Authors England

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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: [email protected]
Design by Naomi Cudmore: www.lighthousecommunications.co.uk
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