New Models of Integrated Care for Frailty

Prof Anne HendrySenior Associate, International Foundation for Integrated Care

ADVANTAGE JA WP 7 Lead

ADVANTAGE JA“A comprehensive approach to promote a disability-free Advanced age in Europe:

the ADVANTAGE initiative”

The number of people 65+ is predicted to rise from 18% to 28% by 2060

12% of the population will be aged 80+

• Policy Joint Action with 22 Member States and 33 organisations

• Co-funded by the EU and the Member States.

• January 2017 - December 2019 (3 years)

• COORDINATOR: Hospital de Getafe SERMAS, Madrid Spain

• UK Lead – Scottish Government / NHS Lanarkshire

ADVANTAGE JA work packages

(Coordination WP1+ Dissemination WP2+ Evaluation WP3)

Knowing frailty at an individual level

WP4

Knowing frailty at a population level

WP5

Treating/approaching frailty at an individual level WP6

Models of care to prevent, delay or treat frailty WP7

Extending and expanding knowledge on frailty

WP8

Develop ‘Frailty PreventionApproach’ (FPA) and buildconsensus on addressing Frailty in Europe

Implementation

Phase I (2017) - State of the Art - background information collection, analysis, rational discussion and drafting of preliminary documents.

Phase II (2018) – Survey of MS status on frailty,developing and testing draft version of common European model to approach frailty (frailty prevention approach –FPA document).

Phase III (2019) - drafting final documents, debating these with participant MSs, and drafting the final framework (FPA document and policy recommendations).

Robust Pre-Frail or Frail Functional

Limitation

Disability Dependency

Healthy life style advice

Technology enabled support for self management

Reablement support , telecare, ADL advice

and support

Rehabilitation, equipment, housing,

care and support

Care coordination, carer support,

palliative and end of life care

Early identification and intervention can reverse / delay the trajectory and enable adaptation and resilience.

Frailty and Multimorbidity

Lancet Public Health 2018Published Online June 13, 2018http://dx.doi.org/10.1016/S2468-2667(18)30091-4

Preventing Frailty

• Start active ageing recommendations at mid life

• Asses risk for malnutrition using the Mini Nutritional Assessment

• Promote a Mediterranean diet /daily protein >1-1.2 g per kg

• Target BMI < 30

• Low intensity exercise (endurance, flexibility, balance, resistance training) in sessions of 30 to 45 minutes, three times per week.

• Vitamin D supplement if increased risk for falls / fracture

Identifying Frailty

Opportunistic screening in patients over 70 years using tools that are:

Quick to administer (taking no more than 10 minutes to complete).

Do not require special equipment.

Have been validated and are meant for screening

Deficits that make up the electronic Frailty Index

36 Frailty deficits of eFI

20 Disease statese.g., • Hypertension • Arthritis• Chronic Kidney Disease• Ischaemic Heart Disease• Diabetes• Thyroid Disease• Urinary System Disease• Respiratory System Disease

8 Symptoms / signs• Polypharmacy• Dizziness• Dyspnoea• Falls• Sleep Disturbance• Urinary Incontinence• Memory & cognitive problems• Weight loss & anorexia

7 Disabilities• Visual Impairment• Hearing Impairment• Housebound• Social Vulnerability• Requirement for care• Mobility & transfer problems• Activity limitation

1 Abnormal Laboratory Value• Anaemia and haematinic

deficiency

Slides from NHS England

“Fit

” (

50

%)

0 -

0.1

2 o

r 0

–4

def

icit

s

“Mild

Fra

ilty

” (3

5%

)>

0 .1

2 –

0.2

4 o

r 5

–8

def

icit

s

“Mo

de

rate

Fra

ilty

” (1

2%

)>

0.2

4 –

0.3

6

or

9 –

13

def

icit

s

“Sev

ere

Fr

ailt

y”

(3%

)>

0.3

6 o

r m

ore

th

an

13

def

icit

s

Increasing eFI = Increasing Frailty

Source: Development and validation of an electronic frailty index using routine primary care electronic health record data

What do eFIscores mean?

Slide from NHS England

Fit

Mild frailty

Moderate frailty

Severe frailty

5 yrs

Outcomes by stage of frailty

Time (days)

Reducing proportion alive

Source: Development and validation of an electronic frailty index using routine primary care electronic health record data

Slide from NHS England

Validated against outcomes associated with frailty, e.g.

• Emergency admissions

• Emergency bed days

• Nursing home admission

• Mortality811

2,028

4,195

7,844

Fit Mildfrailty Moderatefrailty Severefrailty

Emergencybeddaysper1,000personyear

-

36%

53%

119%

Leastfatigued(Q1) Q2 Q3 Mostfatigued(Q4)

%IncreaseineFIfromleastfatiguedquartile

Validated against fatigue, a phenotypic characteristic of frailty (separate research)

Source: Analysis of supplementary data from Development and validation of an electronic frailty index using routine primary care electronic health record data

Source: Unpublished research by Dr Dawn Moody

Validation of eFI

Thanks to Rosie Cooper, Falls Lead, Aberdeen HSCP

Managing Frailty Comprehensive Geriatric Assessment Care planning and tailored MDT interventions Telehealth and telecare solutions Falls prevention interventionsTools to reduce inappropriate polypharmacy

Integrated Care for Frailty

a single entry point – generally in Primary Care

simple frailty screening tools in all settings

comprehensive assessment and individualised care plans – including for carers

tailored interventions by interdisciplinary team – both at home and in hospital

case management and coordination of care and support across providers

effective management of transitions between teams and settings

shared electronic information tools and technology enabled care

clear policies and procedures for service eligibility and processes.

Hendry, A, et al. Integrated Care: A Collaborative ADVANTAGE for Frailty. International Journal of Integrated Care, 2018; 18(2): 1, 1–4. DOI: https://doi.org/10.5334/ijic.4156

Context in Scotland

Population 5.5 million

National Health Service

• Universal coverage

• No co-payments

• 14 unified Health Boards

• 38 Hospitals

• 1020 General practices

• 32 Local Authorities

• Free personal care for 65+

Cabinet Secretary for

Health and Wellbeing

Cabinet Secretary for

Finance, Constitution

and Economy

Minister for Local

Government and

Community

Empowerment

Person centred and Integrated care in all policiesCross Government Collaboration

JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 20

Reshaping Care for Older People

• 2011- 2021

• £300 million Change Fund 2011-15

• Change Plans agreed by health, social care, housing, voluntary and independent sector partners

• 20% of funding to be invested in support for carers

Reshaping Care Programme

22

Frailty in Primary Care

‘Frailty Five - Must Dos for Me’

Anticipatory Care Plan Polypharmacy Review Falls Risk assessment + TEC solutions Carer support plan and emergency plan Care manager - continuity and coordination

Intermediate Care

• Reablement

• Rapid Response / Early Supported Discharge

• Hospital at Home

• Step Up / Step Down community beds

Telecare

0

5,000

10,000

15,000

20,000

25,000

Cu

mu

lati

ve T

ota

l Nu

mb

er

of N

ew

Use

rs 0 to 17

18 to 64

65 to 74

75 to 84

85+

Unknown

31378 31384 31655 31295 30984 31353 30768 31197 30570

1,073 1,775 2,985 3,915 4,476 5,573 5,951 7,213

2009 2010 2011 2012 2013 2014 2015 2016 2017

Care Home residents aged 65+, ScotlandComparison of actual vs projected (2009 base year)

Actual residents Additional projected

Data: Care Home Census, ISDScotland & NRSChart by Peter Knight ISDScotland Sept 2018

Change Fund

8118 7997 7907 7748 7814 7763 8150 7888 7955

262 523 852 989 12001032 1423 1533

2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17

Hospital beds used for emergencies: people aged 65+, Scotland Comparison of actual vs projected (2008/09 base year)

Actual ave.beds occupied additional projected

Data: ISDScotland & NRS Chart by Peter Knight ISDScotland Sept 2018

Change Fund

Public Bodies(Joint Working) (Scotland) Act )

Act 2014People are supported to live well at home or in the

community for as much time as they can and have a positive experience of health and social care when they

need it

• All adult care groups +/- children’s services & criminal justice

• Principles for integrated health and social care

• Integrated governance : body corporate or lead agency

• Integrated budgets for health and social care

• Chief accountable officer has integrated oversight of delivery

• Nine national outcomes for health and wellbeing

• Strategic and locality planning based on population needs

Delegated Integrated Budget

Creating the Conditions

• Political will – cross party, whole of government support • Legislative framework for integrated planning and budgets • Strong professional leadership for interdisciplinary practice • Funding as a catalyst for change • Contractual levers - primary care and pharmacy • Disruptive innovation (social and technology)• Investment in voluntary sector and community capacity building • Value and support carers as full partners • Focus on place, home, community and outcomes that matter• Learning and improvement culture

EC Expert Group on Health Systems Performance Assessment

SCIROCCO – Scaling Integrated Care in Context - Maturity Model http://www.scirocco-project.eu/maturitymodel/

A movement for change

Webinar Series and Topic Resources theScotland www.integratedcarefoundation.org/scotland

Special Interest Groups (SIGs) hosted on IFIC website:

o Polypharmacy and Adherence

o Intermediate Care

o Palliative & End of Life Care

o Frailty

o Self Management and Co-production

Sign up at: https://integratedcarefoundation.org/ific-membersnetwork/groups/

Contact

Marie Curran IFICscotland@integratedcarefoundation.org

Mandy Andrew Mandy.andrew@lanarkshire.scot.nhs.uk

Integrated Care Matters

THANK YOU

www.advantageja.eu

Anne.Hendry@lanarkshire.scot.nhs.uk; mandy.andrew@lanarkshire.scot.nhs.uk