complex care and frailty multidisciplinary meeting dr stuart mackay-thomas clinical lead for frailty
TRANSCRIPT
Complex care and frailty multidisciplinary meeting
Dr Stuart Mackay-ThomasClinical Lead for Frailty
Frailty and complex care in Camden
• Camden’s population is approximately 230000• There are an estimated 3000 frail / complex care
patients in Camden
The CCG definition of frail / complex care patients:>75 years with 1 or more LTCs and 1 or more non-
elective hospital admissions per year<75 years with complex health and social care
needs where a patient’s GP has identified they would benefit from a case management approach
Rationale for the frailty & complex care pathway
• Prevention of avoidable hospital activity– Patients aged 64+ non elective admissions
• 2011/12 - 5,900• 2012/13 – 6,000• 42% resulted in stays of 2 days or less
• Improving outcomes and patient experience through better co-ordination of care– 35% of older people admitted to hospital are discharged
in a poorer functional state than on admission– Continuity of GP care can prevent emergency admissions
(Baker et al 2012)
Camden’s model for those with complex needs
localGP and
Integrated Primary Care
team
centralHub MDT
Hospital
Social services
Mental health services
Camden’s model for those with complex needs
localGP and
Integrated Primary Care
team
centralHub MDT
Hospital
Social services
Mental health services
Comprehensive geriatric assessment
• The gold standard for the management of frailty in older people is the process of care known as Comprehensive Geriatric Assessment (CGA).
• It involves an holistic, multidimensional, interdisciplinary assessment of an individual by a number of specialists of many disciplines in older people’s health and has been demonstrated to be associated with improved outcomes in a variety of settings.
Camden’s current model for those with (very) complex needs
localGP and
Integrated Primary Care
team
centralHub MDT
Hospital
Social services
Mental health services
Camden’s current model for those with (very) complex needs
localGP and
Integrated Primary Care
team
centralHub MDT
Hospital
Social services
Mental health services
Name Co-Morbidities Current Mediaction / (Include strength and dose Problems For Discussion
Patient's name Hypoventilation and nocturnal hypoxaemia Ramipril (d) 5mg PO ON recurrent admission
Hypertension Bisoprolol (d) 7.5mg PO OM
Date of Birth: AF Digoxin (d) 125 micrograms PO OM concern regrading medication compliance- Reported by ward staff pt tend to hide medications on her food
Date of Birth: CRT-D in situ4. NIDDM Atorvastatin (d) 20mg PO ON
CKD- baseline creatinine 112 Glicazide (d) 160mg PO BD optimise hear failure; LV EF 10-15%
NHS No: Schizophrenia Metformin (d) 500mg PO BD
XXXXXXXXXXX Left mid cerebral infarct 2013; Right sided weakness Spironolactone (d) 50mg PO OM has home NIV - ?compliance
Dilated cardiomyopathy EF 10-20% Rivaroxiban (d) 20mg PO 18pm
Main Carers full name: ECG: old LBBB Ivabradine (d) 5mg PO BD
Carers name (son) Chronic type 2 respiratory failure. Mixed pathology, pulmonary and severe LVSD Bumetanide (d) 3mg PO OM
7577319156 MI 2009 Bumetanide (d) 2mg PO 14pm
GP Name: Flupenthixol 60mg IM every 3 weeks Continue Continuing next due 01/04/2015
Dr X Senna 7.5mg PO BD PRN
GP Practice:
Abbey Medical Centre
85 Abbey Rd NW8 0AG
Presented by:
Ivy Macalino
RFH-Resp
Frailty Score:
Has this patient given their consent to view the GP records?
verbal consent yes 14/4/15
Does this patient have capacity sufficient to make decisions around own care? yes
Email to: [email protected]
Hub MDTWeekly Multidisciplinary
meeting
• GP• Geriatrician / secondary care• Complex care nurses• Therapists (eg OT)• Social workers• Mental health consultant• Pharmacist• Camden Carers• Palliative care team• Age UK Camden
Hub MDT communication• Access to EMIS web community i.e. the full GP records (if
consented).• Allied EMIS web community records e.g. community renal
team, or community diabetes.• Framework-I (social work database).• Mental health consultant uses RiO.
• Camden Integrated Digital Record - web-based access to EMIS, secondary care data, community nursing, mental health and social work databases.
• Videoconference facility – currently with one practice.
15-Apr-2015 Case conference (South Camden Centre for Health) MACKAY-THOMAS, Stuart - GP (Dr)
Problem Chronic obstructive pulmonary disease (Review)
Problem [X]Schizoaffective disorders (Review)
Problem Type 2 diabetes mellitus (Review)
Problem Left ventricular failure (Review)
Problem Atrial fibrillation (Review)
History Has been discharged from hospital recently, and it is reported that patient missed her medication for 3 days (by Percy the heart failure nurse).
Rebecca Broadhurst is the allocated social worker.
Plan Dr Mackay-Thomas to contact Percy re: meds. Dr Mackay-Thomas to contact Rebecca Broadhurst
re: adult safeguarding.
Hub to review next week. GP - please consider rechecking HbA1c.
Dear Doctor,Ms X was discussed by the Multidisciplinary Team for frailty at South Camden Centre for Health today.
Hub MDT example care plan
Hub MDT outcomes• Recent data from an evaluation has shown reduction in
unscheduled care by 50% in those managed at the Hub.– At a time when A&E admissions increasing ~ 10% per year
• 47.7% reduction in accident and emergency attendances; and
• 32.9% reduction in first and follow up outpatients’ appointments.• 30% of patients referred into the MDT spent more time at home following
their intervention than in the 6 months previous.
Hub MDT Outcomes
• Data illustrates a 32% reduction in A&E 6 months after an MDT intervention.
Hub MDT Outcomes
• 18% reduction in emergency beddays in the 6 months following an MDT intervention
Hub MDT Outcomes
• MDT has also led to financial efficiencies around A&E and emergency admissions
Further readingDe Lepeleire et al. (2009) Frailty: an emerging concept for general practice BJGP 59 (562) e177-e182
Clegg A et al. (2013) Frailty in elderly people. Lancet 781: 352-362
Sayer, C. (2014) Improve frail elderly care with evidence, not intuition. HSJ http://m.hsj.co.uk/5070273.article
Fit for frailty – British Geriatrics Society 2014 http://www.bgs.org.uk/index.php/fit-for-frailty