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

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

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

5. All admissions to MAU from 23 to 29 Jan 2015

7. Frail Non-frail p-value47 56
Age, years
Mean (SD)
Range
79.3 (8.1)
75.8 (6.3)
<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

8. 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:

9. 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:

10. 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

11. 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

12. 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

13. 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

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

15. 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

16. 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

17. 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

18. 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

19. Health Improvement Scotland: Think Frailty

20. MAU SJH
Average medical take = 25

21. MAU SJH
15 are >65 years

22. MAU SJH
11 will screen positive

23. MAU SJH
Only 7 will be frail

24. 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

25. Home is best
Admission avoidance

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

27. 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

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

29. 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

30. 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

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

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

33. 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

34. 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

35. Discussion