Primary and Community Care

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1679
MF Muhammed Ali Noor, A Puffett; S Davidson
1. Department of Elderly Care; Withybush General Hospital
Clinical Quality
CQ - Improved Access to Service
Mental Health
Frailty
CGA
Primary and Community Care

Abstract

Introduction

People with frailty (Rockwood Frailty Score of 4 or more) represents 43% of the medical take at Withybush Hospital. There was a lack of front door frailty and comprehensive geriatric assessments (CGA). It was postulated that this was leading to delays in discharge and limiting the number of patients receiving a CGA by teams led by a geriatrician

Methods

In mid-November 2022, the acute medical take was adapted to stream stable patients with frailty through a frailty assessment unit. Prior to this, the area was being used as a surge ward for short stay acute medical patients. On the frailty unit, patients receive a CGA creating a problem list and plan. The patients are then streamed into either short stay and discharged from the unit itself or to an appropriate ward area. Number of discharges was the main outcome measure.

Results

In the 2 months preceding the intervention the number of discharges from the short stay assessment unit was 16% of total medical discharges. The percentage of patient’s discharged from frailty wards was also 16% of medical discharges. In the 2 months after the intervention, discharges from the frailty unit accounted for 21% of medical discharges. Discharges from the frailty wards accounted for 16% of medical discharges. In the post intervention months, the frailty team discharges accounted for 37% of total medical discharges. 

Conclusions

Adoption of frailty unit model improved rates of short stay discharges and allowed frailty team to assess a greater proportion of the hospital patients. Using assessment by the frailty teams as a surrogate for a CGA this has significantly improved the proportion of patients receiving CGA to more fit our patient demographics.

 

 

Presentation

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1363
A Seeley1; M Glogowska 2; G Hayward 3
1-3 Nuffield Department of Primary Health and Care Sciences, University of Oxford
Scientific Research
SP - Neurology & Neuroscience
Frailty
Primary and Community Care

Abstract

Introduction

In 2017 NHS England introduced proactive identification of frailty into the General Practitioners (GPs) Contract. There is currently little information as to how this policy has been operationalised by front-line clinicians, their working understanding of frailty, or perceptions of impact on patient care. Evidence from international settings suggests primary care clinicians may have mixed interpretations of frailty, with important implications for their willingness to support different frailty interventions. We aimed to explore the conceptualisation of frailty, and how community-dwelling frail older adults are identified in primary care.

Methods

Semi-structured interviews were conducted with primary care staff across England, including GPs, physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 12).

Results 31 practitioners participated (12 GPs, 19 non-GPs). Frailty was seen as difficult to define, with uncertainty in its value as a medical diagnosis. The most common working model was the frailty phenotype, associated with deterioration at end of life. There were a mixture of formal and informal processes for identifying frailty. A few practices had embedded population screening and structured reviews. Informal processes included use of ‘housebound’ as a proxy for frailty, identification through chronic disease and medication reviews, and holistic assessment through good continuity of care. Many clinicians described poor accuracy of the electronic Frailty Index, yet it was commonly used to grade frailty during protocolised chronic disease reviews. The Clinical Frailty Score, in contrast, was felt to be easy to use and interpret, but inconsistently recorded within electronic health records. Most clinicians favoured better tools for identifying frailty, alongside resources to support these individuals.

Conclusions

Concepts of frailty in primary care differ. Identification is predominantly ad-hoc, opportunistic and associated with terminal illness. A more cohesive approach to frailty, relevant to primary care, together with better diagnostic tools, may encourage wider recognition.

Presentation

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Comments

Really interesting study, Anna! Fascinating to hear insights from across of the range of HCPs that now see these patients.

What's your gut feeling on this? Is the eFI not useful because of the limitations of the tool itself or because of the healthcare system/current overstretched conditions that it has been implemented in?

Interesting study, it's a shame that there were no other AHP's interviewed such as physiotherapists/OT's/SLT's as I think their perspective and knowledge on frailty may be a bit different.  In my area we have all these professions working as advanced clinical practitioners in frailty.  The EFI I think we all know is a bit of a blunt instrument, really frailty is a clinical diagnosis alongside some tools that may aid that.  But seeing patients face to face is the vital part as you can miss so much over the phone.

Thanks for your poster. Timely and acutely showing the issues around the identification of Frailty as a syndrome, the need for the right tools to identify people living with Frailty, and although not discussed openly, the clear need for Resources that must be provided by the government [whatever their political colour] to ensure this condition is diagnosed early and intensively managed -community and in hospitals.

The eFI is an interesting tool, yet it may be more useful to identify multimorbidity, mainly in those who present to their GP surgery for help -which in itself may leave out those with severe frailty, unable to reach the care services on a timely manner -as you pointed out in your poster.

It is not an option to carry on as we are, not been able to serve one of the most vulnerable sector of our communities. Building Resilience is costly at all levels. This has been shown by other pilot work done by other teams, as the Senior Health Clinic we trialled in Richmond prior to Covid-19, that showed the financial support required and the need for a fully funded, dedicated Geriatric multidisciplinary team [Geriatric MDT] to further develop the service. Preliminary data analysis showed reversibility of frailty in some cases -yet six months were not enough to consolidate the service as it was not fully supported by the challenged financial status of the involved CCG.

The high cost of Frailty is first, a human cost: people living with Frailty and their carers/relatives, care homes carers availability].

But it is also a financial cost: to social care and all healthcare systems, mostly the NHS.

However, it is not acceptable for any local or nationwide government to keep this no-action. These governments ought to supply the resources required to care for older people with frailty as part of their budget. A general government must support and facilitate local teams to create the proper integration of care systems to look after this vulnerable cohort. This seemingly lack of interest [hence, lack of funding] in itself, has led to some foundation trusts to stop their successful Acute Frailty Services in their own hospitals, and in its place, put a therapy-only service to "diagnose and manage" older people presenting with Frailty syndromes [falls, delirium etc], dismantling their front door Geriatric MDT. Politics at play at their worst? It appears so: ignoring the older persons needs appears to be "cheaper" for those trusts, rather than delivering the evidence-based care these older patients deserve. The outcome, high readmissions rates of the same older people with Frailty syndromes, eventually leading to hospital admissions, long length of stay consuming hospital resources unnecessarily [their so called "bed-blockers"] with then excess "outliers" in different wards [and young patients in the Geriatric wards are included].

Unfortunately, the above also cause the subsequent deconditioning and progression of Frailty and Sarcopenia in our older patients. We know the rest: high risk of hospital acquired infections, immobilisation, delirium, continence issues, and an ongoing vicious circle with the older person at high risk of death, and if not, of ending up in a nursing home. Or if lucky, end up back at home with increase input from social services, and the need for the community MDT support.

So, let's start from the beginning: we require a robust community / GP-led team, that have the resources [human, time and money to say the least] required to identify the older person with Frailty conditions/syndromes, refer to a community Geriatrician and Geriatric MDT [yet other resources that must be fully funded] and involve your MP and whoever else is required, to ensure the commitment of funding the services GPs and their teams require to diagnose and manage older persons at risk of Frailty or who may have Frailty conditions as a matter of urgency. 

Your good work is really timely. Thanks for presenting it. Much more to do.

 

Dr Carmen Martin Marero

Consultant Geriatrician and Physician

London

 

 

 

1296
Tayler-Gray J; Patel M; Wigley A; McCall B; Gossage J.
Department of Elderly Medicine, Lewisham & Greenwich NHS Trust, Lewisham, LONDON SE13 6LH
Scientific Research
SP - Cardio (Cardiovascular)
Primary and Community Care

Abstract

Introduction

Demographic evaluation of urgent community response teams [UCR] is important to ensure equity of access and clinical outcomes for patients from all socio-demographic groups using such services. This retrospective descriptive study aimed to evaluate demographic and mortality differences between patients referred to UCR in terms of those managed in the community [Group1] versus those subsequently hospitalised [Group2].

Methods

Data was obtained over a 12-month period [2021-2022] for all new patients referred to a 7-day consultant-led UCR that serves a multi-ethnic, inner-city population. Data included demographic details, source of referral, urgency of referral and mortality within 60 days.

Results

Of 995 patients, 75.6%[n=752] were in Group 1; 24.4%[243] were in Group 2. The two groups were comparable in terms of age [mean(SD): 80.1(12.6) vs 80.0(11.4), p=ns] and gender [males:39.4% vs 42.4%,p=ns]. There were similar proportion of Black and minority ethnic patients within the two groups [21.0% (158) vs 24.7% (60), p=ns]. Source of referral were comparable between the two groups[p=ns]; overall, 67.7%[674] were from GP practices, 5.6%[56] Community Practitioners, 4.7%[47] NHS111, 2.7%[27] Ambulance, 32%[32] Palliative care, 5.9%[59] Emergency department, 10.1%[100] post-hospitalisation. Compared to Group 1 [46.9% (353)], significantly more patients in Group 2 were referred for urgent assessment within 2 hours [65.4% (159), p<.001]. more patients died in group2 within 60 days [22.2% (54) vs 11.3% (85), p<0.001].

Discussion

This large survey has described age, gender and ethnic similarities between the two groups, demonstrating equity of provision irrespective protected characteristics. as might be clinically expected, referred for hospitalisation were assessed urgently had higher mortality rates compared to those managed community. study provides valuable information clinicians researchers similar ucr services future.

1308
Dr Angelene Teo, Hazel Wright NP
Department of Elderly Medicine, Lancashire Teaching Hospitals NHS Foundation Trust
Clinical Quality
CQ - Clinical Effectiveness
Frailty
Primary and Community Care

Abstract

Background:

In response to the COVID pandemic when new robust discharge criteria were introduced to facilitate early discharge to optimise hospital capacity, Post Discharge Frailty Support (PDFS) was established. PDFS provides nurse-led telephone follow-up for patients discharged primarily from the Emergency Department (ED) and the Acute Frailty Assessment Unit (AFAU).

Objectives:

We aim to provide continuity of care by following up frail elderly patients at home, reviewing their medical, functional and social progress post discharge and ensuring they received adequate support to avoid hospital re-admission. Methods: The service is overseen by the Lead Frailty Practitioner, supported by Consultant Geriatricians. Calls are made Monday to Friday by a team of Advanced Specialist Nurses. The case load is split up into 3 categories with different levels of priorities – 1: at least weekly calls; 2: Fortnightly calls; 3: Monthly calls. This service engages closely with community partners such as community frailty service, social care, district nurses and general practitioners.

Results:

In year 1 (1/4/2020-31/3/2021), we had 598 patients on this PDFS. 93 patients were referred to therapy team for urgent equipment to maintain safety, 73 patients were referred to community frailty and 112 patients had urgent discussions with GP to avoid hospital admissions. The 30 days readmissions rate was 14%. 547 patients were discharged. In year 2 (1/4/2021 – 31/3/2022), we had 297 patients. 49 patients were referred to therapy team, 32 patients were referred to community frailty team, and 41 patients required input from GP. The 30-day readmission rate was 11%. 224 patients were discharged.

Conclusion:

PDFS is an effective service that has helped to reduce length of stay of frail elderly patients in an acute hospital setting, maintaining patient safety and prevent hospital re-admission, co-ordinated with community services. Our service has been highlighted in the recent GIRFT report on improving clinical practice.

 

Presentation

Comments

Hi, that's a really interesting poster.

May I ask:

1) Have you looked retrospectively at a cohort of frail patients discharged prior to implementation of this program to look at their readmission rates?

2) How did you negotiate the sharing of clinical responsibility for the patients post discharge?  Were they under the remit of your team for follow up appointments if they had a problem post-discharge, were they signposted to their GP, did your team liaise directly with the GPs to agree a shared plan?

3) Where did the funding stream come from, what was the costing of the project and is the team continuing to operate?

Thank you!  Apologies if some of the answers to these questions are in your presentation - I am unable to open it currently. 

Hi Kathryn, thanks for your questions.

I will try my best to answer them. 

  1. Have you looked retrospectively at a cohort of frail patients discharged prior to implementation of this program to look at their readmission rates?

Answer: We did not retrospectively look at this cohort of patients’ readmission rate prior to implementing the service as it was set up rather quickly and we did not have time to get any baseline data. The 2 frailty nurses who were classified as 'high risks for complications from COVID' had to isolate from clinical work and thus this service was introduced and became part of their day job during COVID outbreak. It was started on the basis of supporting elderly patients – to facilitate early discharge to create bedspace for COVID positive patients at the initial stage of this service. However, we then retrospectively reviewed the patients who have been added onto the caseloads and review their readmission rates.

  1. How did you negotiate the sharing of clinical responsibility for the patients post discharge?  Were they under the remit of your team for follow up appointments if they had a problem post-discharge, were they signposted to their GP, did your team liaise directly with the GPs to agree a shared plan?

Answer: Once the patients have been discharged from the frailty unit, the sole clinical responsibility lies within the GPs. However, if there is some ongoing issue( i.e medical problems/ social needs/ therapist needs) that patients raised during the telephone follow up calls, the nurse practitioner will liaise with consultant geriatricians for advice – the options are

i)                   Can GP sort this issue? normally if this is a new concern raised by the patients, then the team will ring GP to highlight the concerns.

ii)                 If it is an ongoing issue -following discharge from the frailty unit/ ED – the case can be discussed with the consultant geriatricians – either arrange for HOT clinic review / telephone phone consultations by the consultants.

iii)               The team will liaise with GP for a shared plan occasionally

iv)               At times, we refer to the community frailty nurses to review patients at home / refer on to social care services to increase POC etc.

  1. Where did the funding stream come from, what was the costing of the project and is the team continuing to operate?

There is no extra funding for this service as when it was started, the 2 frailty practitioners (who needed to isolate) took on the project and yes, it is still running within existing resources, but the caseloads are smaller - probably around 140+ patients.