Disc
harg
e
Gen Med War
dRehab ward
Refer PTOT
MoE
Boarding ward
Unwell frail older
person
PrinciplesRight to medical diagnosis and equal access to specialistsPatient-centredHome is bestThe right patient looked after by the right team in the right setting Planned care better than emergency careSimpleSustainableFocus on quality and quality improvement
Case-finding for targeted interventionFrail patients identified as soon as possible to enable timely assessment and managementSpecialist nurse supported by Consultant GeriatricianSystematic MDT on all medical wardsRobust referral system from other parts of the system
Right patient, right team, right settingPrompt decision on care trajectory and transfer to most appropriate settingComplex frail patients managed by consultant geriatriciansTracking of less complex frail through liaisonEffective MDT in each ward with regular discussions for goal setting and discharge planning
Templar Rapid Access Frailty Clinic Rapid access CGA in a specialist multidisciplinary ambulatory setting
A ‘one-stop’ clinic offering specialist assessment and same-day diagnostics with real-time decision-making led by a geriatrician
Referrals via telephone to the MoE Single Point of Contact (SPOC) with appointments for the same or the next working day given in the same conversation
Aim to reduce avoidable admissions and facilitate timely discharge when acute hospital care no longer necessary
Close working with REACT, MAU/PAA, Reablement, Crisis care, Primary Care, Social Work, Mental Health and other specialties
Improving Flow
Physio Assessment
OT Assessment
Patient Admitted
Discharge Home
Seen by Doctor
Discharge Planning
Seen by nurse
Rehab in hospitalCare at Home
OT and PT assessmentCare at home Discharge Home
D2A Assessm
ent
Rehabilitation
Home is best Admission avoidance REACT Templar Rapid Access Frailty Clinic Discharge to assess “Medically stable” vs. “No longer in need of acute hospital care” Rehab at home Closer working with community services
Good post-acute care CGA initiated and completed Reassessment Identify patients with highest risk of readmissions, deterioration Advance care plans
Consultant Geriatrician Single Point of Contact
Safe
for d
ischa
rge
REACT
Inpatient
admission
required
Rehab
ward
OPD
Templar Day
HospitalGP care
+ agreed
planSubacute care
Rest of SJH
Scre
en a
ll ≥6
5s
Referral or MDT pick up
FRAILTY PATHWAY ST JOHN’S HOSPITAL
Discharge hub
Medical
ward under a geriatrici
an
A&E
SJHFront door
PAA
MAU
Frailty
nurse
GP
Unwell frail older
person
Summary Frailty is our core business Early identification allows targeted CGA CGA is multidimensional, multidisciplinary and iterative Evidence-based changes to system to allow great frailty care everywhere