Acute medical care of older people - outside hospital Simon Conroy Head of Service/Senior Lecturer, Geriatric Medicine Cardiovascular Sciences University of Leicester

Not an acute medical problem Ageing population Lack of primary care Poor social services What is intermediate care? Inappropriate admissions

Patients come out worse than went they went in Ageing population Too many specialists Too many specialists Black hole Inappropriate investigations Inappropriate admissions

What is the truth? Ageing population, increasingly complex care More attending emergency care Despite intermediate care etc Lower threshold for admissions Coordinated care more challenging as ‘silo mentality’ sets in

Some definitions ‘Unscheduled care’, ‘unplanned care’, ‘emergency care’, ‘urgent care’ Department of Health: ‘Emergency Care is an immediate response to time critical health care need. Unscheduled care involves services that are available for the public to access without prior arrangement where there is an urgent actual or perceived need for intervention by a health or social care professional. Urgent care is the response before the next in–hours or routine (primary care) service is available.’

Scope Emergency care 999/ED Not appropriate for community setting Urgent care ‘In the eye of the beholder’ Most urgent care is sub-acute care

Urgent (sub-acute) care – who?

Urgent (sub-acute) care – who?

Urgent care – what? Non-specific presentations Falls, delirium Multiple comorbidities Polypharmacy Also under-prescribing Differential challenge Communication, discharge support

Urgent care - where? Where there is ready access to: Skilled assessment Diagnostics, if necessary Safe environment Rehabilitation Coordinated care

Figure 3: Fixed-effects meta-analysis of individual patient data: mortality at 6 months. Figure 3: Fixed-effects meta-analysis of individual patient data: mortality at 6 months. Adjusted for age and sex. The N values represent the numbers of participants for which the trialists provided follow-up data (at our request); in some cases these values were less than the numbers of participants initially recruited (as stated in Appendix 2, available at www.cmaj.ca/cgi/content/full/180/2/175/DC2). Note: CI = confidence interval, HR = hazard ratio. Shepperd S et al. CMAJ 2009;180:175-182 ©2009 by Canadian Medical Association

Urgent care - standards The Silver Book http://www2.le.ac.uk/departments/cardiovascular-sciences/people/conroy/silver-book Membership Age UK National Ambulance Service Medical Directors Association of Directors of Adult Social Services British Geriatrics Society Chartered Society of Physiotherapists College of Emergency Medicine College of Occupational Therapists Society for Acute Medicine Royal College of General Practitioners Royal College of Nursing Royal College of Physicians Royal College of Psychiatrists Community Hospitals Association

Underpinning principles All older people have a right to a health and social care assessment and should have access to treatments and care based on need, without an age- defined restriction to services A whole systems approach with integrated health and social care services strategically aligned within a joint regulatory and governance framework, delivered by interdisciplinary working with a patient centred approach provides the only means to achieve the best outcomes for frail older people with medical crises

Standards (some) All older people accessing urgent care should be routinely assessed for: Pain Depression Skin integrity Falls and mobility Continence Safeguarding issues Delirium and dementia Nutrition and hydration Sensory loss Activities of daily living Vital signs End of life care issues

Frailty syndromes & urgent care The presence of one or more frailty syndrome should trigger a more detailed comprehensive geriatric assessment, to start within 4 hours (14 hours overnight) Frailty syndromes Falls & immobility Functional decline UTI & incontinence Pressure sores Delirium and dementia Polypharmacy (>4 items) Carer strain

Who needs referring to the MDT? Population: Refer to: Younger, single system problem Older, single system problem Older, multiple problems, frailty makers Relevant service, e.g. mental health, diabetes Relevant service, e.g. mental health, diabetes & screen for frailty syndromes Virtual ward/ community MDT

Operationalising good practice Delivering multidimensional assessment & multiagency management Home based multidisciplinary teams General practitioners Community nursing, physiotherapy, occupational therapy, mental health Specialist nursing Advanced nurse practitioners Interface geriatricians Social care Voluntary services

Does it work in practice? National Evaluation of the Department of Health’s Integrated Care Pilots; RAND Europe, Ernst & Young; March 2012

Key findings Horizontal > vertical integration Process improvements – e.g. more care plans Professional > patient driven service change Patients less enthusiastic No evidence of reduced emergency care use Reductions in elective care use (in and out-patient) Case management Reduced costs

Effective urgent community care for older people Vertically integrated, using strengths of both sectors Comprehensive geriatric assessment, including social care Coordinated and communicated

EFU/ AFU Intermediate care Frail older person in crisis SPA – clinical discussion Bed-based rehabilitation/ reablement MDT Triage Trajectory Transfer EFU/ AFU Specialist care In-patient CGA Liaison

Summary outcomes for ED Percentage change 2010 vs. 2012

Impact on bed days Despite large increase in older people attending, bed-days only modestly increased

Summary Urgent care = older people It can be in the community, but: Needs to be vertically integrated Holistic & interdisciplinary Underpinned by robust communication and cooperation