Frailty in Midlothian eFrailty Programme Outline Midlothian What - - PowerPoint PPT Presentation

Frailty in Midlothian

eFrailty Programme

Outline

• Midlothian…
• What is eFI…and why?
• History and strategic fit
• What we’ve learned
• So what?!
• TEC Pathfinder

Midlothian

Population:

• 90,000

Area:

• 354km2

Integrated Budget:

• £131m

Workforce (head count)*:

• Midlothian Council: 691
• NHS Lothian: 484
• Voluntary: 340
• Private: 1470

* 2016 figures - incomplete: https://www.midlothian.gov.uk/download/downloads/id/3083/ijb_workforce_planning_2017-22.pdf(p.7)

1

WHY

Why do it? What’s the need?

Frailty is the Global Warming

• f Health & Social

Care

1

WHY

Why do it? What’s the need?

Projected Percentage Population Change to 2037 (2012 Estimate Base Figure)

Data Sources: GROS – www.gro-scotland.gov.uk

Projected Population Change to 2037 (2012 Estimate Base Figure)

20,000 40,000 60,000 80,000 100,000 120,000 2017 2022 2027 2032 2037 Population Year Children (0-15) Working Age Pensionable Ages 75+

Data Sources: GROS – www.gro-scotland.gov.uk & 2011 Census http://www.scotlandscensusgov.uk

20 40 60 80 100 120 2017 2022 2027 2032 2037 Percentage Population Change Children (0-15) Working Ages Pensionable Ages 75+

https://inhabitat.com/photo-of-frail-polar-bear-illuminates-the-tragedy-unfolding-in-the-arctic/

Year

What is eFI…and Why eFI

What (https://doi.org/10.1093/ageing/afw039 )

• Cumulative deficit model of frailty
• Collaboratively developed
• Validated

Why

• Robust predictive validity for outcomes of mortality,

hospitalisation and nursing home admission

• Available within our Primary Care Software
• The eFI will enable treatments and services to be targeted to a

person based on their frailty status rather than their chronological age thus providing a paradigm shift in care for

• lder people living in the community.

Timeline

2016 2017 2018

Collaborate

Building the Quality Improvement Collaborative

HIS

Learning about eFI and engaging with work

Health Foundation

Innovative Data Driven Discovery project

Frailty is the Global Warming

• f Health & Social

Care

1

WHY

Why do it? What’s the need?

https://inhabitat.com/photo-of-frail-polar-bear-illuminates-the-tragedy-unfolding-in-the-arctic/

5900 2200 900

Frailty Stratification by eFI Score in Midlothian

Mild Moderate Severe

50% of citizens identified as frail are under 75 yrs old

• 50% of citizen aged

65+ are frail

Service Use Profile

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Midlothian Population Non-Frail Population Frail (All)

Primary Care

20% of GP contacts 26,000 Practice Nurse contacts

A&E

23% of Emergence Department attendances 4,650 Emergency Department Attendances 50% Result in Admission

Unscheduled Care

37% Total Unscheduled Occupied Bed Days (UOBD) 30,600 UOBD

Stratified Service Use Profile

All Frailty Severe Moderate Mild 10 % Population (GP Contacts) 1% population 2% population 7% population 23% Total ED 2% 7% 14% Total OBD Averaged in a Year (Unplanned Admission) 30.1 days 22.2 days 13.3 days Average Number

• f BNF Sections

14.8 12.2 9.2

2% 32% 22% 8% 98% 68% 78% 92%

POPULATION STRATIFICATION OCCUPIED BED DAYS (FROM GP PRACTICE POPULATION) ADMISSIONS (FROM GP PRACTICE POPULATION) ED ATTENDANCES (FROM GP POPULATION)

UNPLANNED HOSPITAL ACTIVITY BY ESTIMATED FRAILTY STRATA IN A GP PRACTICE (N=17,577)

Severe or Moderate Frailty Other

£

£1.91M per annum

• The cost of unscheduled admissions of patients from a GP

Practice who are estimated to have moderate or severe frailty

eFI Penicuik Housebound Collaborative Red Cross/OT Frailty Learning Collaborative QI Projects

Polypharmacy Review Rational Prescribing Admissions Prevention Continuity of Clinician Reliability of care Frequent users

Severely Frail patients - QI

Metric Before After Named GP 73% 100% Key Information Summary (KIS) 45% 100% Anticipatory Care Plan (ACP) 23% 100% On Palliative Care Register 8% 95%

Benefits Realisation – beyond Statutory Care -

Dimension of citizen benefit Description Personal

• An assessment that gives time to find out ‘what matters’
• Early identification of carers: 1 in 3 referred to VOCAL.

Support

• 1 in 4 go onto receive support by Local Area Coordinators reducing social

isolation Safety

• Falls prevention - Basic home adaptations in 50% of cases. OT training

will enable Red Cross to undertake the whole process and remove duplication of assessment and reduce waiting time for individual

• Emergency Care Plans completed with four clients. On MOSAIC

(Midlothian Council Social Care Management System), shared with GP and KIS updated Financial

• Money and independence - Increase in claims to DWP and Blue Badge
• applications. More than £100k in unclaimed benefits now allocated.

Environmental

• Telecare referrals made
• Boiler replaced to improve heating.

Disconnected Connectedness

15 Trak

Hospital

VISION Trak

Community

Red Cross Mosaic

Timeline

2016 2017 2018 2019

Collaborate

Building the Quality Improvement Collaborative

HIS

Learning about eFI and engaging with work

Health Foundation

Innovative Data Driven Discovery project

TEC Pathfinder

Digital transformation

Technology Enabled Care National Programme Aim

By developing local pathfinder sites, the TEC programme aims to facilitate transformation of local supports for health and wellbeing - embedding digital technology - to shift local delivery upstream towards prevention and supported self-management.

More information: https://tec.scot/

Initial Problem Statement

1. Effort and data are siloed – the Partnership commissions and manages services but these exist largely in respective ‘bubbles’ because we lack the enabling organo-socio- technical infrastructure and service schemas to co-ordinate the assets of respective (physical world) partners to enhance care and empower citizens. Consequentially, services are working blind, perpetuating and exacerbating risk, repeating data collection tasks, not seeing a holistic patient view, sub-optimally organising care, and making patients dependent. 2. Our current operating model ‘puts’ the citizen at the centre rather than doing it ‘by design’ when co-ordinating care. 3. ‘A Partnership of all the talents’ is not possible due to governance constraints and a lack of systems integration. 4. We have no means of integrating effort and information across our care system – including statutory, third sector, and citizen held domains.

Scottish Approach to Service Design

Year 1 FY 2019/20 Year 2 FY 2020/21

OLDER PEOPLE’S PERCEPTIONS OF FRAILTY

• Strong aversion to the term ‘frail’
• Understood to be an irreversiblestate
• Do not self-identify with the term ‘frail’
• Deep fear of losing independence,

dignity and control over one’slife

• Fear of becoming a burden to their

loved ones

• For some, decline and loss of function

are inevitable rather than preventable

• Lack of awareness of risk factors and

prevention strategies

• Medical professionals are not seen by
• lder people as the first port of call for

receiving help with everydaychallenges OLDER PEOPLE’S PERCEPTIONS OF SUPPORT

• Impressions of support tended to veer

towards the extreme (i.e. care homes), therefore fear of losing independence and control is a barrier to accessingservices

• Belief that doctors should not be ‘bothered’

with ‘trivial’ or non-clinical issues

• Tendency to look for their own solutions

rather than external sources of support

• Low levels of understanding of the support

available is a barrier to accessing services to maintain independence OLDER PEOPLE’S PERCEPTIONS OF GERIATRIC ASSESSMENTS

• Lack of understanding of what it is
• Lack of understanding of the goal
• f the assessment
• Do not want to talk about problems

they think are not medical

• If living with long term condition(s),

may not want further medical intervention in their lives DIFICULTY KNOWING WHAT YOU ARE ENTITLED TO AND NAVIGATING MULTIPLE SYSTEMS

• Too many services and no easy way to

find the right one

• Conflicting guidance online
• Shortage of Link workers

DIFICULTY PROVING YOUR NEEDS

• Manual system takes long periodsfor

communicate between organisations

• Services only readily available after

significant negative events occur – difficult to qualify preventatively SAS therapists mental health social care third sector care home

• ther

innovative models current model

eFI ACP KIS review and update

GP-led model GP-led withMDT meeting

GP-led model

N

PRE-

private sector telecare housing benefits

Red Crossvia referrals

• feFI

access to pathways

acute care (front door) secondary care Discharge to assess homecare transport inter- mediate care social

• pportunities

& day care inreach

Care inspectorate (Guidance/ support)

Frailty: Language and Perceptions. A report prepared by BritainThinks on behalf of Age UK and the British Geriatrics Society. 2015. Available from: https://www.nursingtimes.net/Journals/2015/07/23/o/e/e/Age-UK---BGS---Frailty-Final-Report.pdf [Accessed 24th May 2019]

G.Teal

G.Teal

INTERVIEWS WITH PEOPLE WHO USE DAY CENTRE SERVICES x6 ABOUT THEIR EXPERIENCES OF CARE INTERVIEWS WITH CARERS x2 ABOUT THEIR EXPERIENCES OF ACCESSING SERVICES -BOTH FOR THE PERSON THEY CARE FOR AND CARER SUPPORT FOR THEMSELF (via VOCAL) 1 2

Mum has hidden poor health from daughter on occasion which has caused difficulties, e.g. UTI can make her forget to take her

• medication. Also downplays

things to GP. “Older people don’t want to be a bother. With GP my mum feels like she is pushed to the back of the queue”.

• confidence. Very

reluctant to come to Broomhill initially, but now: “I love it. Love the

• company. Takes me
• ut of the

house.” Issues with adaptations and aids. Ended up arranging this himself and paying for it. Concerned that others less able / or who have more difficult financial circumstances would not be able to make up for these difficulties. She thinks communication referral to RNIB for home

• adaptations. She had

to find this out herself. On one occasion, mum was in hospital for 5 weeks when she could have been discharged after 8 days. Even though the POC just needed to between organisations is be reinstated, had to “go back why POC “cannot be put

• n hold”.

Hassle in terms

• f dealing with

services, e.g. trying to understand how systems work, getting services arranged, being the key point of contact. “It can take hours of phone calls”. About Broomhill... “It’s a lifeline. Mum is housebound and it would be a grim existence without it. Something she enjoys when the rest of the week is dominated by health interventions that can get her

• down. When she was

referred here it was like a weight being lifted

• ff me.”

Won’t go out

• alone. Has lost

If late home from dialysis, the care

• rganisation would phone

asking where mum was. Sometimes the call was before poor. The hospital should on the list”. Don’t understand 7pm, despite asking for visit to have automatically made a be shifted back to 7.30pm. It is better now, but has taken time to get this sorted

• ut.

CO-ORDINATING CARE NAVIGATING CARE RELUCTANCE TO ACCESS SERVICES THAT CAN HELP

Carers should be told about their rights and what support is available automatically, e.g. when a loved one is discharged from hospital. “I my rights.” Services involved are all very good, but seem unaware of each

• ther’s involvement.

Lack of communication is the biggest issue. If the district nurse is late she misses the transport to the day centre. The driver tries to come back but not always possible and means she also misses lunch.

ASSESSING CHANGING NEEDS

Reduction in the availability of the housing warden has meant there is now a gap in support. Spoke about taking lots of unsure what tablets are for. What would a medication review show? Can’t walk

• well. Had a stroke
• ne year ago.

Starting to struggle with stairs. Whois this picked up by? medication and being

CHALLENGES

OT gave daughter a list of day centres, but no explanation thought I had tostruggle. that a referral was required, VOCAL helped me a great accessing equipment so not very helpful. Need deal, especially about and advice about home someone to sit down and explain how the system works, rather than just phone numbers.

SOCIAL ISOLATION

At home most of the day “getting out more would be nice”.

G.Teal

G.Teal

G.Teal

Aspiration

Summary

• We’re a small Partnership area in the South East of Scotland our

population is growing at the fastest rate in Scotland.

• Over a number of years we’ve committed to improving the quality of

and access to routine health data to profile our population according to a cumulative deficit model of Frailty as it helps us consider a holistic approach with multi-pathology focus

• We’ve learned a lot about the consumption of health services by

citizen’s identified as frail.

• We have made tangible improvements and are innovating service

models

• We are (and will be increasing) our involvement of citizens in

supporting efforts to redesign services.

• We are exploring how digital offers us an opportunity to structure

information, overcome known barriers, and address what matters to citizens in keeping them well.