Interface geriatrics – acute care for older people in Leicester, Leicestershire
and Rutland
Introduction
In 2009, the well-rehearsed demographic pressures facing Leicester, Leicestershire
(LLR) and the wider health and social care community were identified as a priority
area for development. The care of frail older people remains a major priority for the
Clinical Commissioning Groups (CCGs) across the health community. A wide variety
of initiatives are underway, which are overseen by the Leicester, Leicestershire and
Rutland Frail Older People’s Network, chaired by Professor Mayur Lakhani on behalf
of the three CCGs.
One key area of development has been the restructuring of acute care pathways for
older people, which are described here.
The population
This paper concerns frail older people, defined as people aged 65 or older who need
help with activities of daily living (washing, dressing, eating, toileting etc). Such
people usually have multifaceted care needs that require the support of health and
social care professionals.
Considerable efforts have been undertaken to decide how best to identify frail older
people using routine health and social care data, and this work is on-going. As an
interim measure, it has been agreed that using age 85+ is an acceptable means of
capturing the relative impact of service development on frail older people, though this
measure does not capture the absolute impact. Many people younger than 85 will be
frail and some people older than 85 will be robust; 85+ as a measure covers about
two thirds of frail older people. This is demonstrated in Figure 1 which shows that the
impact of EFU has been greatest in the oldest old, but still significant in older people
generally.
Figure 1 Relative impact on ED performance 2010 vs. 2012
Interface geriatrics – acute care for older people in Leicester, Leicestershire
and Rutland
The problem
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Increasing numbers of frail older people are attending the Emergency
Department (approximately 5% increase each year).
Frail older people have the highest ‘conversion rate’ (proportion of people
attending the ED that are admitted to hospital wards) approximately 75%
compared to 25% for all other groups.
Frail older people admitted to hospital are at high risk of adverse events, have
long stays, high readmission rates and high rates of long term care use.
o Despite comprising less than half of all patients admitted, older people
account for more than two thirds of occupied bed days (Figure 2).
Figure 2 Attendance and bed-day figure for UHL 2012
Solutions
A wide variety of generic interventions will improve outcomes for frail older people as
for younger people, such as increasing access to health care and better
communication systems, but specific care pathways for frail older people need to be
based upon Comprehensive Geriatric Assessment, as described in recent national
policy documents (Silver Book (http://www2.le.ac.uk/departments/cardiovascularsciences/people/conroy/silver-book-1), acute care of older people
(http://www.rcplondon.ac.uk/resources/acute-care-toolkit-3-acute-medical-care-frailolder-people)) .
Comprehensive geriatric assessment (CGA) improves outcomes for older people in
various settings, including reduced mortality or deterioration (odds ratio 0.76),
improved cognition, improved quality of life, reduced length of stay, reduced
readmission rates, reduced rates of long term care use (odds ratio 0.78) and
reduced costs1-6.
Interface geriatrics – acute care for older people in Leicester, Leicestershire
and Rutland
Definition of CGA
CGA is a ‘multidimensional, interdisciplinary diagnostic process to determine the
medical, psychological, and functional capabilities of a frail older person in order to
develop a coordinated and integrated plan for treatment and long-term follow-up’7.
Whilst integrating standard medical diagnostic evaluation, CGA emphasises quality
of life and functional status, prognosis, and outcome; team and standardised
assessment tools are commonly used. A typical team will include a geriatrician, a
nurse specialist, an occupational therapist, a physiotherapist, a pharmacist and
others as needed (speech and language therapy, dietetics).
Challenges for the delivery of CGA in acute care
As hospital length of stay has shortened over the years, it has become increasingly
important to ensure that care pathways are developed across primary and secondary
care to ensure effective continuity of the care. The importance of ‘vertically
integrated’ care pathways across primary and secondary care is highlighted in a
recent review of several integrated care pilots in the UK (National Evaluation of the
Department of Health’s Integrated Care Pilots; RAND Europe, Ernst & Young; March
2012).
Some key service developments in LLR are described here.
Emergency Frailty Unit (16% of consultant activity)
The Emergency Frailty Unit (EFU) is a multifaceted integration of CGA into existing
Emergency Department practice, consisting of:
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Care pathways embedded into ED documentation raising awareness of key
issues such as cognition, falls, continence safeguarding etc and directing ED staff
to relevant resources
An 8-12 bedded unit within the EDU staffed by geriatricians, emergency
physicians, primary care coordinators, nurses and therapists, all of whom who
work in a seamless integrated manner to initiate CGA
In-reach into ED offering advice, support and management of older people in ED
Robust links with community services through the Single Point of Access (SPA)
ED outreach service (offering CGA to patients at high risk of adverse outcomes
on discharge from ED)
Robust links with general practitioners, for example supporting care pathways
relating to admissions to community hospitals through direct conversations with
GPs using the SPA
Education and training of ED clinicians and students
o In situ clinical teaching
o Formal teaching sessions
o Joint governance meetings held fortnightly involving geriatricians, ED staff
and community staff
Interface geriatrics – acute care for older people in Leicester, Leicestershire
and Rutland
o Emergency geriatric medicine fellowships (dedicated one year out of
programme experience offering bespoke training in geriatric medicine in
acute and community settings for ED trainees)
Impact comparing 2012 to 2010
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Average number of people aged 85+ attending ED per month 802 (2012) vs. 638
(2010) (↑26%)
38% of people aged 85+ discharged in Jan-Apr 2012 compared to 31% in 2010
(relative ↑23%)
If sustained over 2012, with average 802 patients per month, 56 patients aged
85+ going home per month who would have been admitted in 2010
Assuming average LoS of 9 days for people aged 85+, this represents 6048 beddays per annum
7 day readmissions down 26%
30 days readmissions down 25%
90 day readmissions down 20%
Additional benefits
Profile raising
The EFU intervention is heralded nationally as representing the cutting edge in acute
care of older people, raising the profile of Leicester and increasing opportunities for
recruitment and retention of staff.
At least 16 other NHS trusts have been to visit the development in Leicester in the
last year, and members of the development team have been invited to give several
national presentations on EFU and related care, as well as preparing national reports
on this topic. The interface geriatrics strategy has been shortlisted as a finalist in the
prestigious HSJ awards in 2012. ECIST uses the EFU model in helping other
struggling trusts to address their acute care flow issues.
Changing attitudes
GPs have historically been fearful of referring frail older people to UHL for acute care
needs, because of the adverse consequences experienced as described above.
Through close collaboration with grass-root GPs as well as CCGs, geriatricians and
team have started to change this attitude. GPs now fell more confident to refer
patients into ED/EFU for assessment, knowing that if appropriate, patients are likely
to be discharged home on a robust care pathway. This is better for patient care, as
an earlier assessment and establishment of a care plan improves outcomes.
Perhaps more importantly, patients are offered holistic patients centred care, and
satisfaction is increased, leading to fewer complaints, and inspiring great confidence
in the hospital.
Interface geriatrics – acute care for older people in Leicester, Leicestershire
and Rutland
Frail Older Peoples Advice and Liaison service (5% of consultant activity)
The Frail Older Peoples Advice and Liaison service (FOPAL) is a peripatetic geriatric
liaison service.
FOPAL phase 1
Phase 1 of FOPAL saw a geriatrician and physician assistant focusing on frail older
people that were admitted to the Acute Medical Unit (AMU), who worked with
existing medical, nursing and therapy staff to deliver CGA. In 2011, FOPAL focused
its efforts on older people who could be discharged from AMU, obtaining important
results (Figure 3).
Figure 3 Impact of FOPAL on decision making in the AMU, 2011
As the EFU developed, the number of people that could be reasonably discharged
from AMU diminished (Figure 4) and FOPAL evolved into more of a ward liaison
service.
Figure 4 Diminishing opportunities for discharge on AMU over time
Interface geriatrics – acute care for older people in Leicester, Leicestershire
and Rutland
FOPAL phase 2
FOPAL phase 2 started in November 2011 and saw the geriatricians working
together with psychiatry services for older people. FOPAL now focuses
predominantly on inpatient wards at the LRI and GGH, with some support to LGH.
FOPAL now consists of the following team members:
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Consultant psychiatrist
Consultant geriatrician
Physician assistant in geriatric medicine
Community psychiatric nurses
Administrative assistant
FOPAL activity is as follows:
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Average 108 patients per month seen
Around 40% requiring follow up visits
44% psychiatry, 46% geriatrics, 10% joint assessment
85% seen within 24 hours, 11% in 48 hours, rest within 72 hours
Outcome data analysis is awaited, but the process information presented above
promises important results given the previous absence of a joint liaison service for
older people.
Locality geriatricians (‘interface geriatricians’, 5% of consultant activity)
A key ambition of the department has been to support the care of older people in
community settings, especially concerning acute care pathways – aiming to support
the delivery of CGA at all stage of the patient pathways. Efficiencies in community
care translate to increased capacity and flow in the acute hospital setting and are
given equal priority to conventional acute hospital activity.
Community hospital wards
Geriatricians support hospital practitioners and ward teams in the delivery of CGA in
8 of 11 rehabilitation ward across the county and in both city intermediate care units.
The ambition is to extend this coverage to include all community hospital wards as
well as the developing intensive community support service. The presence of
geriatricians has increased substantially over the last 18 months, and along with
other initiatives running in the community hospitals has led to important
improvements in patients care as well as efficiency gains.
Over 2009-2011, community hospital length of stay remained relatively static at 2526 days; following the introduction of greater geriatric presence in the community
setting, length of stay has fallen to 20 days in 2012.
Interface geriatrics – acute care for older people in Leicester, Leicestershire
and Rutland
Access to community hospitals
As GPs were historically fearful of referring frail older people to acute care services,
there was an enthusiasm or delivering acute care in community hospitals, which they
were not resourced to deliver. This led to 10% of patients being stepped up being
referred to acute services within 24 hours and 40% being referred in at some stage
during their stay.
Following consultation with the CCGs an innovative single point of access (SPA)
system, run by nurse practitioners was introduced. The SPA manages the liaison
between GPs and consultant geriatricians prior to any community hospital
admission. GPs have one number to call, all calls are auditable and a geriatrician
must respond within 20 minutes. The new referral pathways went live in March 2012.
Data from May 2012 shows interaction between GPs and the EFU is already being
converted into a length of stay reduction in community hospitals of one day per
patient. A 5 per cent reduction in readmissions has also been achieved.
Integrated care
Several key initiatives led by the CCGs focus on delivering holistic assessments for
frail older people closer to home, with the aim of maintaining independence in the
community settings and reducing reliance on secondary care services. An example if
this is the merger of reablement and intermediate care teams in the County, and the
push to deliver CGA involving geriatricians supporting community MDTs (e.g.
Proactive care in WLCCG, Integrated care in the City CCG). These developments
reflect the vertically integrated pathways for frail older people described by the King’s
Fund report, and have a strong evidence base1 3 6 8.
Other interdependencies
Orthogeriatrics (5% of consultant activity)
The management older people with hip fracture is a major national priority. Geriatric
services have reconfigured over the last year to provide daily input to orthopaedics in
the form of:
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Daily MDT meetings
Daily ward rounds/reviews
Weekly MDTs
As a consequence, performance for key national metrics has moved from being in
the bottom to the top quartile.
Key to the reduction in length of stay in orthopaedics has been the establishment of
post-acute pathways delivering CGA across primary and secondary care. The
orthogeriatricians all have a role in managing patients in the acute sectors as well a
in the community setting.
Interface geriatrics – acute care for older people in Leicester, Leicestershire
and Rutland
Geriatric base wards (21+% of consultant activity)
Geriatricians run 5.5 acute wards across the LRI and GGH. These predominantly
cater for the needs of frail older people and consistently deliver high quality CGA in a
discrete, ward based setting – for which there is robust evidence3.
Outpatient services (20% of consultant activity)
Outpatient falls services are provided in the City at LGH and in most community
hospitals.
Other geriatric medicine outpatient services offer expertise in the management of
Parkinson’s disease, syncope and gastrointestinal problems in older people.
Non-clinical activity (23% of consultant activity)
This includes SPAs for CPD, audit, education, training and research. Despite
increasing pressures to manage in-patients the department continues to deliver
undergraduate and post-graduate education, participate in trust and nation audits as
well as deliver a number of NIHR portfolio projects (Error! Reference source not
found.).
Interface geriatrics – acute care for older people in Leicester, Leicestershire
and Rutland
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Cochrane collaboration, 2011.
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