Frailty pathway Latana A. Munang Consultant Physician and Geriatrician St John’s Hospital

Outline The status quo Frailty Comprehensive Geriatric Assessment The Frailty Pathway Summary & Discussion

Projected population change West Lothian 85+ increase of >300% General Register Office for Scotland

All admissions to MAU from 23 to 29 Jan 2015

Frail Non-frail p-value 47 56 Age, years Mean (SD) Range 79.3 (8.1) 68 - 101 75.8 (6.3) 65 - 90 <0.05 Length of stay, days Median (IQR) 18.2 (20.7)* 11 (4.25 – 22.75)* 1 – 85* 7.6 (12.1) 3 (1 – 6) 1 - 57 Readmission (%) 7 day 30 day 60 day 2 (4.3) 8 (17) 6 (10.7) 12 (21.4) 15 (26.8) NS Mortality (%) Inpatient 7 (14.9) 3 (6.4) 5 (8.9) 1 (1.8) 2 (3.6) 7 (12.5) Frail group older, stay longer. 2 still inpatients - 1 thrombolysed stroke, transferred for endarterectomy, now still in stroke rehab; the other Edinburgh patient who went to RVH (presumably to board), fell with #NOF, now at Ortho RIE Non-frail appear to have more readmissions, but not statistically significant Mortality higher for frail, but only significant for 30 day mortality * 2 patients are still inpatients

Frailty ‘A biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative decline across multiple physiologic systems, and causing vulnerability to adverse outcomes' Walston et al. Research Agenda for Frailty in Older Adults: Toward a Better Understanding of Physiology and Etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. JAGS 2006; 54: 991-1001

Vulnerability of frail elderly people to a sudden change in health status after an illness Same stressor results in more functional decline, longer recovery period and return to lower level as new baseline Clegg, Young, Iliffe, Rikkert, Rockwood Frailty in elderly people Lancet 2013; 381: 752 - 762

Survival curve estimates by frailty status at baseline Classified by Fried’s phenotype system – frail if 3 or more of: 1. Unintentional wt loss, 2. self reported exhaustion, 3. weakness (grip strength), 4. slow walking speed, 5. low physical activity Fried L P et al. J Gerontol A Biol Sci Med Sci 2001;56:M146-M157

Comprehensive Geriatric Assessment Multidimensional diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person in order to develop a coordinated plan to maximize overall health with aging

Domain Assessment Medical Mental health Functional capacity Co-morbidity & disease severity Medication review Nutritional status & dentition Continence Vision & hearing Advance care preferences Mental health Cognition Mood & anxiety Fears Spirituality Functional capacity Basic activities of daily living Gait & balance Activity / Exercise status Instrumental activities of daily living Social circumstances Support from family & friends Social network eg. Visitors, daytime activities Finances Eligibility for care resources Environment Home facilities, comfort & safety Potential use of telehealth technology Transport facilities Access to local resources CGA is multidimensional

Case Manager Geriatrician GP Physiotherapist Occupational Therapist Nurse Speech & Language Therapist Dietician Social Worker Pharmacist Case Manager CGA is multidisciplinary. Need a case manager for big picture view, coordinate care

CGA Assessment Problem list Goals Intervention CGA is a process, not an event. CGA is iterative

CGA vs. usual care Outcome No. of studies No. of participants Effect size Living at home Up to 6 months End of follow up 14 18 5117 7062 1.25 [1.11, 1.42] 1.16 [1.05, 1.28] Mortality 19 23 6786 9963 0.91 [0.80, 1.05] 0.99 [0.90, 1.09] Institutionalisation 4925 7137 0.76 [0.66, 0.89] 0.78 [0.69, 0.88] Death or deterioration 5 2622 0.76 [0.64, 0.90] NNT 13 to prevent one death or adm to NH Ellis G, Whitehead MA, O'Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2011, Issue 7

Unwell frail older person CURRENT MODEL OPD Unwell frail older person A&E SJH Front door PAA MAU Gen Med Ward Refer PT OT MoE Templar Day Hospital Rehab ward Discharge REACT GP Boarding ward GP

Principles Right to medical diagnosis and equal access to specialists Patient-centred Home is best The right patient looked after by the right team in the right setting Planned care better than emergency care Simple Sustainable Focus on quality and quality improvement

Case-finding for targeted intervention Frail patients identified as soon as possible to enable timely assessment and management Specialist nurse supported by Consultant Geriatrician Systematic MDT on all medical wards Robust referral system from other parts of the system

Health Improvement Scotland: Think Frailty

MAU SJH Average medical take = 25

MAU SJH 15 are >65 years

MAU SJH 11 will screen positive

MAU SJH Only 7 will be frail

Right patient, right team, right setting Prompt decision on care trajectory and transfer to most appropriate setting Complex frail patients managed by consultant geriatricians Tracking of less complex frail through liaison Effective MDT in each ward with regular discussions for goal setting and discharge planning

Home is best Admission avoidance

Hospital at Home Rehab at Home Since 1st May 2013, 900 patients, 6000 care days

Templar Rapid Access Frailty Clinic Rapid access CGA in a specialist multidisciplinary ambulatory setting A ‘one-stop’ clinic offering specialist assessment and same-day diagnostics with real- time decision-making led by a geriatrician Referrals via telephone to the MoE Single Point of Contact (SPOC) with appointments for the same or the next working day given in the same conversation Aim to reduce avoidable admissions and facilitate timely discharge when acute hospital care no longer necessary Close working with REACT, MAU/PAA, Reablement, Crisis care, Primary Care, Social Work, Mental Health and other specialties

Home is best Admission avoidance REACT Templar Rapid Access Frailty Clinic Discharge to assess

Improving Flow D2A Assessment Patient Admitted Seen by Doctor Seen by nurse Physio Assessment Rehabilitation OT and PT assessment Care at home Discharge Home Care at Home Discharge Home Discharge Planning Rehab in hospital OT Assessment

Home is best Admission avoidance REACT Templar Rapid Access Frailty Clinic Discharge to assess “Medically stable” vs. “No longer in need of acute hospital care” Rehab at home Closer working with community services

Simple Single point of contact Telephone or electronic contact Reproducible and scalable

Good post-acute care CGA initiated and completed Reassessment Identify patients with highest risk of readmissions, deterioration Advance care plans

FRAILTY PATHWAY ST JOHN’S HOSPITAL Safe for discharge REACT Screen all ≥65s Unwell frail older person A&E SJH Front door PAA MAU Frailty nurse OPD Discharge hub Templar Day Hospital Rehab ward Inpatient admission required GP care + agreed plan GP Medical ward under a geriatrician Rest of SJH Referral or MDT pick up Subacute care Consultant Geriatrician Single Point of Contact

Summary Frailty is our core business Early identification allows targeted CGA CGA is multidimensional, multidisciplinary and iterative Evidence-based changes to system to allow great frailty care everywhere

Discussion