England Toolkit for general practice in supporting older people with frailty and achieving the requirements of the Unplanned Admissions Enhanced Service (2014) Authors Helen Lyndon, Nurse Consultant for Older People, Clinical Lead for Frailty, NHS England South Region, South West Dr Grant Stevens, General Practitioner, Locality Lead, NHS Kernow Toolkit for general practice in supporting older people with frailty and achieving the requirements of the Unplanned Admissions Enhanced Service (2014) CONTENTS OneIntroduction 3 Two Summary of ES requirements 5 Three Case finding and populating your register 7 Four Case finding and assessment Appendices 11 15 1 ONE:INTRODUCTION T he development of this toolkit is a collaboration between New Devon CCG, NHS Kernow and the NHS England Devon, Cornwall and Isles of Scilly Local Area Team. Following masterclasses held across Devon and Cornwall for GPs and practice staff in May 2014, there were requests for a common approach to case finding, assessment, care planning and case management of frail older people. There was also a request to provide tools to support practices in achieving the Unplanned Admissions Enhanced Service (ES). Older people living with frailty make up between 9% and 25% of the population. They are the highest users of services across health and social care and have the highest levels of unplanned admissions to hospital. Yet we know that between 20% and 30% of the admissions in this group could be prevented by proactive case finding, assessment, care planning and use of services outside of hospital (Mytton et al, 2012). Frailty is a combination of the natural effects of ageing and the impact of multiple long-term conditions leading to a loss of function and reserves. It can be managed like any other long-term condition within primary care. It takes five to ten years to develop and there is often a trajectory of slow functional deterioration. However, frail older people often present in crisis and, as clinicians, we may manage the crisis but not recognise and address underlying frailty. We know that if recognised early, there are effective interventions that can be used at all stages of the trajectory to prevent exacerbation and improve independence and quality of life. The aim of this toolkit is to provide GPs and practice nurses with a suite of tools to support the case finding, assessment and case management of frail older patients, while also achieving the requirements of the Unplanned Admissions ES. This is entirely aimed to support local clinicians in response to your questions – it is in no way a mandatory approach. 3 TWO:SUMMARY OF ES REQUIREMENTS A new Unplanned Admissions Enhanced Service (ES) has been in place since 1 April 2014 and is worth £2.87 per registered patient per practice. This is not additional income, as the funding has been made available by the removal of 100 QOF points from other areas. The purpose is to reduce unplanned admissions to hospital through: 1. Identifying and creating a register of 2% of the practice list most at risk of unplanned admissions. These should be patients aged 18 years and over, but children with complex needs should also be considered for the register. 2. Improved access: For care/healthcare staff to enable interventions that might avoid unplanned admission; practices will implement a dedicated telephone line for this. For same-day telephone conversations/appointments for patients on the register. 3. Personal Care Plan for patients on the register: To ensure vulnerable/at-risk patients are in receipt of planned consistent care. To ensure that patients’ wishes are taken into account when their care is planned. To put in place an escalation plan for interventions if their health deteriorates. Review and oversight of effectiveness of the practice care plan. 4. To review any unplanned admissions or ED attendances for any of the patients on the register. Useful guides to the ES can be found at: http://www.qualitypractice.co.uk/wp-content/uploads/2014/04/ Action-Plan-for-Unplanned-Admissions-Enhanced-Service1.pdf http://www.england.nhs.uk/wp-content/uploads/2014/04/gp-prog-action2.pdf The full ES guidance can be found at: http://www.nhsemployers.org/~/media/Employers/Publications/ Avoiding%20unplanned%20admissions%20guidance%202014-15.pdf 5 THREE:CASE FINDING AND POPULATING YOUR REGISTER T he ES suggests the use of risk-stratification tools or other methods to case find and populate the register of at-risk patients. However, risk stratification has the potential to miss 25% of frail older patients as it relies on numbers of admissions and so may not always highlight high-risk patients, but those who have had multiple admissions for other very valid reasons, e.g. pregnancy, chemotherapy, etc. Case finding should ideally be done as part of primary care multi-disciplinary team discussions with the three aims of: Identifying the person. Identifying the key person in the team to coordinate care. Selecting the appropriate care process, which may include holistic care/CGA if medical problems dominate, care and support planning aimed at promoting self-management, third-sector/community care and support for issues such as social isolation and loneliness, social services care and support for those with care needs. 7 Toolkit for general practice in supporting older people with frailty and achieving the requirements of the Unplanned Admissions Enhanced Service (2014) Suggested methods for case finding and populating your register are: Use the Rockwood Clinical Frailty Scale (Appendix one) at every consultation with patients aged 75 years and over (takes 10 seconds to complete). Consider doing this within appropriate clinics, e.g. flu/shingles vaccine clinics, chronic disease clinics. Add those who are Rockwood >5 to your register. Rockwood scores can also be completed in the community by community nurses/community matrons, etc. and fed back to the practice. Gait speed test (Appendix two) can be used as an additional tool if there is difficulty establishing frailty. 1 2 Use the primary care record to identify patients who may be considered for completion of the Rockwood Scale and the gait speed test using the following criteria: a. Those >85yrs. b. Those in care homes (all will have Rockwood >5). c. Those >75yrs of age admitted or who attended ED in last 3-6 months. To search for this data your practice would either need to read code the attendance or admissions. If this is not done, the patient could be Rockwood scored if you hold discharge meetings. If the patient has a high Rockwood score and this has been completed when the patient is acutely unwell, then consider using PRISMA7 (Appendix three) once the patient has stabilised/been discharged from hospital, as Rockwood may not be as accurate in an acute illness. d. Those with an obvious frailty syndrome. These include: Falls (e.g. collapse, legs gave way, ‘found lying on floor’). Immobility (e.g. sudden change in mobility, ‘gone off legs’, ‘stuck in toilet’). Delirium (e.g. acute confusion, sudden worsening of confusion in someone with previous dementia or known memory loss). Incontinence (e.g. change in continence – new onset or worsening of urine or faecal incontinence). Susceptibility to side effects of medication. e. Those housebound or known to community nurses – this data could be obtained from those community nurses who visit for flu vaccines, if not read coded. f. Those on dementia register. g. Those on EOL register or cancer care lists. h. Those on community matron or district nursing caseload. i. Those on >7 medications. j. Those with neurological conditions, e.g. stroke, MS, Parkinson’s Disease. k. Those with rheumatological conditions. l. Those known to Adult Social Care and Support Services. To confirm frailty on these cases identified via Rockwood, if the score is borderline 4 or 5, a PRISMA7 score could be sent to the patient to confirm. Gait speed can be used if there seems to be a mismatch between Rockwood and PRISMA. 8 Three: Case finding and populating your register Use PRISMA7 to develop a birthday card system (Appendix three). The practice sends out the PRISMA7 questionnaire to all patients from 75 years and over every year. The frailty screening questionnaire is completed by the patient/carer and then scored by the practice. Those who score 3 or more should be brought into the practice for Rockwood and brief CGA if appropriate. 3 4 Electronic frailty index An electronic frailty index (EFI) is under development by Dr Andrew Clegg and colleagues at Leeds University; it uses indicators of frailty coded on general practice systems to identify frail people, giving them a frailty score linked to the Rockwood score. This will identify patients for further screening and assessment. There is a pilot of this method of case finding being undertaken in Devon, Cornwall and Isles of Scilly. If successful, this tool could replace other methods of case finding in primary care. More information will follow when it is available. 5 Read coding for frailty There is a read code for the Rockwood Clinical Frailty Scale, it is: ‘38DW Canadian Study of Health and Ageing Clinical Frailty Scale’. A value will be required to be entered according to level of frailty (score). This will alter depending on computer system being used. This is required so that a search will be able to define the read code and the value separately. It is recommended that you check with your practice provider how to do this, if it does not become clear from your computer system. There are new read codes available to enable frailty to be recorded as a diagnosis and for frailty registers to be populated. They are: CTV3 X76Ao | Frailty XabdY | Mild frailty Xabdb | Moderate frailty Xabdd | Severe frailty Read V2 2Jd.. | Frailty 2Jd0. | Mild frailty 2Jd1. | Moderate frailty 2Jd2. | Severe frailty SNOMED CT concepts for frailty: All linked to the concept 248279007 | Frailty (finding): 925791000000100 | Mild frailty (finding) 925831000000107 | Moderate frailty (finding) 925861000000102 | Severe frailty (finding) 9 FOUR:CASE FINDING AND assessment I n Devon and Cornwall we have suggested a two-step approach to CGA in the community. New guidance from the British Geriatrics Society (BGS) (2014) suggests that it is not feasible for everyone with frailty (from mild up to severe, life-limiting frailty) to undergo a full multi-disciplinary review with geriatrician involvement. Nevertheless, all patients with frailty will benefit from a holistic medical review based on the principles of CGA. Therefore it is recommended that the following process is followed once a patient is identified as being between 5 and 7 on the Rockwood Scale: 1. Completion of brief CGA (Appendix four) and generation of a problem list. 2. Holistic medical review aimed at optimising management of long-term conditions and referral to other disciplines if needed. Underlying diagnoses and reversible contributors to frailty should be addressed. 3. A full medication review using STOPP START methodology (Appendix five). 4. Individualised goal setting in collaboration with the patient and carers if appropriate. 5. Generation of a personalised care plan using the national ES template based on identified goals. Completion of the brief CGA enables you to create a problem list and this will inform your care-planning activity as required in the ES. Appendix four is an example of a brief CGA tool which has been produced by a steering group of clinicians across Devon and Cornwall. It takes approximately 8-10 minutes to complete. It is suggested that after the brief CGA is completed, there is discussion at the MDT meeting and core group members should then decide which patients require a more in-depth CGA and who will be involved in carrying it out. In-depth CGA involves a holistic, multi-dimensional, interdisciplinary assessment of an individual by a number of specialists of many disciplines in older people’s health, usually including a geriatrician (BGS, 2014). If polypharmacy is identified by the MDT, then it may be appropriate to organise a joint care coordinator/community pharmacist review. References British Geriatrics Society (2014). Fit for Frailty: Consensus best practice guidance for the care of older people living with frailty in community and outpatient settings. Mytton et al (2012). Avoidable acute hospital admissions in older people. British Journal of Healthcare Management, 18 (11), pp.597-603. 11 APPENDICES One Rockwood Clinical Frailty Scale 14 Two Gait speed test 15 Three PRISMA7 questions 15 Four Brief CGA form 16 Five STOPP START Medication Review Tool 18 Six Care plan template 22 13 Toolkit for general practice in supporting older people with frailty and achieving the requirements of the Unplanned Admissions Enhanced Service (2014) Appendix one: Clinical Frailty Scale 14 Appendices Appendix two: Gait speed test Average gait speed of longer than 5 seconds to walk 4 metres is an indication of frailty. The test can be performed with any patient able to walk 4 metres using the guidelines below. 1. Accompany the patient to the designated area, which should be well-lit, unobstructed, and contain clearly indicated markings at 0 and 4 metres. 2. Position the patient with his/her feet behind and just touching the 0-metre start line. 3. Instruct the patient to “Walk at your comfortable pace” until a few steps past the 4-metre mark (the patient should not start to slow down before the 4-metre mark). 4. Begin each trial on the word “Go”. 5. Start the timer with the first footfall after the 0-metre line. 6. Stop the timer with the first footfall after the 4-metre line. 7. Repeat three times, allowing sufficient time for recuperation between trials. Appendix three: PRISMA7 questions A score of three or more indicates frailty. 1. Are you more than 85 years? 2. Male? 3. In general do you have any health problems that require you to limit your activities? 4. Do you need someone to help you on a regular basis? 5. In general do you have any health problems that require you to stay at home? 6. In case of need can you count on someone close to you? 7. Do you regularly use a stick, walker or wheelchair to get about? 15 Toolkit for general practice in supporting older people with frailty and achieving the requirements of the Unplanned Admissions Enhanced Service (2014) Appendix four: Brief CGA form Initial Comprehensive Geriatric Assessment Form Patient Contact Clinical Frailty Score (Rockwood Scale): Home Care Home Patient's Details Patient's Address OPD Name Add 2 GP Title ED Date of Birth Frailty Postcode Mild Cognitive Impairment Within Normal Limits Abbreviated Mental test (AMT) Score: Main lifelong occupation: ↓Mood Depression Within Normal Limits Other Delusion Low High Usual Good Fair Excellent Poor Speech: Vision: Within Normal Limits Within Normal Limits Weak Within Normal Limits Occasional Frequent Within Normal Limits Falls Number: Slow Independent Slow Independent Standby Independent Pull Independent None Stick Normal Under Within Normal Limits Within Normal Limits Continent Elimination Bowel Continent Bladder Independent ADLS Feeding Independent Bathing Independent Dressing Independent Toileting Independent IADLS Cooking Independent Cleaning Independent Shopping Independent Medications Independent Driving Independent Banking Disrupted Sleep Marital Status Lives Married Alone Social Spouse Divorced Other Widowed Single Dementia Delerium Mental Capacity Assessment required Anxiety Assessor: (Name, Grade & Signature) Date: 16 Yes No Hallucination Couldn't say Hearing: Impaired Within Normal Limits Understanding: Impaired Within Normal Limits Proximal Distal Lower: Proximal Distal Assisted Assisted Assisted Assisted Can't Dependent Dependent Dependent Within Normal Limits Falls Number: Slow Independent Slow Independent Standby Independent Pull Independent None Stick Normal Under Within Normal Limits Within Normal Limits Impaired Assisted Assisted Assisted Assisted Can't Dependent Dependent Dependent Frame Chair Frame Chair Obese Obese Over Over Fair Poor Fair Poor Impaired Fluids Impaired Fluids Impaired Solids Impaired Solids Constipated Incontinent Continent Constipated Incontinent Catheter Incontinent Continent Catheter Incontinent Assisted Dependent Independent Assisted Dependent Assisted Dependent Independent Assisted Dependent Assisted Dependent Independent Assisted Dependent Assisted Dependent Independent Assisted Dependent Assisted Dependent Independent Assisted Dependent Assisted Dependent Independent Assisted Dependent Assisted Dependent Independent Assisted Dependent Assisted Dependent Independent Assisted Dependent Assisted Dependent Independent Assisted Dependent Assisted Dependent Independent Assisted Dependent Daytime drowsiness Frequent Occasional Not Socially Engaged Home Supports House… Informal Number of levels: Steps… Number of steps: Other Apartment Requires more support Supported Living None Care Home Other Caregiver Relationship Caregiver Stress Spouse Advance directive in place: CPR decision: Fatigue Impaired Impaired Upper: Not Impaired Current (today) Balance Falls Walk inside Walk outside Transfers Bed (in/out) Aid use Weight Appetite Swallow Baseline (two weeks ago) Motivation Health Attitude Communication Nutrition Town GP Practice Emotional Mobility Add 3 NHS Number Cognition Strength Exercise Balance Add 1 Allow a natural death Resuscitate Sibling Offspring Other Caregiver Occupation: None Low Moderate High PLEASE TURN OVER Appendices Initial Comprehensive Geriatric Assessment Form Associated Medication *(Mark meds started in hospital with an asterisk) - Consider STOPP / START Medication Dose Problem List Action Required Date Commenced Action by: 1 2 3 4 5 6 7 8 9 10 Long Term Conditions: 1 2 3 4 5 Notes: For MDT discussion, consider long CGA Long CGA not required, copy of Clinical Frailty score to GP Outpatient Appointments Department Date and Time Assessor: (Name, Grade & Signature) Date: 17 Toolkit for general practice in supporting older people with frailty and achieving the requirements of the Unplanned Admissions Enhanced Service (2014) Appendix five: STOPP START Medication Review Tool STOPP START Information STOPP: Screening Tool of Older People’s Potentially Inappropriate Prescriptions The following drug prescriptions are potentially inappropriate in persons aged 65 years of age Drug name or class (+ examples) Cardiovascular Digoxin >125µg/day Diuretic (monotherapy) Thiazides (bendroflumethiazide) Non-cardioselective Beta-blocker (propranolol, carvedilol, sotalol etc) Beta blocker + verapamil Diltiazem or verapamil Calcium channel blockers Aspirin + Warfarin Dipyridamole (monotherapy) Aspirin + Condition Low GFR Hypertension Gout Wheeze (COPD/asthma) Toxicity Safer, more effective alternatives Exacerbation of gout Bronchospasm Any Heart failure Chronic constipation Without gastro-protection Stroke Peptic ulcer >150mg/day Heart block Exacerbation of heart failure Exacerbation of constipation Gastrointestinal bleeding No evidence for efficacy Bleeding Bleeding, no evidence for increased efficacy Not indicated Without arterial occlusive disease Dizziness, without stroke as cause st 1 deep vein thrombosis st 1 pulmonary embolus Any bleeding disorder Warfarin >6 months Warfarin >12 months Aspirin, clopidogrel, dipyridamole or warfarin Central Nervous System & Psychotropics Tricyclic antidepressants (amitriptyline, Cognitive Impairment imipramine etc) Glaucoma Cardiac arrhythmia Constipation + Opiate or calcium channel blocker Prostatism or urinary retention Benzodiazpines >1 month Any Neuroleptics >1 month (haloperidol, rispderidone etc) Prochlorperazine & chlorpromazine Anticholinergics (Procyclidine, orphenadrine, trihexyphenidyl) Selective serotonin re-uptake inhibitors (SSRIs, fluoxetine etc) Old antihistamines (cyclizine, chlorpheniramine, alimenazine etc) Gastrointestinal Constipating drugs (Loperamide or codeine phosphate) 18 = Risk / reason If used as hypnotics Parkinsonism Epilepsy To treat extra-pyramidal side-effects of neuroleptics Current or <2 months Hyponatraemia >1 week use Unexplained diarrhoea Not indicated No proven benefit No proven benefit Bleeding Worsening cognitive impairment Exacerbation of glaucoma Pro-arrhythmic effects Exacerbation of constipation Severe constipation Urinary retention Prolonged sedation, confusion, impaired balance, falls Confusion, hypotension, extrapyramidal side effects, falls Extra-pyramidal symptoms Lower seizure threshold Anticholinergic toxicity Further hyponatraemia Sedation & anti-cholinergic side effects Delayed diagnosis, exacerbate constipation + overflow diarrhoea, Appendices STOPP: Screening Tool of Older People’s Potentially Inappropriate Prescriptions The following drug prescriptions are potentially inappropriate in persons aged 65 years of age Drug name or class (+ examples) Prochlorperazine (Stemetil) or metoclopramide High dose proton pump inhibitor > 8 weeks Anticholinergic antispasmodics (hyoscine, atropine) Chest Theophylline (monotherapy) Systemic corticosteroids (instead of inhaled) Ipratropium (nebulised) Musculoskeletal Non-steroidal anti-inflammatory without gastric protection Non-steroidal anti-inflammatory drugs (NSAIDs) (ibuprofen, naproxen, diclofenac etc) + Condition Severe infective gastroenteritis Parkinsonism Peptic Ulcer Chronic constipation COPD COPD Glaucoma = Risk / reason toxic megacolon in inflammatory bowel disease, delayed recovery in unrecognised gastroenteritis Exacerbation or protraction of infection Exacerbating parkinsonism Dose reduction or earlier discontinuation indicated Exacerbation of constipation Safer, more effective alternatives Unnecessary exposure to longterm side-effects Exacerbation of glaucoma Peptic ulcer /gastrointestinal bleeding Mod-severe hypertension Heart failure >3 months in mild osteoarthtitis Chronic kidney disease + Warfarin Rheumatoid Arthritis Peptic ulcer relapse To prevent gout Allopurinol first choice prophylactic drug in gout Cognitive impairment Glaucoma Constipation chronic prostatism Male & urinary incontinence >1 daily Long-term urinary catheter Increased confusion, agitation Exacerbation of glaucoma Exacerbation of constipation Urinary retention Urinary frequency & worsening of incontinence Not indicated Type 2 diabetes mellitus Hypoglycaemia 1 per month Breast cancer Venous thromboembolism Intact uterus Prolonged hypoglycaemia Masking hypoglycaemic symptoms Recurrence Recurrence Endometrial cancer Falling Benzodiazepines Recurrent falls disorder Neuroleptic drugs First generation antihistamines Recurrent falls disorder Recurrent falls disorder Sedative, may cause reduced sensorium, impair balance Gait dyspraxia, parkinsonism Sedative, may impair sensorium Corticosteroids (>3 months, monotherapy) NSAIDs or colchicine Urogenital Bladder antimuscarinics (oxybutinin, tolterodine, solifenacin etc) Alpha-blockers (doxasocin, tamsulosin, terazocin etc) Endocrine Glibenclamide or chlorpropamide Beta-blockers (atenolol, bisoprolol etc) Oestrogens Oestrogens without progestogen Exacerbation of hypertension Exacerbation of heart failure Simple analgesics preferable & usually as effective for pain relief Deterioration in renal function Gastrointestinal bleeding Major side-effects 19 Toolkit for general practice in supporting older people with frailty and achieving the requirements of the Unplanned Admissions Enhanced Service (2014) Appendix five: STOPP START Medication Review Tool STOPP: Screening Tool of Older People’s Potentially Inappropriate Prescriptions The following drug prescriptions are potentially inappropriate in persons aged 65 years of age Drug name or class (+ examples) = Risk / reason Vasodilator antihypertensives (hydralazine, minoxidil, sildenafil etc) Long-term opiates >20mmHg drop in systolic blood pressure Recurrent falls disorder Syncope, falls Analgesia Long-term strong opiates Mild-moderate pain World Health Organisation analgesic ladder not observed Severe constipation Regular opiates >2 weeks + no laxative Long-term opiates Any duplicate drug class 20 + Condition Constipation Drowsiness, postural hypotension, vertigo Dementia + not palliative + not managing specific pain syndrome Exacerbation of cognitive impairment Any Optimisation of monotherapy within a single drug class should be observed prior to considering a new class of drug Appendices Screening Tool to Alert Doctors to Right i.e. appropriate, indicated Treatments These medications should be considered for people 65 years with the following conditions, where no contraindication to prescription exists Condition Cardiovascular Atrial fibrillation Vascular disease & in sinus rhythm Blood pressure >160 mmHg (consistently) Vascular disease + independent for activities of daily + life expectancy >5 years Chronic heart failure Acute myocardial infarction Chronic stable angina Chest Mild to moderate asthma or COPD Moderate-severe asthma or COPD & FEV1 <50%. Chronic type 1 respiratory failure (pO2 < 8.0kPa, pCO2 <6.5kPa)a Chronic type 2 respiratory failure (pO2 < 8.0kPa, pCO2 > 6.5kPa) Neuro Parkinson’s Disease with definite functional impairment & resultant disability Depression, moderate-severe <3 months Gastro Severe gastro-oesophageal acid reflux disease Peptic stricture requiring dilatation Diverticular disease with constipation MSK Active moderate-severe rheumatoid disease > 12 weeks Maintenance corticosteroid therapy Osteoporosis (previous fragility fracture, acquired dorsal kyphosis Endocrine Type 2 diabetes +/- metabolic syndrome Diabetes + proteinuria or microalbuminuria + GFR <50ml/min Diabetes mellitus + major cardiovascular risk factors Key: COPD = Chronic obstructive pulmonary disease GFR = Glomerular filtration rate Drug Anticoagulant Aspirin or clopidogrel Antihypertensive Statin Angiotensin Converting Enzyme inhibitor Angiotensin Converting Enzyme inhibitor Beta-blocker Regular inhaled beta 2 agonist or anticholinergic Regular inhaled corticosteroid Continuous oxygen Continuous oxygen Levo-dopa Antidepressant Proton Pump Inhibitor Proton Pump Inhibitor Fibre supplement Disease-modifying anti-rheumatic drug Bisphosphonates Calcium & Vitamin D Metformin ACE inhibitor or Angiotensin Receptor Blocker Statin FEV1 = forced expiratory volume in one second MSK = Musculoskeletal This document was amended from the original with the kind permission of the authors. For more detail & references, see: Gallagher P, Ryan C, Byrne S, Kennedy J, O’Mahony D. STOPP (Screening Tool of Older Persons’ Prescriptions) & START (Screening Tool to Alert Doctors to Right Treatment): Consensus Validation. Int J Clin Pharmacol Ther 2008; 46(2): 72 –83. PMID 18218287 21 Toolkit for general practice in supporting older people with frailty and achieving the requirements of the Unplanned Admissions Enhanced Service (2014) Appendix Six – Care Plan Template Appendix six: Care plan template [NAME OF PRACTICE] [PRACTICE ADDRESS] [PRACTICE TELEPHONE NUMBER] Patient name: PERSONALISED CARE PLAN PATIENT INFORMATION Title: NHS Number: Address: Date of birth: / / Post code: Is the patient a nursing or care home resident: YES / NO Contact details: Key safe door access code: Named accountable GP: Care coordinator (if appropriate): Other named professionals (e.g. care coordinator, other healthcare professionals or social worker) involved in patient's care, if appropriate (include contact details where possible): Has information been shared on the patient’s behalf?: YES / NO If YES, by whom: (only applicable where the patient does not have the capacity to make this decision) Patient (or other allowed individual) consent to share information: with other healthcare professionals involved in the patient's care, e.g. carer, OOH etc: YES / NO with the multi-disciplinary team: YES / NO NEXT OF KIN / CARER / RESPONSIBLE ADULTS INFORMATION Name: Title: Address (if different from above): Contact details: Post code: Relationship: Additional emergency contact (if appropriate): Name: Contact details: Relationship: PATIENTS MEDICAL INFORMATION Relevant conditions, diagnosis and latest test results: 22 Appendices Significant past medical history: Current medication: Date of planned review of medications: Allergies: KEY ACTION POINTS For example: guidance on intervention / deterioration, unmet need to support patient (specify), agreed plan in emergency (ICE)/ useful situation etc. OTHER RELEVANT INFORMATION (if appropriate) Preferred place of care : Other support services e.g. local authority support, housing Identification of whether the person is themselves a carer (formal or informal) for another person Anticipatory care plan agreed: YES / NO/ Anticipatory drugs supplied: YES / NO/ N/A N/A Emergency care and If yes, please specify outcome: treatment discussed: YES / NO e.g.: cardiopulmonary resuscitation – has the patient agreed a DNR or what treatment should be given if seizures last longer than x do y etc. Date of assessment: / / Date of review(s): Any special communication considerations (e.g. patient is deaf or language communication differences): Any special physical or medical considerations (e.g. specific postural or support needs or information about medical condition - patient needs at least x mgs of drug before it works etc): 23 Toolkit for general practice in supporting older people with frailty and achieving the requirements of the Unplanned Admissions Enhanced Service (2014) Appendix six: Care plan template Patient signature: SIGNATORIES (if appropriate and / or possible) Carer (if applicable) signature: Named accountable GP signature: Care Coordinator signature (if applicable): Date: Date: Date: Date: 24 CONTACT Helen Lyndon Nurse Consultant for Older People, Clinical Lead for Frailty, NHS England South Region, South West Sedgemoor Centre Priory Road St Austell Cornwall PL25 5AS Tel: 01726 627763 Mobile: 07918336015 email: h.lyndon@nhs.net Design by Naomi Cudmore: www.lighthousecommunications.co.uk