1. Frailty Concept/ Hospital without Walls
Professor Pradeep Khanna MBE
Chief of Staff, Community Services
Aneurin Bevan Health Board

2. Commissioning & Care Planning
Strategic Planning
Specify Outcomes
Develop Business Case
Procure Services
Manage Demand
Maintain Performance

3. CASE FOR CHANGE Demand will always beat supply
Pressure on cost is remorseless
NHS can not provide a comprehensive service on current assumptions after 2011
(Kings fund and the Institute of Fiscal Studies – IFS)

5. Some Facts
Nearly 33% of inpatients could safely be cared for in another setting than in an acute hospital [Kings fund audit 1992; DOH 2000]
29% of patients in acute hospital beds are medically stable [43% in elderly wards] [Barbara Vaughan; Gill Withers 2002]
In Wales, higher proportion of chronic long term conditions (23%) compared to England (18%); Northern Ireland (20%)
Audit of 5 GP Practices in Swansea revealed 3% of population with 2 comorbidities + emergency admission accounted for 59% of hospital admissions [Ref = WAG 2007 – Designed to improve health …chronic conditions Wales]
Conclusion: A focused integrated approach of Health and Social Care, Housing and Transport is recommended

7. Drivers For Change
Wanless Report: Hard hitting facts about Health Services in Wales
Designed for life: Strategic framework: Health & Social Care Services in Wales
Fulfilled lives, Supportive Communities: Emphasis on Social Care
Making the connections [Public involvement & redesign services around the needs of the users]
5. Primary Care & Community Services Strategy (Chris Jones)

8. Current System of Care “Push System full of Black Holes”
Local government
FRAGMENTED AND DISORGANISED COMMMUNITY BASED CARE
COM
NURS E
TMS
HEALTH
SOCIAL
HOSPITAL
BASED CARE
DISCHARGE
INCREASING DEPENDENCY
INCREASING COMPLEXITY
DECREASING FUNCTIONALITY
PRIMARY CARE
DEPENDENT
FRAIL NH RH
OOH AE
INDEPENDENT
FIT
PARA MED
NHSD
PUSH
Patient journey

10. Hospital-at-Home: definition………
Hospital care but delivered in the person’s own home !!!
HaH = “….a service that provides active treatment by health care professionals, in the patient’s home, of a condition that would otherwise require acute hospital in-patient care, always for a limited period.”
Cochrane definition, 2005
Combination of personal support & rehabilitation care

11. Admission Avoidance Hospital at Home/Inpatient Care (Review)
[Systematic Review & Meta Analysis]
Mortality at 3 months NS (P= 0.15)
Mortality at 6 months Significant (P=0.005)
Readmission Rates NS (P=0.08)
(within 3 months)
Functional Ability (12 months)
i. Quality of Life
ii. Physical abilities
iii. Cognitive Status NS
Reference: Sheppard S, Doll H, Etal: The Cochrane Library 2009: Issue 3

12. Hospital at Home
CLINICAL OUTCOME: (Adverse Events & Medical Complications)
Bowel Complications = % (96% C.I = 34% to 10.82)
Urinary Complications = % (95% C.I = 25.4% to 3.3%)
c Antipsychotic Prescribing = % (95% C.I = 28% to 0.3%)
in Dementia Patients
COPD = Antibiotic = % (95% = 34.6% to 1.4%)
PATIENT SATISFACTION: Significant (P < )
3. ECONOMIC ANALYSIS:
(Co Morbidity: Older Group) Costs = Per episode $2011; 95% C.I (= $2800 to $1222)
= Per day $293; 95% C.I (= $318 to $268)
CONCLUSION: Admission Avoidance Hospital at home can provide an effective
alternative for selected group of Patients (Outcome Similar)

13. Early Supported Discharge Teams Vs Conventional Care 11 Trials (6 countries)
Outcome
Patients randomised
Summary result
(95% CI)
P Values
Patients’ outcomes
Death or dependency
1597
0.79 (0.64 to 0.97)
0.02
Death or institution
1398
0.74 (0.56 to 0.96)
Extended ADL Score
1051
0.12 (0 to0.25)
0.05
Satisfied with outpatient services
513
1.60 (1.08 to 2.38)
Carer outcomes
Subjective health status score
613
0 (-0.25 to 0.24)
0.97
279
1.56 (0.87 to 2.81)
0.14
Resource outcomes
Length of hospital stay
1015
-7.7 (-10.7 to - 4.2)
<0.0001
Readmission to hospital
633
1.14 (0.80 to 1.63)
0.48
Conclusion: “Appropriately Resourced and Co-ordinated Services” in clearly defined Target Groups has clear potential benefits
Langhorne P, et al - Lancet 2005;365;

14. THE EVIDENCE-BASE FOR INTERMEDIATE CARE
RCTs
HOSPITAL-AT-HOME
DAY HOSPITAL 12
NURSE-LED UNITS 10
COM. REHAB.TEAMS
CARE HOME REHAB
COMMUNITY HOSPITAL 1
Message: (a) Target people with greatest clinical
need (Frailty)
(b) Integrate I.C with Mainstream
Services 
Expensive
Very expensive 
Shifts costs to social care 

15. Messages From Research
Develop closer integration between IC and Mainstream Services
Target Patients with greatest clinical need: Frailty
Place stronger focus on Admission Avoidance Scheme (Health & Social Care)
(Closer liaison with Ambulance Service, 3rd Sector, A&E, Mental Health)
VANTAGE POINT
Reablement:
More Research/Evaluation needed

16. Clinical Futures: Gwent
Newport
Caerphilly
Torfaen
Blaenau
Gwent
Monmouth
Powys
Other
All Gwent
medical
117
121 96 82 77 1 7
501
surgical 2 8
total
119
122 98 83 79
509 38 39 31 26 25
162
places at-home 81 67 57 54 5
347
total places
Intermediate
Care and/or
Non-acute
Non-acute beds and
places required by LHB
with new MoC
NHS etc beds
Provided as
509 ADDITIONAL BEDS IN ALL BY 2014/15
*Selected HRGs – need to give examples

17. Joint Partnership Sub-Group
5 LHB CEOs, Trust CEO and 5 LA CEOs
Aims: to develop better services along whole patient journey through closer working. To find better way of supporting people who end up needing Continuing Care
Frailty Pathway chosen
Gwent wide multi-agency, multi-professional workshop held April
Task and Finish Groups to expand /develop ideas.

18. Frailty Programme Board
Membership
Chair – Alison Ward, CEO, Torfaen LA
LA reps (social care)
LHB reps
Trust Corporate and Divisional reps
Voluntary sector GP
Ambulance
Work Streams
Independent Living and Reablement
Urgent Response and Intervention
Capacity and Financial Modelling

19. Frailty Syndrome (Environmental x social factors)
Frailty = (Dependency x vulnerability x
co-morbidity) +
(Environmental x social factors)

20. Physical characteristics
What is it?
Physical characteristics
Multidimensional
Weakness
Slowness
Poor endurance
Weight loss
Physical inactivity
Socio-demographic
Biomedical
Functional
Effective and cognitive components 20

22. FRAILTY PREVENT/ DELAY ADVERSE OUTCOMES PROVIDE CARE PREVENT FRAILITY
MODIFIERS
Biological
Psychological
Social 22

23. Prevalence of Frailty 3 or more of the outcome
Age
65-69
70-74
75-79
80-84
85+
%Frailty
18.3
21.7
32.1
32.5
48.8
Estimated numbers of frail elderly people by Local Authority
Estimated Total
Blaenau Gwent
604
621
838
563
646
3275
Caerphilly
1399
1402
1816
1154
1231
7002
Monmouthshire
784
825
1043
695
864
4211
Newport
1127
1222
1472
1085
1156
6062
Torfaen
797
844
1105
683
712
4141
Total by age band
4177
4914
6274
4180
4609
24154
Source: Census 2001

24. Happily Independent

25. What we stand for: Principles & Values
The underpinning principle of the Gwent Frailty Programme is to provide:
‘Help when you need it to keep you independent’
The mantra for those delivering services is to provide help that is
Sustaining independence.
We start with a view that the present system is untenable and that we are not treating people as well as we could or in a way that best uses the available resources and skills.
We believe that people are made more helpless and lose the vital ingredients of confidence and control by present processes that lead to hospitalisation.
We believe that people want to and can stay longer and more successfully in their own home environment provided that is of an acceptable standard, e.g. is warm and safe and accesses technology such as Telecare.
We believe that people should not be in institutional care unless absolutely necessary.
We firmly believe that people have to be seen as individuals with a life, a history, a future. Consequently, at a time when they can be most fearful then it is more important to respect and listen to what they want and need and provide simple, clear communication ideally through one allocated coordinator.
We believe that people are the experts in their own life and that we need to tap into that expertise.
We know that we can do a better job if we work together and that we need each others professional perspectives.
We uphold the necessity of real multi agency work where each profession keeps its own distinctive colour and by sharing our expertise we deliver the sort of service that people deserve.
We see the need for locality work that is integrated at the health and social care delivery end and is based on:Shared values
Joint ownership
Joint outcomes
The Person at the centre
We consider that the integrity of separate organisations within health and social care can add to the dynamism and productivity of the model.
We believe that a range of community activities and services are key to ensuring that people are supported in maintaining and returning to independent living.

26. Outcomes: What frail people tell us they want
Be able to remain living in their own home with support
Receive services in their home
Be listened to by people who are responsible for providing services to assist them
Have their health and social care problems solved quickly and considered as a whole rather than individually.
Be safe and secure
Live in good quality homes
Be able to cook, wash, clean and go out
Be able to maintain their standards
Be financially stable to make independent choices
Be receiving the benefits available to enable them to live independently
Not be lonely
Have a supportive family
Have good friends and neighbours keeping an eye out for them
Have company
Be going out to social activities
Have planned for old age
Be accessing peer support
Be able to keep a pet if they so wish

27. Frail Elderly Workforce Skills Matrix
Specialist Health Care Skills
Health Care Skills
Social Care Skills
Generic Worker
Skills
Specialist Social Care Skills

28. Generalist as the New Specialist (Intermediate Care)
GP’s Changing Roles
Geriatrician Changing Roles
AHP’s Changing Roles
Training In The Community

29. Community Nursing Service
Based on Nursing Strategy: Wales
(Coordination of care)
24 hour Nursing cover in each locality
Overnight on call nursing service including Twilight nursing
Key role in early identification & proactive care of frail clients

30. Common Service Characteristics (I.C)
Urgent Response & Intervention
Reablement & Independent Living
ACCESS
Via locality Single Point of Access
HOURS OF OPERATION
7 days a week 365 days a year 8am to 10pm
7 days a week 365 days a year 8am to 8pm
RESPONSE TIME
2-4 hours (for both health and social care components)
24 hours
ASSESSMENT
Comprehensive Needs & Frailty Index Assessment
Agreed shared assessment document
SERVICE PROVISION
Home upto 14 days
Approximately 6 weeks reabilitation and reablement support
No charge to user for first 6 weeks
ACCESS TO
‘Hot Clinics’ for rapid access to specialist and diagnostic support (Monday to Friday)
Specialists including psychology, dietetics, pharmacy, speech & language therapy, podiatry, EMI teams.
Rapid access to equipment and adaptations.
WORKFORCE
Flexible Health & Social Care Workforces

31. Components of Comprehensive Needs Assessment
1 Medical assessment
2 Assessment of functioning
3 Psychological assessment
Social assessment
Environmental assessment
Elements
Co-morbid conditions
Medication review
Nutritional status
Activities of daily living
Gait and balance
Mental status
Assessment of needs, assets
and resource eligibility
Home safety, transportation and
tele-health

32. Proposed Locality Structure
Joint Chair: Director of Social Services
Locality Manager (Health)
Members: Project Manager
Human Resource
Finance
Intermediate Care Consultant
General Practitioner
Lead Nurse
Voluntary Sector
Co-opted Members: Pharmacist, Mental Health, Therapies, CHC

33. Urgent Response & Intervention
Comprises of three key elements:
Urgent Comprehensive Assessment (Health & Social Care)
Rapid Response Intervention (health)
Social Care Crisis Intervention

34. Proposed Capacity Model (Crisis Management)
Aims
Better management at home or in a community setting.
Engagement with care homes and the independent sector.
Management of patients in Accident & Emergency
Patients handed over to DN teams on discharge from service
Main Functions
Assessment of 200 new patients per month for acute exacerbations of chronic conditions and associated disorders.
Follow-up of 200 patients per month.
7-day presence in A & E and MAU to assess patients and prevent admissions, pulling them back into the community, as required.
Daily Hot Clinics for each borough, run by ACAT/RRT for the provision of advice for GPs.
Formal links with other specialties, including General Medicine, Falls, Trauma & Orthopaedics.
On-going management of patients at home for a 5 – 7 day length of stay (care package)
The Gwent-wide combined team of ACAT, Rapid Response and PATH to provide around 70 virtual beds across Gwent.

35. Staffing Model (Crisis Management)
Based on population of 70-90k
1 wte Consultant Specialist
2 wte Staff Grades or GPswSI (salaried GPs)
4 wte Band 7
10 wte Band 6
3 wte Band 4 Reablement Officers
1 wte Band 6 OT for Reablement
1 wte Social Worker
Approx 50 wte generic Health & Social Care Support Workers, and/or Rapid Access to Immediate Home Care
1 wte Secretarial Staff and 2 wte Typists shared with the Reablement Team

36. Independent Living & Reablement
Approximately 6 weeks coordinated review and reablement to sustain independence
Rapid access to equipment and minor adaptations
Care & Wellbeing Workers able to work across the different elements of the integrated locality team

37. Proposed Capacity Model for Locality Reablement Teams (1)
Based on 70-90k population
5 WTE Occupational Therapists (able to work across ACAT, PATH and Reablement)
5 WTE Physiotherapists
50 Band 3 Generic Support Workers*
2 WTE Case Managers (role needs to be clarified)
2 WTE Social Workers
* Proportion of generic support workers up-skilled to perform some functional assessments?
Shared resources:
IT officer
Training and Development officer
Administrative Support
Hot clinics for Falls, Gen Med and Orthopaedics

38. Proposed Capacity Model for Locality Reablement Teams (2)
Sessional support from:
2 WTE Dieticians
2 WTE Speech and Language Therapists
2 WTE Psychiatric Liaison Nurse (1 for older people, 1 for younger people)
Podiatrist – unable to quantify because many clients using private
1 WTE Community Pharmacologist attached to PATH and Reablement

39. Implementation Workstreams
Communication & Stakeholder Engagement
Workforce Planning
Governance & Structure
Outcome Indicators, Performance and Continuous Improvement
Information sharing & Single Point of Access
Locality Planning (including longer-term care and interfaces with other services)
Financial Modelling/ Building the Business Case

40. Communication & Stakeholder Engagement
Workstream lead: Dr Liam Taylor
Development of a communication strategy for all key stakeholders
Specific programmes of work –
a. Stakeholder Briefings
b. Staff Communication
c. Public Engagement
d. Power Brokers (Politicians and Executive Key Members)

41. Financial Planning Use the outputs from the other workstreams to:
Workstream lead: Nigel Stephens
Use the outputs from the other workstreams to:
confirm demand
map capacity
identify the resource gaps
calculate the financial requirements
Set up pooled budget arrangements

42. Locality Planning
(including longer-term care and interfaces with other services)
Workstream lead: Jo Williams
Support planning for preventative services and delivery at locality level
Ensure that core standards are met and outcomes achieved.
Key Aims:
a. Each locality sharing innovation
b. Joint problem solving
c. Work through operational challenges
d. accessing expertise

43. Information Sharing & Single Point of Access
Workstream lead: Jayne Griffiths
Single Point of access
Information System and Develop agreed information sharing protocols
Develop safe means of electronic transfer

44. Outcome Indicators, Performance & Continuous Improvement
Workstream lead: Angela Jones
Use the Outcomes-Based Approach.
Happily Independent:(5 key elements)
Be able to remain living in their own home with support
Receive services in their home
Be listened to by people who are responsible for providing services to assist them
Have their health and social care problems (holistically) solve quickly
Have a general good health

45. Governance & Structures
Workstream Lead: Bobby Bolt
Agreed standards and protocols
3 Groups of work:
a. Clinical accountability
b. Operational issues
c. Clear lines of management (professional and regulatory issues)

46. Workforce Planning Workstream lead: Kevin Barber
Challenges: To Integrate -
a. 6 organisations
b. 9 professional groups
Key Aims:
a. Harmonising the structure (extremelly complex)
b. Managing the transition
c. Managing multi-agency staff groups (responsibility, accountability, training and development)

47. Next Steps Capacity Plan Service Model Financial Plan Workforce Plan

49. Resource Package Wanless funds (WAG) – Approx £5million:2004
Public Service Committee (Chaired by Finance Minister – Wales): £60million over 2009/10 and 2010/11
(Scheme: Invest To Save)
3. Transitional cash required: £20million
(Fund new teams and manage additional capacity)
4. Over time:
● Shifting of resources from Secondary to Primary Care
● ? Nursing and Residential Purchasing Budgets
● Continuing Care Budget

50. Current Situation 1 +- - + Locality Frailty care model (DGH)
Co-located teams
Single point of referral
Community Consultant
Caerphilly +- - +
Newport
Torfaen
Blaenau Gwent
Monmouthshire

51. Current Situation 2 *Referral criteria variable in all 5 localities.
Locality
Consultant operational team
Primary and secondary interface
Rapid response
ACAT
Reablement
team
Formal GP involvement
Caerphilly +- + -
Newport
Torfaen
Blaenau Gwent
Monmouthshire

53. Performance Indicators
As per Frailty Programme Work stream and including:
Pre-crisis Assessment (CGA): 100% offered within 28 days
An episode of crisis requiring hospitalisation should normally require no more than 72 hours in hospital
Service responses will be delivered within agreed time limits
50% of frail older people will be managed in the community during an episode of crisis
80% of frail older people with a social crisis will be maintained at home
75 % of rehabilitation services for frail older people will be based and delivered in the community.
Assessment of equipment needs delivered within 24 hours
Equipment provided within 72 hours of assessment

55. Paul Williams Director General, Health & Social Services Chief Executive, NHS Wales
I want the service to focus on:
Changing behaviour not structures;
Collaboration not confrontation;
Planning not commissioning;
Whole systems not hospitals;
Clinical engagement;
Partnership working; and
Wellness not illness
(1st October 2009)