Acute medical care of older people
- outside hospital
Simon Conroy
Head of Service/Senior Lecturer, Geriatric Medicine
Cardiovascular Sciences
University of Leicester
Not an acute
medical problem
Ageing
population
Lack of
primary care
What is
intermediate
care?
Poor social
services
Inappropriate
admissions
Patients come
out worse than
went they went
in
Ageing
population
Too many
specialists
Inappropriate
investigations
Black hole
Inappropriate
admissions
What is the truth?
• Ageing population, increasingly complex care
• More attending emergency care
– Despite intermediate care etc
• Lower threshold for admissions
• Coordinated care more challenging as ‘silo mentality’
sets in
Some definitions
• ‘Unscheduled care’, ‘unplanned care’, ‘emergency
care’, ‘urgent care’
• Department of Health:
– ‘Emergency Care is an immediate response to time critical
health care need. Unscheduled care involves services that
are available for the public to access without prior
arrangement where there is an urgent actual or perceived
need for intervention by a health or social care
professional. Urgent care is the response before the next
in–hours or routine (primary care) service is available.’
Scope
• Emergency care
– 999/ED
– Not appropriate for community setting
• Urgent care
– ‘In the eye of the beholder’
– Most urgent care is sub-acute care
Urgent (sub-acute) care – who?
Urgent (sub-acute) care – who?
Urgent care – what?
• Non-specific presentations
– Falls, delirium
• Multiple comorbidities
• Polypharmacy
– Also under-prescribing
• Differential challenge
– Communication, discharge support
Urgent care - where?
• Where there is ready access to:
– Skilled assessment
– Diagnostics, if necessary
– Safe environment
– Rehabilitation
– Coordinated care
Figure 3: Fixed-effects meta-analysis of individual patient data: mortality at 6 months.
Shepperd S et al. CMAJ 2009;180:175-182
©2009 by Canadian Medical Association
Urgent care - standards
• The Silver Book
– http://www2.le.ac.uk/departments/cardiovascular-sciences/people/conroy/silver-book
• Membership
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Age UK
National Ambulance Service Medical Directors
Association of Directors of Adult Social Services
British Geriatrics Society
Chartered Society of Physiotherapists
College of Emergency Medicine
College of Occupational Therapists
Society for Acute Medicine
Royal College of General Practitioners
Royal College of Nursing
Royal College of Physicians
Royal College of Psychiatrists
Community Hospitals Association
Underpinning principles
• All older people have a right to a health and social
care assessment and should have access to
treatments and care based on need, without an agedefined restriction to services
• A whole systems approach with integrated health
and social care services strategically aligned within a
joint regulatory and governance framework,
delivered by interdisciplinary working with a patient
centred approach provides the only means to
achieve the best outcomes for frail older people with
medical crises
Standards (some)
• All older people accessing urgent care should be
routinely assessed for:
– Pain
– Delirium and dementia
– Depression
– Nutrition and hydration
– Skin integrity
– Sensory loss
– Falls and mobility
– Activities of daily living
– Continence
– Vital signs
– Safeguarding issues
– End of life care issues
Frailty syndromes & urgent care
• The presence of one or more frailty syndrome should
trigger a more detailed comprehensive geriatric
assessment, to start within 4 hours (14 hours
overnight)
• Frailty syndromes
– Falls & immobility
– Functional decline
– UTI & incontinence
– Pressure sores
– Delirium and dementia
– Polypharmacy (>4 items)
– Carer strain
Who needs referring to the MDT?
Population:
• Younger, single system
problem
Refer to:
Relevant service, e.g. mental
health, diabetes
• Older, single system
problem
Relevant service, e.g. mental
health, diabetes & screen for
frailty syndromes
• Older, multiple problems,
frailty makers
Virtual ward/
community MDT
Operationalising good practice
• Delivering multidimensional assessment & multiagency
management
• Home based multidisciplinary teams
– General practitioners
– Community nursing, physiotherapy, occupational
therapy, mental health
– Specialist nursing
– Advanced nurse practitioners
– Interface geriatricians
– Social care
– Voluntary services
Does it work in practice?
• National Evaluation
of the Department of
Health’s Integrated
Care Pilots; RAND
Europe, Ernst &
Young; March 2012
Key findings
• Horizontal > vertical integration
• Process improvements – e.g. more care plans
• Professional > patient driven service change
– Patients less enthusiastic
• No evidence of reduced emergency care use
• Reductions in elective care use (in and out-patient)
– Case management
– Reduced costs
Effective urgent community care for older people
• Vertically integrated, using strengths of both sectors
• Comprehensive geriatric assessment, including social
care
• Coordinated and communicated
Intermediate care
Frail older person
in crisis
SPA – clinical discussion
Bed-based rehabilitation/
reablement
MDT
Triage
Trajectory
Transfer
Liaison
Specialist care
EFU/
AFU
In-patient
CGA
Summary outcomes for ED
Percentage change 2010 vs. 2012
Impact on bed days
Despite large increase in older people attending, bed-days
only modestly increased
Summary
• Urgent care = older people
• It can be in the community, but:
– Needs to be vertically integrated
– Holistic & interdisciplinary
– Underpinned by robust communication and
cooperation