Primary and Community Care

Introduction:

Socio-economic costs of hip fractures are formidable. Despite osteoporosis and falls being major risk factors, preventative screening in Primary Care does not occur. Evidence shows screening older women for osteoporosis prevents hip fractures, but to make a greater clinical and economic impact simultaneous screening of falls and fracture risks is logical. This cross-sectional study evaluates an innovative digital questionnaire and computer programme to combine person-reported data with medical data, and auto-calculate fracture and falls risks without the need for clinician time.

Method:

Digital questionnaires were distributed via email or SMS to adults aged ≥65 who had consented to receive electronic correspondence over a 16-week period in one medical centre. Excluded were adults in nursing/residential care or receiving palliative care. A computer programme combined patient-reported information with existing medical data required to calculate FRAX® & FRAT scores. A robot computer function retrieved fracture risk scores from the FRAX® online tool. A weekly report showed those at high/medium risk of fracture and high risk of falls. Personalised bone health and lifestyle advice was automatically distributed.

Results:

632 (37%) of 1692 questionnaires were returned. Ages ranged from 65 to 92 years (M=72.5, SD=5.7), 47.8% identified as male and 52.2% female. Using NOGG UK Guidelines (2021), 217 (34%) adults were identified at amber and 46 (7%) at red fracture risk. 131 (20.7%) adults had fallen within the previous year and 122 (19%) had a high-risk FRAT score ≥3. Personalised bone health and lifestyle advice was delivered to all 632 adults.

Conclusion:

This automated screening process accurately identifies adults who are falling and/or at risk of osteoporosis and enables personalised bone health and lifestyle advice to be distributed without the need for clinician time. Prevention of falls and hip fractures would result in significant savings to the NHS and Social Care budgets.

Introduction

The housebound population are growing in number, with a large proportion living rurally or in coastal areas, which increases the risks of isolation and health inequalities. This population are an under researched and underserved group (Public Health England, 2019). Being unable to leave the home is a factor for living in the poorest of health, which contributes to advancing levels of frailty, Curtis et al (2018). Considering the current focus of empowerment to ‘age well’ (NHS England Long Term Plan, 2019), a granular understanding of community focused ageing well interventions is the focus of this review to empower clinicians to ‘make every contact count’ (NHS England 2020).

Method

A narrative evidence review of findings has been completed entitled ‘ageing well interventions to improve and maintain independent living for community housebound populations.’ The review was registered with PROSPERO international prospective register of systematic reviews (CRD 42022371047) and reported according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA). Data screening was undertaken by two reviewers at each stage to ensure accuracy, quality, and reliability.

Results

The results have identified key health interventions designed and delivered by community clinicians, including benefits of exercise, medication review, oral health, and health empowerment to improve outcomes for the housebound population. The results have outlined a total of twenty-nine outcome measures, which have been examined intrinsically and extrinsically to explore greatest impact for housebound health.

Conclusion

At the time of the Autumn conference, the research study will have completed the systematic review and be able to present findings to illustrate the areas of intervention synthesized for the target population. Key to this will be understanding the effectiveness and generalizability to a wider population of the literature findings. The poster presentation will be able to share progress of the wider study with opportunities to take part.

Curtis, L and Price, H. (2018) Meeting the challenges of housebound patients with diabetes. Practical Diabetes. 35:2. Pp55-57.

National Health Service England (2019) Long Term Plan. NHS England. London.

National Health Service England (2020) Making Every contact count: a consensus statement. NHS England. London.

Public Health England. (2019) Health Profile for England. Public Health England. London.

Background 

Deconditioning in the acute setting is associated with adverse outcomes, that cannot always be mitigated by increasingly stretched MDT workforce. We partnered with the Saints Foundation (SF), to test the feasibility and acceptability of a non-clinical Exercise Practitioner (EP) to work alongside therapies to promote physical activity (PA) of hospitalised older people. 

Methods 

Charity funded joint appointment of an NVQ3 EP with Postural stability Instructor (PSI) qualifications delivered quality education and rehabilitation programmes to hospitalised older patients. These took place in both one to one and gym-based group settings whilst working with the SF team to improve access to community-based exercise programmes. 

Results 

Between Sept 2022 and May 2023, the EP assessed 169 patients, mean age 86 yrs; male (62%), admitted after a fall. 105 patients (62%) underwent one to one rehabilitation consisting of falls education and individual exercise plans, 64 patients (38%) underwent gym-based rehabilitation, where strengthening and balance exercises were conducted in groups to improve overall function and increase confidence in functional ability. No adverse safety incidents were reported and a high level of satisfaction after interaction with the EP was conveyed. Initial focus was on patient feedback and satisfaction to ensure input of an EP was well received and accepted. 

Conclusion 

Intervention by a non-clinical EP to improve the PA of hospitalised older people is acceptable, feasible, appears to be safe and is associated with increased patient satisfaction. By capitalising on SF expertise, we provided a clinical standard on exercise for older adults and built a strong relationship between our workforce to bridge community and acute services. Next steps are to increase the scope of interventions, evaluate quality of life pre and post hospitalisation, capture trust level metrics including length of stay, readmission rates and discharge destination to further evaluate the impact on service users. 

Introduction: Sedentary behaviour has been associated with several deleterious health outcomes and older adults are the fastest-growing and most sedentary group in society. This review aimed to systematically review quantitative and qualitative studies examining interventions to reduce sedentary behaviour in community-dwelling older adults.

Methods: This mixed-method systematic review (PROSPERO registration number: CRD42021264954) considered quantitative articles (randomised-controlled trials (RCTs) and cluster RCTs), qualitative articles (semi-structured interviews and focus groups) and mixed-method studies that explored interventions to reduce sedentary behaviour in community-dwelling older adults. Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Cinahl, SportDiscus and PEDRO were searched from inception to March 2023. Articles were appraised using the Mixed Method Appraisal Tool. Quantitative evidence was meta-analysed, qualitative evidence was thematically synthesised and both were combined in a mixed-method synthesis.

Results: Forty-one studies (15 RCTs, 21 qualitative and 5 mixed-method studies) were included. Interventions were somewhat effective at reducing sedentary time (-29.10 mins/day, 95% CI -51.74, -6.46). Three analytical themes were identified (what sitting means to older adults, expectations of ageing and social influence in older adults). The mixed-method synthesis identified that existing interventions have been limited by a recruited sample that is not representative of the wider population of older adults, and outcome measurement and intervention content that is not consistent with older adults’ priorities.

Conclusions: Future research should focus on inclusive recruitment strategies to recruit underrepresented populations (such as adults aged 75 years and above), incorporate outcome measures that are valued by older adults, and incorporate older adults’ preferences in intervention content.

Background:

The development of integrated care occurs alongside climate emergency, where transport is a large contributor to carbon emissions (1). Care previously delivered in hospital outpatients, or a central ‘hub’ is now being delivered in integrated care clinics, “spokes”. We aimed to assess the environmental impact of transport to integrated care clinics.

Methods:

Geriatric Medicine Integrated Care attendances from January 2023 to March 2023 were included. Distance from the patient’s home address to the location of Integrated Care Clinic(spoke), and to the affiliated hospital(hub) were recorded in kilometres.   

For the primary analysis, we have not considered staff travel as there was heterogeneity in number of staff per clinic and distance travelled per staff member.  

Where more than one route was available, the shortest distance was recorded. Carbon emissions were estimated based on kilometres travelled by a standard new passenger car (2).  

Results:

Among 206 clinic attendances, the mean distance to ‘spoke’ clinic was 16.06 km (15.98) compared to a mean distance of 39.29 km (17.82) to the ‘hub’ clinic.

The estimated total distance travelled by patients to integrated care clinics was 3293.45km, whereas the distance which would have been travelled to ‘hub’ clinics was 8055.85km. Total carbon emissions for 3-month travel to ‘spoke’ clinics were estimated at 371kg, compared to 907kg to the ‘hub’.  

Conclusion:

The development of integrated care services, which provides necessary care to older adults, may also have an environmental advantage.  

Healthcare’s contribution to climate change action is another incentive to invest in integrated care services.

References:​

1. CO₂ emissions [Internet]. 2023. Available from: https://www.seai.ie/data-and-insights/seai-statistics/key-statistics/co… ​

2. Average CO2 emissions from New Passenger Cars, by EU Country [Internet]. 2022. Available from: https://www.acea.auto/figure/average-co2-emissions-from-new-passenger-c…

Introduction Factors contributing to frailty result in increased hospitalisations, with 5- 10% of patients attending Accident and Emergency department living with frailty, and 30% of those patients admitted to acute medical units (Conroy, 2013). Hospital admissions result in functional decline and deconditioning (Get It Right First Time, 2021). The number of people in the UK over the age of 85 is set to double in the next 20 years and treble in the next 30 (Office of National Statistics, 2013). Their needs are best met in the community with a multi-disciplinary approach. Method Patients, residing in Benfleet and Leigh-on-sea, discharged from Geriatric wards at Southend Hospital were identified during ward MDT meetings. Inclusion criteria: • Recurrent admissions • Prolonged hospital stay • Clinical Frailty Score > 5 • Social support Using this criteria, 216 patients were included. 7 day readmission and 30 day readmission data was collected and compared to readmission rate prior to intervention. Intervention On discharge patients were linked with Frailty Nurses within their Primary Care Network and were reviewed within 48- 72 hours of discharge. Community support was provided via MDT, with involvement from consultant geriatrician. Concerns that could result in readmission were highlighted during these meeting, with patients being seen in Day Assessment Unit for review of sub-acute frailty syndrome if appropriate. Results Following intervention of utilising community MDT there was a reduction in rate of readmission. 9 patients (4.1%) were readmitted within 7 days of discharge and 14 patients (6.4%) were readmitted within 30 days, in comparison to 7.6% and 19.3%, respectively, prior to commencement of MDT. Conclusion This concludes that utilising community MDT with review following discharge has positive impact in reducing readmission rates. Highlighting potential risks of readmissions allows the MDT to address issues within the community and use bridging services appropriately.

Introduction: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to frailty at the front door or a community based service and has access to rapid diagnostic and intervention services.

Aims: The aim of this research is to share and describe the model of this relatively new and novel service for the benefit of other service providers.

Method: A prospective database review was performed to provide descriptive data on the service between 2021 & 2022. Variables examined included referral source, MDT members involved on initial assessment and follow up, patient’s objective outcome measures and a history of falls.

Result: Between the years 2021 and 2022, 350 new patients and 912 review patients were seen by the team with an additional 139 Medical Assessment Unit consultations carried out also. Of these service users 37.38% were male and 62.61% female. The average Clinical Frailty Score was 4.98 (4.91 men, 5.05 women). This indicates the mean service users is ‘Living with Mild Frailty’ - a cohort that may be otherwise missed by other services.

Conclusion: This research highlights the demand for access to out-patient frailty interventions in line with the National Clinical Programme for Older Persons which promotes access to ‘the right person, in the right place, at the right time’.

Objective: To evaluate the environmental impact from home visits the ESD team carry out and the implementation of electric vehicles to reduce the carbon footprint.

Methods: Travel expense data of the ESD team across the last 2 weeks of April was collected and CO2 emissions from each team member was derived. A focus group was conducted to gather the team’s stance on electric vehicles for home visits.

Results: A significant amount of CO2 is produced daily, with the total across the two weeks being close to that of a small-to-medium enterprise. Introducing an electric vehicle would help reduce the CO2 emissions, with a 62% reduction seen in week 1 if the person with the greatest emissions were to have the vehicle.

Conclusion: Although there are disadvantages, implementing an electric car into a department where multiple home visits are carried out in a day would help significantly in reducing the carbon footprint and help NHS Wales reach their environmental targets.

Introduction

Sustaining independence is important for older people, but there is insufficient guidance about which community services to implement.

Methods

Systematic review and network meta-analysis (NMA; PROSPERO CRD42019162195) to synthesise effectiveness evidence from randomised or cluster-randomised controlled trials of community-based complex interventions to sustain independence for older people (mean age 65+) living at home, grouped according to their intervention components. Main outcomes: Living at home, activities of daily living (ADL), care-home placement, and service/economic outcomes at one year. We searched five databases and two registries, and scanned reference lists. A random-effects NMA was used. We assessed risk of bias, inconsistency, and certainty of evidence.

Results

We included 129 studies (74,946 participants). Nineteen intervention components, including ‘multifactorial-action’ (individualised care planning), were identified in 63 combinations. Few studies contributed to each comparison. High risk of bias and imprecision meant results were very low certainty (not reported) or low certainty (unless otherwise stated). Findings may not apply to all contexts. For living at home, evidence favoured ‘multifactorial-action and review with medication-review’ (odds ratio (OR) 1.22, 95% CI 0.93 to 1.59; moderate certainty), and three other interventions: ‘multifactorial-action with medication-review’; ‘cognitive training, medication-review, nutrition and exercise’; and, ‘ADL, nutrition and exercise’. Four interventions may reduce odds of remaining at home. For instrumental ADL (IADL), evidence favoured ‘multifactorial-action and review with medication-review’ (standardised mean difference (SMD) 0.11, 95% CI 0.00 to 0.21; moderate certainty). Two interventions may reduce IADL. For personal ADL, evidence favoured ‘exercise, multifactorial-action and review with medication-review and self-management’ (SMD 0.16, 95% CI -0.51 to 0.82). Among homecare recipients, evidence favoured addition of multifactorial-action and review with medication-review (SMD 0.60, 95% CI 0.32 to 0.88). Other findings were inconclusive.

Conclusions

The intervention combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Unexpectedly, some combinations may reduce independence.

Introduction: Scotland's National Dementia strategy (2017) highlights the need to improve identification and management of dementia. Hospital at Home (H@H) teams often identify undiagnosed cognitive decline as part of comprehensive geriatric assessment. A trainee ANP in dementia services was appointed in 2019 in West Lothian; before this, the average waiting time to memory clinic assessment was 6 months for a home visit, and 12 months for outpatient clinic review. Affiliated with REACT H@H, the ANP identified a significant unmet need for assessment of cognitive decline in a patient cohort referred to H@H.

Method: Baseline data from patients reviewed by the dementia ANP was collected between Sept 2021 – Feb 2022, including referrals from H@H. A new pathway was then introduced to streamline referrals including education and upskilling of the H@H team. Further data was collected between Sept 2022 – February 2023.

Results: In the first cohort, 161 patients were assessed by the Dementia ANP, of which 39 (24%) had been referred from H@H. 60 patients (37%) were seen as a home visit, and 101 (63%) in clinic. 2 (1%) of referrals were managed with advice only. 125 patients (78%) were given a diagnosis of dementia; other diagnoses included delirium, low mood and anxiety. In the second cohort, 168 patients were assessed by the Dementia ANP, 39 (23%) being referred from H@H. 94 (56%) were seen in clinic and 74 (44%) as home visits. 10 (6%) of referrals were managed with advice only. 138 (82%) were given a diagnosis of dementia. Time to diagnosis assessment of dementia was reduced to 1 month for home assessment, and to 4 months for outpatient clinic assessment.

Conclusion Appointment of a Dementia ANP and integration with H@H  services improves time to assessment and diagnosis of dementia.