Frailty pathwayLatana A. MunangConsultant Physician and GeriatricianSt John’s Hospital

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

Projected population change West Lothian

General Register Office for Scotland

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

9 6

159 6

1016

88

7

4 8

83

14

12

7

124

4 4

Medical Admissions by Age<65 65-75 >75

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

10 116 5 7 6

2

7 5

6 7 31

2

54

2 42

5

3

Frailty screening For >65 in MAU

Frail Screen positive, but not frailNot frail

Frail Non-frail p-valuen 47 56Age, years Mean (SD) Range

79.3 (8.1)68 - 101

75.8 (6.3)65 - 90

<0.05

Length of stay, days Mean (SD) Median (IQR) Range

18.2 (20.7)*11 (4.25 –

22.75)*1 – 85*

7.6 (12.1)3 (1 – 6)1 - 57

<0.05

Readmission (%) 7 day 30 day 60 day

2 (4.3)8 (17)8 (17)

6 (10.7)12 (21.4)15 (26.8)

NSNSNS

Mortality (%) Inpatient 7 day 30 day 60 day

7 (14.9)3 (6.4)7 (14.9)8 (17)

5 (8.9)1 (1.8)2 (3.6)

7 (12.5)

NSNS

<0.05NS* 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

Clegg, Young, Iliffe, Rikkert, Rockwood Frailty in elderly people

Lancet 2013; 381: 752 - 762

Survival curve estimates by frailty status at baseline

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 AssessmentMedical Co-morbidity & disease severity

Medication reviewNutritional status & dentitionContinenceVision & hearingAdvance care preferences

Mental health CognitionMood & anxietyFearsSpirituality

Functional capacity

Basic activities of daily livingGait & balanceActivity / Exercise statusInstrumental activities of daily living

Social circumstances

Support from family & friendsSocial network eg. Visitors, daytime activitiesFinancesEligibility for care resources

Environment Home facilities, comfort & safetyPotential use of telehealth technologyTransport facilitiesAccess to local resources

GeriatricianGP

Physiotherapist

Occupational Therapist

NurseSpeech & Language Therapist

Dietician

Social Worker

Pharmacist

Case Manager

Assessment

Problem list

Goals

Intervention CG

A

CGA vs. usual careOutcome No. of

studiesNo. of

participantsEffect size

Living at home Up to 6 months End of follow up

1418

51177062

1.25 [1.11, 1.42]

1.16 [1.05, 1.28]

Mortality Up to 6 months End of follow up

1923

67869963

0.91 [0.80, 1.05]

0.99 [0.90, 1.09]

Institutionalisation Up to 6 months End of follow up

1419

49257137

0.76 [0.66, 0.89]

0.78 [0.69, 0.88]

Death or deterioration

5 2622 0.76 [0.64, 0.90]

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

GP

A&E

SJHFront door

PAA

MAU

OPD

Templar Day

Hospital

REACT

GP

CURRENT MODEL

Disc

harg

e

Gen Med War

dRehab ward

Refer PTOT

MoE

Boarding ward

Unwell frail older

person

PrinciplesRight to medical diagnosis and equal access to specialistsPatient-centredHome is bestThe right patient looked after by the right team in the right setting Planned care better than emergency careSimpleSustainableFocus on quality and quality improvement

Case-finding for targeted interventionFrail patients identified as soon as possible to enable timely assessment and managementSpecialist nurse supported by Consultant GeriatricianSystematic MDT on all medical wardsRobust referral system from other parts of the system

Health Improvement Scotland: Think Frailty

MAU SJH

MAU SJH

MAU SJH

MAU SJH

Right patient, right team, right settingPrompt decision on care trajectory and transfer to most appropriate settingComplex frail patients managed by consultant geriatriciansTracking of less complex frail through liaisonEffective MDT in each ward with regular discussions for goal setting and discharge planning

Home is best Admission avoidance

Hospital at Home

Rehab at Home

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

Physio Assessment

OT Assessment

Patient Admitted

Discharge Home

Seen by Doctor

Discharge Planning

Seen by nurse

Rehab in hospitalCare at Home

OT and PT assessmentCare at home Discharge Home

D2A Assessm

ent

Rehabilitation

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

Consultant Geriatrician Single Point of Contact

Safe

for d

ischa

rge

REACT

Inpatient

admission

required

Rehab

ward

OPD

Templar Day

HospitalGP care

+ agreed

planSubacute care

Rest of SJH

Scre

en a

ll ≥6

5s

Referral or MDT pick up

FRAILTY PATHWAY ST JOHN’S HOSPITAL

Discharge hub

Medical

ward under a geriatrici

an

A&E

SJHFront door

PAA

MAU

Frailty

nurse

GP

Unwell frail older

person

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