Integrated care for older people with frailty

Executive summary

The role of GPs and geriatricians is more important now than ever given the complex healthcare needs of the UK’s rapidly ageing population, and will only increase in the years to come.

The prevalence of multimorbidity is on the rise, with 44 per cent of people over 75 now living with more than one long-term condition. Around 10 per cent of people over 65 will also be living with frailty, a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves, putting them at greater risk of adverse outcomes after apparently minor events.

GPs and geriatricians are uniquely suited to lead the response to the challenges of caring for this group. As generalist disciplines, general practice and geriatrics look at the whole person and consider care within the context of the patient’s family, carers and the wider community. They take continuity of responsibility for care across many disease episodes and over time, and coordinate care across organisations. These shared holistic values provide opportunities for collaboration between the  two specialisms, and this should be at the forefront of the future design and delivery of care for  older people.

However, in the past, service development has all too often taken place in isolation, leading to the creation of services in silos. Not only does this fragmentation have a detrimental impact on patient experience and outcomes, there are also negative consequences for service efficiency  and effectiveness.

This has been particularly true at a national level and, in this respect at least, little has changed. However, improvements are being made at a local level where GPs and geriatricians are providing clinical leadership in spite of the organisational barriers they face. This report has been designed to showcase examples of these new approaches that are putting the positive talk around integration  of care into practice.

The case studies were all selected as examples of collaboration between GPs and geriatricians that provide innovative and interesting ideas about the care of older people. They were also chosen to cover a range of locations across the UK, including urban and rural populations, and a range of settings, including services based in the community, in GP practices, in care homes and in hospitals. While the majority are led by GPs or geriatricians, the initiatives were selected to illustrate the vital role that many other professionals play, including nurses, therapists, pharmacists and social workers. The case studies have been grouped into three areas:

• Ageing well and staying well
• Extending primary and community support
• Integrated care in acute settings.

The three areas cover the whole frailty trajectory, from keeping people healthy and independent right through to supporting them in hospital. One possible version of a full strategy for the care of older people with frailty is a strategy that is built on these three pillars.

Common themes and key messages

The schemes are at different stages in their development: some are pilots that have begun in recent months, such as case study I in North West Surrey, or are now planning a wider roll-out across a local area, such as case study XI in Rushcliffe. Others, including case studies IV and V in Southampton and Ullapool, have been established as part of normal working practice for many years. However, there are many common themes and these give an indication of the keys to their success:

• Person-centred care. A recurring theme in the efforts to deliver person-centred care is the emphasis on patient involvement and choice to support a positive patient experience. Case study II in North Wiltshire provides a striking example of how this can work: by knowing that the patient’s preference was to avoid medical interventions,  the simple step of sharing information about a patient’s  pre-existing history of fainting regularly saved unnecessary and unwanted intervention.
• Continuity of care. The value of strong professional relationships across the primary and secondary care interface underlies many of the models. Some of the initiatives here have taken the joined-up approach a step further by designating a care coordinator, such as the  role of the well-being coordinator in case study I in North West Surrey, to support patients in navigating complex  care pathways.
• Proactive approaches. The three main elements of delivering more proactive care in this report are risk stratification, conducting Comprehensive Geriatric Assessments, and creating care plans for multiple eventualities4. The initiatives in both West Yorkshire (III) and Leeds (XIII) are using the electronic Frailty Index to identify patients at risk of frailty. Developing care plans takes time, but many initiatives have seen the benefits of this investment. For those under extreme time pressures, Lothian (VIII) provides a simple but effective template for kick-starting the care planning process.
• Collaboration and communication. Strong communication links between GPs and geriatricians is the cornerstone on which their collaboration is built. Whether it is by email, telephone or through dedicated face to face sessions, immediate access to expert advice is crucial.  Case studies V and VII in Ullapool and Wakefield are  leading the way by using a mixture of all three.
• Multidisciplinary working. In the initiatives in this report GPs and geriatricians often provide clinical leadership for integrated, multidisciplinary teams which draw together professionals from right across health and social care services. In case study VI in Midlothian, for instance, others involved include speciality trainees, advanced nurse practitioners, physiotherapists, occupational therapists and  a community psychiatric nurse.
• Professional development. One of the real successes of many of the case studies has been the benefits for the clinicians involved. This impact can be tangible – for example, in case study VII in Wakefield, part of the scheme has been to expand workforce skill-sets so occupational therapists have been trained in clinical assessments, clinical observations and phlebotomy, and nurses have received environmental and cognitive assessment training. One of the most interesting ideas to support working across the interface is in Rushcliffe (XI), where GPs and geriatricians have invested time in shadowing each other on ward rounds and in surgeries, in order to support relationship-building by gaining a better understanding of different roles, responsibilities and skills.
• Community resources. Many of the initiatives are part of the drive to expand provision of services in the community. This means improving both the provision of integrated urgent care, such as in many of the case studies in section 2, and the awareness of local resources so that patients are signposted to the appropriate service. The case study in Southampton (IV) has been particularly successful in this regard, developing links with a local Anglican minister specifically for older people, and working with Age Concern to develop healthy walks based around GP surgeries.
• Shared records. Effective collaboration often relies on access to shared electronic patient records. The Islington scheme (X) uses EMIS Community which also enables clinicians to add notes to the record, while in Rushcliffe (XI) SystmOne is also used to send messages to the GP on discharge with follow-up actions and details of continuity of support required. This has proved so useful that standard desktop connectivity to SystmOne has been rolled-out on the hospital wards as a permanent resource.
• Technology. As one of the primary enablers of integrated care, use of new technology, which also requires investment in training staff to use systems, is a frequent theme. South Sefton (IX) is particularly advanced in its use of technology to support the delivery of integrated urgent care and enable patients to remain in their own homes. The initiative includes a virtual ward, an urgent care team equipped with tele-video technology for remote assessment and support, and secure NHS video conferencing facilities in care homes.
• Implementation. Rather than trying to start with a big bang, many of the schemes in this report have undergone a phased development. This has meant services can be built around patients and clinicians and learnings can be incorporated. Guidance was created for using Lothian’s (VII) revised three-part questionnaire to support care planning in response to user feedback, while the ‘Hospital at Home’ service in Midlothian (VI) was developed as an enhancement to a successful Rapid Response Team.
• Outcomes. Evaluation plans have been built into most schemes. While it is too early to draw firm conclusions, there are promising indications that, under the right conditions, services can be developed that deliver both better outcomes for older people with frailty and financial savings. While many report a decrease in demand on acute services, some of the most striking statistics are in Leeds (XIII), where the conversion rate from A&E attendance to hospital admission fell from 74 per cent prior to the introduction of the geriatrician service to 39 per cent during the times when the geriatrician is in the department. Islington (X) have also calculated that the reduction in bed days amounts to around a £300,000 saving to the local health care economy in the two years since their service was established.
• Investment. None of the innovation in this report would be possible without sufficient investment, and it is notable that the schemes that are the most developed and the longest established, such as case study VI in Midlothian, have benefited from ongoing, ring-fenced funding. However, this financial commitment tends to be from local decision-makers or specific schemes such as NHS England’s vanguard programme. This needs to be combined with metrics that demonstrate potential savings for the whole system and greater national investment to support those shaping and planning health services if these models are to be adopted more widely.