Frailty pathway
Latana A. Munang
Consultant Physician and Geriatrician
St 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
MEDICAL ADMISSIONS BY AGE
<65
65-75
>75
7
14
12
7
4
12
3
4
8
8
4
8
8
16
15
9
MONDAY
4
6
TUESDAY
9
WEDNESDAY THURSDAY
10
6
FRIDAY
SATURDAY
SUNDAY
FRAILTY SCREENING FOR >65 IN MAU
Frail
Screen positive, but not frail
Not frail
5
4
7
5
2
4
2
6
10
7
3
5
1
11
6
5
7
6
3
2
2
MONDAY
TUESDAY
WEDNESDAY THURSDAY
FRIDAY
SATURDAY
SUNDAY
Frail
Non-frail
47
56
79.3 (8.1)
68 - 101
75.8 (6.3)
65 - 90
<0.05
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)
NS
NS
NS
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)
NS
NS
<0.05
NS
n
Age, years
Mean (SD)
Range
Length of stay, days
Mean (SD)
Median (IQR)
Range
p-value
* 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
Medical
Assessment
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
Co-morbidity & disease severity
Medication review
Nutritional status & dentition
Continence
Vision & hearing
Advance care preferences
Geriatrician
GP
Pharmacist
Social
Worker
Case
Manager
Physiotherapist
Occupational
Therapist
Dietician
Speech &
Language
Therapist
Nurse
Assessment
Intervention
CGA
Goals
Problem list
CGA vs. usual care
Outcome
Living at home
Up to 6 months
End of follow up
Mortality
Up to 6 months
End of follow up
Institutionalisation
Up to 6 months
End of follow up
Death or deterioration
No. of studies
No. of participants
Effect size
14
18
5117
7062
1.25 [1.11, 1.42]
1.16 [1.05, 1.28]
19
23
6786
9963
0.91 [0.80, 1.05]
0.99 [0.90, 1.09]
14
19
4925
7137
0.76 [0.66, 0.89]
0.78 [0.69, 0.88]
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
CURRENT MODEL
OPD
SJH
Front
door
Gen
Med
Ward
Refer
PT
OT
MoE
A&E
GP
PAA
Rehab
ward
Discharge
Unwell frail
older person
Templar Day
Hospital
REACT
Boarding ward
MAU
GP
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
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
Health Improvement Scotland: Think Frailty
MAU SJH
MAU SJH
MAU SJH
MAU SJH
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
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 realtime 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
Patient
Admitted
D2A
Assessment
Seen by Doctor
Seen by nurse
Rehabilitation
OT and PT assessment
Care at home
Discharge Home
Care at Home
Discharge Home
Discharge Planning
Rehab in hospital
Physio
Assessment
OT Assessment
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
SJH
Front
door
A&E
PAA
Frailty
nurse
MAU
Inpatient
admission
required
GP
Rest of
SJH
Discharge
hub
Referral or
MDT pick up
Rehab
ward
REACT
Safe for discharge
Unwell frail
older person
Screen all ≥65s
FRAILTY PATHWAY ST JOHN’S HOSPITAL
Medical
ward
under a
geriatrician
Consultant Geriatrician Single Point of Contact
OPD
Templar
Day
Hospital
GP care +
agreed
plan
Subacute
care
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