NHS West Kent Clinical Commissioning Group Frail Elderly Care Developing a whole system model of care for West Kent

NHS West Kent Clinical Commissioning Group Defining frail elderly Frailty is a clinically recognisable state of increased vulnerability resulting from aging- associated decline in reserve and function across multiple physiological systems such that the ability to cope with every day or acute stressors is compromised. It is often, but not always, associated with the presence of multi- morbidity.

NHS West Kent Clinical Commissioning Group Understanding our population Emergency admissions numbers and rates for ‘frail and old’ patients is rising, West Kent rates rising faster However, emergency admission rates still lower in West Kent than for all Kent & Medway Majority of West Kent CCG registered patients admitted to MTW 94+% of emergency admissions are via A&E, conversion rate higher in West Kent than Kent & Medway Primary reasons for emergency admissions include circulatory, respiratory and injury Length of stay is reducing across Kent & Medway but West Kent average higher then Kent & Medway Most patients aged 85+, 99% 75+

NHS West Kent Clinical Commissioning Group The West Kent Strategic Fit Underpins the delivery of: –Mapping the Future –The CCG’s five year strategic vision detailed in the Commissioning Strategic Plan –Better Care Fund Embedded within the CCG’s roll out of microsystems, risk stratification and MDTs across primary care, as well as the care plan management system

NHS West Kent Clinical Commissioning Group Principles for developing a local model Care should be performed in the most appropriate location, by the most appropriate people Care should be performed in a timely fashion All frail older people should undergo Comprehensive Geriatric Assessment as this improves outcomes. Frail Older people should have an advanced/anticipatory care plan, agreed with the patient and/or carers, which is available to all in social and health care. Inpatient hospital care should be delivered by specialists on dedicated wards, as this improves outcomes. When a patient is fit for discharge from hospital they are discharged promptly

NHS West Kent Clinical Commissioning Group West Kent Frail Elderly Model of Care

NHS West Kent Clinical Commissioning Group Service redesign to deliver the model Frailty Multidisciplinary Teams (MDTs) –MDTs attached to primary care clusters Clinical leadership from a geriatrician Core team to include: GP, complex care nurses, therapists, social care Developing hospital front end services –HIT team –Frailty unit Admission criteria Staffing model –Proactively approach prolonged hospital stays –Discharge to assess Flexible community provision –Utilisation of community hospitals –Step up and step down facilities –Support to care homes

NHS West Kent Clinical Commissioning Group Questions for the PPG Chairs. What do you consider to be the most important outcomes for this care pathway redesign? Have we got the right principles for developing a local model? What are the current barriers to frail elderly care? What are the gaps in provision currently? Next steps – have we got the right focus?