A service improvement focused on frailty using an R&D approach, pop up uni, 3pm, 3 september 2015

A service improvement focused on

Frailty using an R&D approach

facilitated by AQuA Lindsey Darley - Directorate Manager for North Manchester Community Services

Carol Kavanagh - Intermediate Care Manager, North Manchester

Adele Markland - Improvement Advisor, AQuA

Suzanne Wilson – Reablement Manager

Who we are Pennine Acute Hospitals NHS Trust •North East sector of GM – population 820,000 across urban and rural areas

•Approx 9,000 staff, approx 300 in North Manchester Community services (adults) •4 hospitals, 3 A&E departments, 1 Urgent care Centre

•4 CCG’s and 4 Local Authorities

Advancing Quality Alliance (AQuA) • Established in 2010 as a NHS health and care quality improvement

organisation www.AQuAnw.nhs.uk

• Our aim is to transform health and care quality • Membership: 73 commissioner and provider organisations, plus consultancy work

across the UK

http://www.aquanw.nhs.uk/

National Context • Policy drivers:

– Five Year Forward View – Francis report

– Keogh report – NHS England – Safe,

compassionate care for frail older people using an integrated care pathway

• Demographic drivers:

– Ageing population • Guidance from clinical bodies

• Financial drivers

IHI 90 Day R and D Process

What it is

• Quick way to research innovative ideas to assess their

potential for rapid cycles of change

• Answers specific question

• Timeframe for investigation (90 days)

• Within each cycle a number of ideas are tested to find the

best solution

• Helps identify risk and factoring this into testing

What is isn’t

• Large scale transformational change

• Stakeholder engagement is important. If you find yourself

having to undertake a considerable engagement process

you should question whether it is R&D

• R&D is about discovery, not about a plan for

implementation. You may discard many ideas you have

tested but will be able to hone down to more intensive

tests in a narrower field.

Institute for Healthcare Improvement 90-Day Innovation Process

http://www.ihi.org/about/Documents/IHI%20Innovation%20Summary.pdf

http://www.ihi.org/about/Documents/IHI Innovation Summary.pdf

http://www.ihi.org/about/Documents/IHI Innovation Summary.pdf

IHI 90 Day R and D Process

90 day cycle Phase What is involved

30 days Scan • Scanning the literature

• Conducting key interviews with relevant individuals /organisations to understand the dimensions of the problem or issue

• At the end of the 30 days AQuA workbook documentation is produced which includes: • Aim of the project

• Description of the current landscape • A set of theories for how to solve the problem

• The specifications for an effective solution • Bibliography

60 days Focus • A move from theory into practice

• Testing theories at the front line and refining details about what actually works • A key activity at this stage is describing the key components of the system that perform ‘to

specification’ • Creating a driver diagram to demonstrate learning

90 days Summarise

and disseminate

• Time spent:

• Concluding tests • Summarising lessons learned

• Preparing final report

Cycle 1

1/07/14 – 30/09/14

Cycle 2

1/10/14 – 31/12/14

Cycle 3 01/01/15 – 24/03/15

Scan

01/07 -31/7

Focus 01/08-31/8

Summarise and

disseminate 01/09-30/09

Scan 01/10-31/10

Focus 01/11-30/11

Summarise and


Scan 01/01-31/01

Focus 01/02-28/02

Summarise and


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3

0/0

9

Wo

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0

6/0

1

Wo

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2

4/0

3

Coach support: - Weekly calls

- Monthly visits Participating site support:

- Monthly webexes?

Additional support: Analytics

Improving the patient experience Clinical lead

Master classes and visits as appropriate

AQuA’s R&D Approach



- Monthly webexes?



- Monthly webexes?

Local Context

North Manchester focus

•Population – very diverse, very deprived, frailer at a younger age

•Living Longer Living Better programme of transformation

•New Delivery Model for Frail Older People and Adults with Dementia •Re-design of local Intermediate care and Reablement teams

•North Early Implementer for the city of Manchester •Limited numbers of COTE physicians

•No focus on frailty in PAHT or MCC

City of Manchester Aim

“To understand how identifying frailty can impact on a

persons choice of care pathway”

North Manchester Aim

“To assess frailty within Intermediate Care and Crisis

Services to ensure patients are referred on to the correct

pathway”

Intermediate Care Locations

Team

• Crisis Response

• Home Pathway

• Henesy House

• ICT Suite (opened Nov 2014)

Function • 72hr intervention with a 2 hour response

time to people with a medical or social crisis and at serious risk of admission to hospital.

• Intermediate Care within a person’s home setting.

• 15 bedded residential Intermediate Care unit with GP input.

• 9 bedded Enhanced Intermediate Care unit, nurse led with GP input.

Cycle 1 Jul-Sep 14

1. Identified a frailty tool

2. Used Edmonton Frail Scale (EFS) tool with patients referred to:

- Intermediate Care Unit – Henesy House

- Intermediate Care at Home

- Crisis Response

3. Analysed impact of tool on a patients pathway

Cycle 2 Oct-Dec 14

1. Continued to use EFS with all teams from cycle 1 then started to test with ICT Suite

2. Reviewing patient outcomes at day 30 and day 91 to see if there is any correction with a pathway

3. Undertook a focus group with practitioners to understand how a frailty tool impacts on practitioners decision making process

Cycle 3 Jan-Mar 15

1. Continued to use EFS with all teams from cycle 1 and 2 then started to test with Reablement

2. Training for Reablement staff

3. Starting to link work into Primary Care via CGAs

4. Sharing the learning from this work with internal and external networks

5. Reviewing the outcomes from the project to identify what is needed to make the connection across palliative areas

What we did…

Frailty Tools

Groningen Frailty Index

Rockwood (2014) Edmonton Frail Scale

Usability

• How easy was the tool to use?

• How long did the tool take to complete?

• How would the tool work in other services outside Intermediate Care?

Output from the tool

• How is frailty scored?

• How reliable is the frailty score?

• How could information from the tool be used to inform what pathways patients should be referred on to after Intermediate Care?

Experience

• What did patients think of the tools?

• What did staff like or dislike about the tools?

Frailty tools evaluation criteria

The team

were testing

the tools

against

the specific

criteria of:

Summary of Tools

Groningen Edmonton Rockwood

Usability

• 10 minutes

• Easy to complete and self

explanatory

• Could w ork in a IMC, hospital

or community environment

• 10 minutes

• Easy to complete and self explanatory

• Could w ork in a IMC, hospital or community

environment

• 15 to 30 minutes

• Little harder to complete as no supporting

descriptions to start the conversation w ith

patient

• Could w ork in a IMC, hospital or

community environment

Output from

the tool

Score >= to 4 indicates frailty

4/15 (Patient 1) Age 81


4/15 (Patient 4)Age 98



Not frail



Apparently vulnerable


7/17 (Patient 4)Age 98

Mild frailty


• Couldn’t score the frailty of a patient

• Patients scored themselves higher on the

function questions than a professional

w ould

Experience

Patient views:

• Patients didn’t mind

answ ering the questions and

w ere happy w ith the format

Staff view:

• All 6 staff preferred this tool

Patient views:

• Patients didn’t mind answ ering the questions and

w ere happy w ith the format

Staff view:

• Staff liked the practical tests and the frailty scores

w ere reflective of how they w ould assess patients

• Concerns about how the practical tests w ould

w ork w ith patients w ith cognitive impairment

Patient view:

• 2/5 patients like this tool

Staff view:

• This tool generated lots of discussion e.g.

“I rode a bike until I was 96 and I still like

going dancing”

• Some of the pictures are misleading or

slightly unpleasant

Frailty Levels Data across teams

What the Data Shows

• The services are achieving what they were intended and commissioned to do

• Patients are travelling within the correct pathways

• Provides and understanding of the impact of frailty levels on other services

• Has the potential to demonstrate acuity at a service level over a period of time

• It supports clinicians to recognise patients that are more suited to a palliative approach to care

• Moderate and severely frail patients are moving to palliative care pathways, recognising this shifts a focus of care and supports continuity

• Can inform commissioning plans at a population level

What is the impact of using a

frailty tool on practitioner

decision making?

Learning: • Has hi-lighted the ‘red flags’ of frailty and heightened

awareness • No impact on clinical decision making

• No value as an outcome measure within individual services

• It provides a good snapshot of levels of dependency and would appear to demonstrate acuity.

• Enhanced ICT have used HCA’s to administer the tool, and have found it supports more focused feedback

• Could be used to trigger a CGA request across all services.

• Use of a frailty tool has allowed some practitioners to start thinking differently in relation to more severely frail patients, having palliative care requirements.

• Worthwhile to consider identifying ‘less frail’ people who may benefit from a more preventative approach.

A focus group comprising of:

• Mix of professions – nursing, Occupational Therapy, Physiotherapy

• Across the range of Intermediate Care services.

Questions included:

• What difference does the tool make to practitioners decision making?

• How has the tool been used?

• Did the tool influence the MDT approach?

• What pathw ays are frail patients referred on to?

• How transferable is the tool to other services?

• Did the outcome make a difference to patient care?

• What questions is it raising for staff about frailty?

• What matters to us?

• What are the key learning from the measurements?

• What are the key learning form the outcomes?

• What are the next steps?

• Do w e test something new ?

What we did next… • CGA’s - Explore the triggers for a CGA, how primary care can support a CGA,

gaps in CGA information in Intermediate Care

• Use of the frailty score across the whole pathway – changes between point of entry and point of discharge.

• Palliative needs – exploring further how identifying frailty can support a shift in care when it is required

• Expand the use to other services – particularly Re-ablement who work alongside Intermediate Care, and District Nurses as high referrers and onward referrals.

• Focus on the ‘less frail’ and further preventative approaches.

• Links to levels of dependency – test how this relates to activity and intensity of input, and acuity across the services pre and post a service change.

Sustainability and Spread –

March 2015 Total score – 53.9

0.0

4.0

8.0

12.0

16.0Benefits

Credibility of the evidence

Adaptability

Monitoring progress

Involvement and training

Behaviours

Senior leaders

Clinical leaders

Fit with goals and structure

Infrastructure

Portal Diagram

Factor Score

Maximum Score

CQUIN CCG recognising the importance of addressing frailty and embedding this within commissioning

of services

1: To identify and assess frailty within North Manchester community

Intermediate Care, Social Care and Crisis Response Services.

2: Identification of Severe Frailty within the community crisis response

service and onward referrals to the Enhanced Community Palliative care

team.

CQUIN

CQUIN Sector wide CCG’s recognising the importance of addressing frailty and embedding this within

commissioning of services

1: Development of a vision and strategy for frail elderly populations across the NE sector

CQUIN

Frailty Champion for North

Manchester Community Services Voice

Education and Training

Supporting and Leading with others

Clinical Impact of current evidence and research

Influencing strategic development and vision around frailty

Integrated health and social

care delivery End to end CASS pathway

Screening at assessment and discharge

Integrated Key Performance Indicators

Embedded in documentation

Empowered HCA’s and Reablement staff

Informing decisions and discussions about long term care

Sustainability and Spread –

September 2015 Score – 91.7

0.0

4.0

8.0

12.0

16.0Benefits

Credibility of the evidence

Adaptability

Monitoring progress

Involvement and training

Behaviours

Senior leaders

Clinical leaders

Fit with goals and structure

Infrastructure

Portal Diagram

Factor Score

Maximum Score

What matters to me…

What difference have we made…

Outcomes for North

Manchester People

• Frailty Champion raising the profile of frailty across services

• Frailty screening is ensuring the right pathways are identified for

individuals

• Pathways are tailored for their needs in context to degrees of frailty

• A more rounded picture of individuals is apparent

• Hi-lighted individuals perception of their frailty

• Re-focused care on people as individuals

Reminder: Why are we doing this?

“Frailty, understood as a vulnerability state with an increased risk of adverse

outcomes, can be quantified. This method of quantifying frailty can aid our

understanding of health and frailty related health characteristics and outcomes

in older adults” (Searle et al, 2008)

Outcomes for North

Manchester Staff • Developed skill and knowledge in understanding frailty and its impact

• Engaged staff to be part of the big picture in relation to Frailty

• Demonstrates acuity • Created a ‘common language’, binding practitioners and managers to a

common goal

• Provide non-registered staff with a framework for a conversation with a person, enabling a story to be told

• Recognises a shift from active rehabilitation to a palliative rehabilitation approach

• Discrepancy between customer and staff scores on the screening tool generated conversations

• Highlights when a Comprehensive Geriatric Assessment is • required

Outcomes for North

Manchester Commissioners

• Provides an evidence base for commissioning on a needs based approach

• Clear understanding of how frailty links to appropriate pathways

• Supports future commissioning plans for services more accurately

understanding need

• Provided assurance of services targeted appropriately

• Demonstrates changes in acuity and dependency over time, enabling

evidence based adjustment to local commissioning plans

Benefit for AQuA Members Highlights:

• Topics have created a breadth of learning

• Opportunities for individuals to develop clinical leadership and quality improvement knowledge

• Developed staff confidence around new ways of working

• Teams valued the opportunity to test small cycles of change in a safe environment and on a topic that was important to them

• Sites benefitted from the research element of the process as improvement projects don’t always include this

Lessons learnt:

• Sites benefitted from the research element of the process as improvement projects don’t always include this

• R and D process is not easily applied to all types of projects

• Ok to test theories which don’t work in reality

• Small test of change provide ownership

AQuA’s 12 top tips to aid with

successful R and D cycles

1. Be clear from the outset who your project team is 2. Have a clear ‘Aim’ and which all stakeholders are signed up to 3. Have regular meetings and calls with the project team 4. Patient and carer participation is a must, and this needs to involve more than passive

activities like a questionnaire 5. This is about testing small cycles of innovative change, not large scale redesign 6. Be clear about what you want to deliver within the cycle and any tests you do need to

be tested against your specification 7. Collect baseline and outcome measures 8. Make sure people who need to know, know what is happening 9. Engage with key stakeholders to promote your work 10.Speak to people who have tried and tested similar things 11.Celebrate successes, but also feedback on challenges as this will provide a wealth of

learning 12.Share your story; consider who you want to share your story with and how the story

should be framed

Why has it been a success for Integration?

• Strong interaction and collaboration between health and social care

• Takes local politics out of the equation

• Frailty is now very much in the social care agenda, forming part of the MCC Adult Social Care Improvement Programme

• Developing work with NM GP’s– generating real conversation and intrigue from this piece of work

• Common aim & common outcome measures

• Closing the gap on missed opportunities by collecting discharge destinations across health and social care

• Frailty is made real in strategic terms

Not stopping and building on

from this • 2 PDSA cycles led by frailty champion

• Focus on the ‘less frail’ -self care options and further preventative approaches

• Links to palliative care with Active Case Managers

• Education

• Use data to challenge current thinking

• Testing in primary care

Not stopping and building on

from this • Frailty training package roll out from September 1st

onwards, following CASS roll-out

• Frailty Network

• Monthly reporting across CASS pathway

• Roll-out into Heywood Middleton and Rochdale

• Link into secondary care Integrated Discharge Teams to support pathway identification

• Aim for strategic buy-in for developing a Manchester wide Frailty strategy

Team reflection and learning

Improving outcomes and pathways for patients has been

central to this project and remains central

Has developed a practice forum and

brought people together who have

not worked together before

Made me want to be a clinician again.

Sophie Wallington Jason Holland Jen Littler Amelia Smith

Paul Teale Anne Nicholas Suzanne Wilson

Lucy Degisi

Acknowledgments

Contact details

Lindsey Darley

Pennine Acute Hospitals NHS Trust

Directorate Manager for North Manchester Community Services

[email protected]

Carol Kavanagh

Pennine Acute Hospitals NHS Trust

Intermediate Care Manager

[email protected]

Adele Markland

Advancing Quality Alliance (AQuA)

Improvement Advisor

[email protected]

Contact Details

Any Questions?

A service improvement focused on frailty using an R&D approach, pop up uni, 3pm, 3 september 2015

Healthcare

Transcript of A service improvement focused on frailty using an R&D approach, pop up uni, 3pm, 3 september 2015