CQ - Improved Access to Service

Introduction
The Assessment and Rehabilitation Centre (ARC) in Edinburgh sees around 600 new patients a year who are beginning to demonstrate signs of frailty, principally around mobility and balance. When taking a comprehensive geriatric assessment, we commonly identify concerns around cognition. We noted in some cases people were already waiting to be seen by the Memory Clinic Services, the current wait for which is approximately 10 months. We decided to see what ARC could do to help.
Method
From within existing resources, alongside the Psychiatry of Older Age (POA) Team, the ARC multi-disciplinary team coproduced a pathway that involved an initial assessment comprising identification of potentially cognitively frail patients, taking a corroborative history, performing cognitive and imaging investigations. Each step was added to a shared spreadsheet enabling us to chart progress of diagnostic information steps.
Then once assessment complete, a POA colleague reviewed the evidence and made a diagnosis with treatment recommendations.  The ARC team then discusses the outcome with the patient and their family, arranges a medication tolerance follow-up in ARC, then refers onward for ongoing community support.
Results
Between March 2023 and 2024, 52 patients completed the Memory MDT process, 34 (65%) of which were diagnosed with a dementia, 20 (33%) of which were started on dementia medication. 16 were removed from the Memory service waiting list (2.5%) and a further 18 avoided the need to be referred.
Conclusion
We identified a group of patients with a common underlying pathology that had resulted in them being referred to multiple specialities.  By arranging our services around this vulnerable patient group rather than the other way around, we reduced their need for multiple hospital attendances and freed up resource in the memory service. Work is underway to spread and scale up.

Introduction:

Home Treatment Service (HTS) is a frailty Hospital at Home team that provides comprehensive geriatric assessment, hospital level diagnostics and treatments for people in their own home. This option of care is often suitable for people living with frailty or those with advance care planning directing them to community options. The team is dynamic with many disciplines within it to allow urgent care provision.  HTS is formed of ACPs, SAS Doctors, Therapists and Healthcare Assistants.

Referrals used to be from direct clinician discussions only via a triage line but more recently has increased links with the Acute and Ambulance Trusts. This has been done by providing a Multi-Disciplinary Team that interacts with visiting paramedics via a clinical navigation hub (CHUB). 

Home Treatment Service now has two main referral routes as illustrated by the infographic below.  The CHUB has increased the interaction with paramedics in real-time when people are experiencing an acute medical crisis.  This has allowed rapid access to senior clinical decision makers allowing holistic patient-centred joint decision-making with often complex and frail patients.

Method:

61 HTS referrals from the CHUB were compared with 61 direct clinician referrals from December 2023 to February 2024.  The NEWs score, length of stay (LOS) and Advance Care Planning (ACP) documents were analysed.

The data also interprets the index of deprivation codes for all patients using the 2019 survey.  1 is the most deprived LSOA (Lower Super Output Area used to compare) and this score is a measure of deprivation based on measurements of seven different domains.

Results:

The average LOS under HTS via the CHUB was 2.61 days and 3.65 days for direct referrals.

27% of NEWS scores from the CHUB were high compared with 14% from direct referrals.

48 out of the 61 (78.6%) patients identified as requiring HTS by the CHUB had no ACP documents (the presence of a DNAR was not counted as this does not give community options). 37 out of 61 (60.6%) had no ACP on direct referral to HTS triage.

NEWS SCORE

CHUB HTS Referral

Direct HTS Referral

Low and Medium

45

51

High

17

9

The source of referrals were analysed further to consider the geographical areas that patients were referred from by considering the English Indices of Deprivation 2019 data available (Indices of Deprivation 2015 and 2019 (communities.gov.uk)).  This was to allow consideration of any difference in access to either referral route according to markers of socioeconomic deprivation.

48 out of the 61 (78.6%) patients identified as requiring HTS by the CHUB had no ACP documents (the presence of a DNAR was not counted as this does not give community options). 37 out of 61 (60.6%) had no ACP on direct referral to HTS triage.

Conclusion(s):

Referrals directed to HTS proactively from the CHUB have a higher percentage of NEWS scores that would require hourly observations and access to urgent medical assessment.  The CHUB explores community options while weighing benefits and risks of transfer to hospital in real time.

The Length Of Stay between the two referral sources is not hugely different and suggests that HTS are identifying patients requiring similar management regardless of source of referral.

The CHUB gives options to patients with fewer advance decisions recorded to support the direction of their care during a medical crisis.  The CHUB allows HTS to access a different group of patients who may not have had routes to HTS enabled previously.

The pattern of spread of cases across the Indices of Deprivation groups are not hugely different between the referral routes.  This may be because referrers consider social factors when referring or because of the acuity found during assessment.

Introduction

Global estimates indicate over half of individuals aged 85 and older are frail (1), costing the UK healthcare system approximately £5.8 billion annually(2). Locally, over 6,500 patients aged 65+ are admitted to West Middlesex University Hospital (WMUH) every six months. The proposed frailty team aims to implement early comprehensive geriatric assessments (CGAs) through a multidisciplinary approach. Timely CGAs can increase the likelihood of patients remaining in their own homes at 6 and 12 months(3), reduce length of stay (LoS), and lower healthcare costs, contingent upon available community infrastructure. WMUH serves multiple boroughs, necessitating coordination with various community services to support discharges. These services include Hospital at Home and Integrated Care Response Services.

Objective

To gather baseline data on frail patients admitted before the introduction of a 'Front Door Frailty' team.

Methods

Data were collected for all medical admissions to WMUH from 1st to 14th July 2022, including:

• Patients aged ≥65 years

• Numbers with a frailty syndrome

• Clinical Frailty Score (CFS)

• Admissions in the previous year

• Length of stay

• Mortality at 5, 9, and 12 months

Results

From 459 admissions over 2 weeks, 278 patients (61%) were ≥65 years old. Among these patients:

• 54% had a CFS ≥ 6

• 44% presented with a frailty syndrome

• 83%, 72%, and 67% were alive at 5, 9, and 12 months respectively

• Mean LoS was 11.0 days

• 37% had ≥1 admission in the following 6 months

• Of those with a CFS ≥ 6, 63% had ≥1 admission in the previous year

Conclusions

A high percentage of acute admissions at our hospital are characterised by frailty. Through early identification, multidisciplinary management, and improved links with local community services, the new acute frailty team aims to decrease length of stay and improve patient experience.

Introduction:

Frailty significantly affects outcomes like length of stay and readmissions in elderly patients. At Queen Alexandra Hospital, inpatients under 85 are under the care of General Internal Medicine (GIM) wards and they lack regular access to frailty services. This baseline audit evaluated frailty assessment, management practices and patient outcomes, implementing staff education, ward posters, and a frailty Multidisciplinary Team (MDT) between cycles.

Methods:

Data were retrospectively collected from three GIM wards over two cycles—January and August 2024. Eligibility criteria: Patients aged 65-85, admitted to GIM were included. The audit measured frailty assessment using the Clinical Frailty Scale (CFS), Comprehensive Geriatric Assessment (CGA) practices, frailty prevalence (CFS ≥ 5), advance care planning (ACP), and readmission rates.

Results:

Frailty assessment compliance rose from 76.6% to 94.4%. Frailty detection (CFS ≥ 5) increased from 36% to 75%. CFS documentation improved to 34.5%, with better CGA documentation. However, ACP rates remained low at 3.03%, and 56.6% of frail patients were readmitted within the year, indicating ongoing challenges. Conclusion: Improvements were seen in frailty assessments and detection, yet ACP remains underutilized, and readmission rates are high. Continued efforts are needed to enhance ACP documentation and frailty management strategies.

Recommendations:

1. Implement robust policies for ACP and implement a straightforward pathway for ACP documentation by all doctors.
2. Educate all doctors to practice comprehensive geriatric assessment and participate in frailty MDT meetings.
3. Further audits to specifically investigate the proportion of patients admitted with frailty syndrome and assess their prognosis.
4. Prioritize triage based on CFS scores/frailty over age to enhance targeted care and resource allocation.

Introduction

Zoledronic acid, a bisphosphonate used primarily for treating osteoporosis and other bone-related conditions, traditionally requires hospital visits for administration, which can be burdensome, especially for frail older patients. The administration of intravenous (IV) Zoledronic acid at home via Community Rapid Response Teams (CRT) represents an innovative approach to enhance patient care and accessibility while offering significant benefits to patients and healthcare services. Service Delivery CRT team is typically composed of highly trained nurses and doctors, equipped to handle potential adverse reactions promptly and effectively, ensuring patient safety. The involvement of CRT in administering IV Zoledronic acid ensures high-quality immediate care, maintaining the standards of good medical practice. In Caerphilly, our team has been successfully administering IV Zoledronic acid at home, having treated several patients without any complications, using a thorough, easy-to-use checklist process developed by our pharmacists. This checklist helps deliver prompt care in a safe and user-friendly manner.

Benefits

1. This approach enhances patient convenience and comfort, allowing them to receive necessary treatments without travelling, thereby reducing the physical and emotional distress associated with hospital visits.

2. It minimises exposure to hospital-associated infections, an essential consideration for immunocompromised individuals.

3. It can lead to improved adherence to treatment regimens, as patients are more likely to continue with therapy delivered in the comfort of their homes.

4. The reduction in hospital visits also alleviates the burden on secondary care facilities, allowing resources to be allocated more efficiently.

Conclusion

Administering IV Zoledronic acid at home via CRT not only enhances patient convenience and safety but also supports better healthcare resource management, potentially leading to improved treatment adherence and overall patient outcomes. We aim to develop this service further and extend it to other hospital requiring services like parenteral iron for heart failure.

Introduction:

Population is growing old worldwide and UK is no exception. Health service models designed to cater the needs of service users are under immense pressure due to the aging phenomenon. With unprecedented demand, their often low acuity, hence low priority and delayed conveyance to hospital and unavailability of services to address their needs due to delayed arrival; frail older patients often have to wait longer in emergency department (ED) to receive care in ED. Innovation and news models of care are therefore need of the hour to address this challenging situation.

Methods:

Quality improvement initiative to establish acute frailty service.

Development of Older Person assessment unit (OPAU) in Oct 2022 with already established and functional acute frailty team.

Plan for direct referral to OPAU from South East coast ambulance service (SECAmb) colleagues.

Weekly meetings with SECAmb.

Geriatrician of the Day supporting alternative pathways instead of ED.

Development of frailty poster with criteria to referral and uploaded on SECAmb work iPads, displayed in ambulances delivery area and ambulance queuing area inside the hospital.

Single point of access phone number launched April 2023 to access frailty team & other alternative services from outside the hospital.

SECAmb webinar for education and awareness of alternative pathways (UCR, SDEC, frailty, virtual ward), attended by 40 front line SECAMB staff.

Results:

October 2022 – 0 patients.

November 2022 – 2 patients.

December 2022 – 8 patients.

January 2023 – 18 patients.

February 2023 – 32 patients.

March 2023 – 33 patients.

April 2023 – 39 patients.

Conclusion:

With sustained efforts and effective collaboration, number of patients being referred to alternate pathway (frailty team) are increasing with anticipated significant reduction to SECAmb conveyance to ED in the long run, addressing overcrowding issues.

Introduction. The multidisciplinary assessment clinic (MDAC) is an outpatient service for older people at a district general hospital. Patients are triaged to the MDAC clinic if they have geriatric syndrome (for example falls) plus comorbidity and/or mobility, social or cognitive concerns. The service had a high ‘did not attend’ (DNA) rate compared with other geriatric outpatient clinics. This project aimed to reduce MDAC DNA rates and improve cost effectiveness through implementation of a new pre-appointment telephone service.

Method. We analysed six months of attendance data prior to establishing the pre-appointment telephone service. The existing system consisted of a standardised trust appointment letter and a text message reminder. For the new system a healthcare assistant (HCA) telephoned patients the day before their appointment to confirm attendance and discuss any concerns. We analysed six months of attendance data following the implementation of the new system and compared DNA rates.

Results. Prior to implementation of the new pre-appointment telephone service, 29 of 268 patients DNA (11%). From the second data set, following implementation of the new telephone system, 11 of 253 patients DNA (4%). Successful contact was made with 72% of those phoned, allowing confirmation or cancelled appointments to be rebooked. Chi square analysis found a significant difference between the two systems, with a p value of <.01 indicating an improvement in attendance rates with the new system.

Conclusion. Telephoning frail older patients prior to outpatient clinic appointment significantly reduces DNA – a similar system could be implemented other geriatric medicine settings.

INTRODUCTION: Guidance around optimal management of patients with cognitive impairment within a Parkinson’s disease (PD) multidisciplinary team (MDT) is lacking. This project aimed to improve the service pathway by integrating a Parkinson’s disease specialist psychiatrist (PDSP) within the MDT rather than referring patients to a separate mental health service.

METHODS: Data including mental health symptoms, time to review, diagnosis, treatment, and follow-up were collected over 12 months from the electronic clinical records of all patients referred to the PDSP with cognitive impairment. This data set was subject to descriptive analysis and economic evaluations.

RESULTS: 47 patients with Parkinson’s and cognitive impairment were referred to the PDSP - median waiting time to review was one month. Fourteen patients were diagnosed with mild cognitive impairment, 5 with dementia, and 28 with another condition or requiring further diagnostic assessment. Review with the PDSP prevented onward referral to another service in 29 cases, saving an estimated £1140 and reducing duplication of assessments.

CONCLUSIONS: Integration of a PDSP into a PD MDT avoided the need to refer the majority of patients to a separate mental health service, led to fewer health care professional contacts, reduced duplication, and cost savings. It is likely that the model led to earlier diagnoses and treatment. Evidence as to patient and carer experience is not yet available.

Over the last 12 months, an oncogeriatric clinic was successfully established to assess frail 2-week wait (2WW) patients referred with upper and lower gastrointestinal (GI) symptoms. The clinic was initially funded by the West Yorkshire Cancer Alliance, enabling a weekly clinic, run by a geriatrician, clinical specialist nurse and an advance clinical practitioner. A total of 350 patients were assessed, with only a third of them remaining on the 2WW pathway compared to traditional surgical patients; this was due to patients being too frail or an alternative diagnosis being made through comprehensive geriatric assessment, and a shared decision-making process. Patients with a clinical frailty score of 6 or more were eligible for referral, and due to demand exceeding capacity, remaining patients were referred on through the default surgical or GI pathways. Patients were triaged by endoscopy nurses from ‘straight to test’ referrals after training provided to assess frailty scores using routinely data available. The patient level information and costing system (PLICS) demonstrated that the oncogeriatric was a cost effective clinic, costing approximately £340 less per patient than the default pathways of care. Feedback from patients demonstrated extremely high satisfaction rates with the service provided. One of the most significant interventions was medicines management, which has led to a pharmacist supporting the clinic through further innovation funding. Lessons learned included developing a better understanding of cancer diagnosis and frailty, providing a ‘one stop centre’ for cancer care, and managing complex comorbid conditions in frail older people suspected of having cancer. As a result of this QI service development project, a Frailty Cancer Strategy for the Trust has been developed and will be presented to the executive team with the aim of developing a comprehensive oncogeriatric service for frail patients in Leeds, providing the right care, and right treatment first time.

Introduction:

Frailty is the concept of increasing vulnerability to minor stressors in the context of a reduction in physiological reserves (Clegg et Al. The Lancet 2013, Volume 381, pages 752-762). It affects 10% of people presenting to Emergency departments (ED) and around 30% of inpatients in acute medical units (NHS England and NHS Improvements. 2019). Implementing a CGA is known to result in a significant increase in your likelihood of being alive and in your own home at 6 months (Ellis et Al. BMJ 2013).
 

Aims:

To implement an ED in reach frailty service with the goal of performing a CGA at the earliest opportunity.
 

Methods:

We undertook a 3 week pilot with a small team comprising a consultant, frailty ACP, SHO and geriatric registrar. The team were based in ED and worked alongside the existing ED navigator team and in conjunction with various community teams. Data was collected assessing completion of the usual domains within the CGA and discharge data.

Results:

62 patients were seen in total. Mean age was 82.4 years with a mean CFS of 5. Each patient received a CGA. 9/62 (15%) of patients were discharged on the same day. 15/53 (28%) were discharged within 72 hours of admission. Other notable results include: 100% completion of 4AT and 70 medications de-prescribed. Feedback from patient and relatives in addition to ED and AMU doctors was extremely positive.
 

Conclusion:

We demonstrated that performing a CGA in ED resulted in higher numbers of patients being discharged on the same day or within 72 hours of admission. We were able to demonstrate a significant increase in assessment of delirium allowing earlier detection and a much higher rate of deprescribing with significant benefits for both patient and the trust.