Frail Older People Programme
Greater Nottingham
Jeremy Griffiths
Clinical Lead / Chair of SIGNS
30th October 2013
Greater Nottingham
approach
• Frail Older People – how we started
• Learning from others - Warwick - Jan
2013
• What we have done since
Who are we?
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4 CCGs
2 Local Authorities
Nottingham University Hospital
2 community providers
Nottinghamshire Healthcare Trust
How we started
August – November 2012
• Mandate from an existing health and social care senior
leaders forum (Productive Notts)
• Drawing on the evidence base
– Comprehensive Geriatric Assessment (CGA)
– Enhance intermediate care
• Engagement with main clinical groups across acute and
community
• Event of 80 staff to determine priorities
Learning from visit to
South Warwickshire
January 2013
• Snappy titles
– Support to Thrive/Choose to Admit/ Transfer to
Assess
– 5 a day challenge –became 7 a day for us
• Impact of ageing population on demand for services
• Providers working together
The Burning Platform – the impact of
our ageing population
To avoid opening more beds in
2013/14 and 2014/15 we need to
reduce admissions by 9% per
annum
How we continued
January – October 2013
• High level communication (H and WB), including
ambition for older people
• Time based standards against the bow tie
• Focus on Choose to Admit/Transfer to Assess in 4
projects
• Understanding our patients and where we currently
cannot meet their needs in the community
• Implementation of phase 1 on October 14th
Our ambition for older
people
• I wish to retain my independence wherever possible
• When I am unwell, I am assessed using Comprehensive (Geriatric)
Assessment
• Community services are there for me if I need support at home or
overnight
• Hospital is there for me if I I need specialist clinicians to manage my
medical conditions until I am stabilised, or I need an operation
• I leave hospital as soon as my health is stable enough for me to do
so
• I see a specialist in medicine for older people if this is needed
• Staff on my ward organise what is needed for me to leave hospital
• I will only be transferred to long term care or a nursing home if that
is the best place to meet my needs
• While I am recovering, my care is planned using Comprehensive
(Geriatric) Assessment
All standards and timings are for discussion and
development
Draft V2.1
Frail Elderly Pathway – Care standards (time based)
Self
care
Support
older
people at
home
Enhanced
support at
home
Manage
Crisis
Effectively
Input in
acute
setting
Manage
step
down
from
acute
effectivel
y
Enhanced
support at
home
Support
older
people at
Home
Self
care
All standards relate to patients assessed as being ‘frail’
Home/care
home
Std H1. All patients
remotely identified as an
emerging risk (by e.g.
the Devon tool) will be
assessed* within 7 days
Std H2. Primary care will
respond to a request for
a GP visit and make a
‘treat/refer/admit /no
action’ decision within 4
hrs
Crisis
Acute
Std C1. For all
patients identified as
being at risk of
admission to an
acute hospital, an
assessment *will be
initiated within 2 hrs
of the request
Std C2. All patients
in crisis will start to
receive a package of
enhanced support at
home within 2 hrs of
the need being
identified. NB
working patterns
Std C3. Within XX
hrs of the need
being identified for a
Community bed, all
patients in crisis will
be transferred to that
bed
Std A1. On arrival in
ED / admissions unit,
all elderly patients at
risk of adverse
outcomes will be
ISAR scored within 4
hrs .
Std A2. Patients with
an ISAR score of 3 or
more will be notified
to the CGA case
manager and
assessed*within XX
hrs
Std A3. All patients in
hospital will be
assessed* before they
leave hospital. HOLD
pending D2A
discussions
Trf of care
Std T1. All patients will
be transferred to the
most appropriate care
setting following a
decision of ‘medically
fit for discharge’ as
follows:
T1a. For first time care
home placement:
Arrival by 17.00 within
XX days of the
decision
T1b. For return to care
home: Arrival by 21.00
if decision by 14.00.
By 12.00 next day if
decision after 14.00
T1c. For assessment
bed / I.C. bed: Arrival
within 24 hrs between
10.00 and 16.00
Home/care home
Standards to be
developed
Self
care
* All assessments are carried out
using a Comprehensive Geriatric
Assessment (CGA) approach
6 Strategic Priorities aligned to ‘levels of care’
SCOPES
Support to Thrive
Support to Thrive
(planned care only)
Choose to
Admit
Transfer to Assess
Comprehensive Geriatric Assessment (CGA)
Pathway Standards - time based
Enabling sub groups - Outcomes & Commissioning, Communications & Consultation, Workforce Planning
Enabling approach - SHARING of information, risks, challenges, successes etc. will be key
Transfer to Assess
Our approach
• Simplify the interface between NUH and community
services (including social care) on transfer of care out of
NUH
• Transfer patients out of acute hospital as soon as their
acute needs have been met. Those patients who need
time for further recovery are assessed in a community
setting for longer term plans about their ongoing care.
• Increase the capacity of community services to meet all
needs without referral criteria
Who are our patients?
The ‘oldest old’, physically, cognitively or socially frail
(Silver Book)
Patients admitted
to a HCOP ward
until they transfer
out of HCOP ward
Half of the patients
are over 85
88% have dementia, delirium or
other mental health problems
(excluding anxiety). Half of these
have moderate to severe mental
health problems
Capacity modelling
Commissioners and providers
worked together to undertake
detailed analysis and modelling
using 2012 activity figures to
show that…….
There are 38 patients in
beds in NUH who could
be elsewhere
This equates to 7
additional discharges a
day and an average
reduction in delays of 5
days per patient
Capacity modelling
We agreed some
assumptions
about what would
additional
capacity would be
needed in the
community to
enable those
patients to go
home sooner
We need 21 more
community beds
and 22 more
community
places
But they need to meet the needs of patients who
currently have no community provision – frail,
clinically unstable older people with
dementia/delirium. This may be why we have empty
community beds
Choose to Admit and Transfer to
Assess projects
Patient Information
exchange including
Alerts
3.Community 2.Community
capacity
Hubs
1.Care co-ordination
team
(underpinned by NUH’s
– flow, streaming,
discharge project)
4. CGA /
information
sharing
4. CGA /
information
sharing
2.Community 3.Community
Hubs
capacity
4. CGA /
information
sharing
Choose to Admit/Transfer to Assess
Planned deliverables
By 1st Oct 2013
Care Coordination
Team
Current resources working as
one team to support ED, ass
beds and 8 HCOP wards (14th
October)
Community
Hubs
CCG-based community hubs
established with access to a
clinician with streamlined
interface to Care Co-Ordination
Team
Community
capacity
CGA and
information
sharing
An additional 6 beds that are
staffed to meet the needs of
the most complex patients as
part of an integrated
community service
Standardised transfer of care
template used to share
information on needs
between NUH and
community hub (fax)
By 1st Dec 2013
tbc
17th Sept 2013
By March 2014
Establish single integrated Care Coordination Team to support Choose to
Admit and Transfer to Assess,
reconfiguring existing resources, to
case manage all ‘supported transfers’
Community hubs manage all health
and social care local service capacity
and organise packages of care to
support transfer from hospital within
24 hours
Total of 21 additional beds that
are staffed to meet the needs
of the most complex patients
as part of an integrated
community service
Transfer of care template
operating electronically on
SystmOne
Strategic decision on the future
provision of community based services
– including balance between bed and
home based services
Agree and implement a method of
recording and sharing CGA across
primary care, social care, NUH and
community services
Back to time based standards…..
Crisis
2 hour
standard
Transfer of care
2 hour
and 24
hour
standard
Where next?
• Monitor changes – do they work and what is the impact on
flow through acute and community services?
• Work towards March deliverables
• Benefits/financial analysis to understand impact on
commissioners, providers and social care
• Agree strategy beyond March