dorset frailty toolkit - nihr clahrc wessex · 2017-12-08 · first dorset frailty toolkit a model...

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DORSETFRAILTYTOOLKIT

Amodelfortheidentification,assessmentandcareplanningoffrailpatients

Version1.November2017

CONTENTS

Introduction………………………………………………………………………………………………………………………………………1

GPMultidisciplinaryTeamMeetings…………………………………………………………………………………………………2

MDTProcessChart……………………………………………………………………………………………………………………………3

TermsofReference…………………………………………………………………………………………………………………….…….4

MDTDiscussionTool…………………………………………………………………………………………………………………………6

RiskProfiling……………………………………………………………………………………………………………………………….…….7

eFI………………………………………………………………………………………………………………………………………….….…....8

Hub referrals / MDT data………………………………………………………………………………………………………….….….12

DailyAdmissions………………………………………………………………………………………………………………….………….13

TheDorsetCarePlan…………………………………………………………………………………………………….….…………….14

CGA………………………………………………………………………………………………………………………………………………...21

Outcomemeasures…………………………………………………………………………………………………………………………22

Mild Frailty / E-learning.…………………………………………………………………………………………………………….…….23

CaseStudy,Acknowledgements&References…………………………………………………………………………..……24

Appendices……………………………………………………………………………………………………………………………..….….25

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IntroductionFrailtyisdefinedbytheBritishGeriatricsSociety(BGS)as‘adistinctivehealthstaterelatedtotheageingprocessinwhichmultiplebodysystemsgraduallylosetheirin-builtreserves.’

Overrecentyears,frailtyhasbeenincreasinglyrecognizedasalongtermconditionanditisofparticularconcernbecauseindividualslivingwithfrailtyareatriskofdramaticdeteriorationintheirphysicalandmentalwellbeingafterevenapparentlyminorevents.Howeverthereisevidencethatindividualswithfrailtycanhaveimprovedoutcomesandpotentiallyreducedhospitaladmissionsifaperson-centered,goal-orientatedcomprehensiveapproachistaken.ThisissummarizedintheBGSdocument‘FitforFrailty’publishedin2014.

InOctober2016theWeymouth&PortlandLocalityweresuccessfulinabidtoreceiveayear’sfundingfromHealthEducationWessextodevelopandimplementamodelthatwouldenableustoprovideproactiveinterventionsforpatientsincreasinginfrailty.

Thistoolkitexplainstheprocessofongoingidentificationof‘atrisk’patientsusingdifferentinformationsources.ItcomplementsandenhancestherequirementsofthecurrentGPcontractrelatingtofrailty(July2017)andensuresthattheright,oftenunknownpatientsareidentified.ItalsosupportsthegoalsofIntegratedCommunityandPrimaryCareServicesensuringajoined-upapproach,reducingduplicationandenhancingpatientcare.

Itisintendedasapracticalguide;formalisingthestructureoftheMulti-DisciplinaryTeam(MDT)processwithstepbystepguidanceonriskprofiling,TheDorsetCarePlan(DCP)andanintroductiontotheComprehensiveGeriatricAssessment(CGA).

ThismodelisrecommendedtobedeliveredatalocalityleveltoenablestronglinksbetweenDorsetHealthCareUniversityFoundationNHSTrust(DHC)andPrimaryCare,butcanbeadaptedtobeusedwithinindividualpractices.

Introduction .......................................................................................................................................... 1

GP Multidisciplinary Team Meetings ..................................................................................................... 2

MDT Process Chart ................................................................................................................................ 3

Terms of Reference ................................................................................................................................ 4

MDT Discussion Tool .............................................................................................................................. 6

Risk Profiling .......................................................................................................................................... 7

eFI .......................................................................................................................................................... 8

Hub referrals / MDT data ..................................................................................................................... 12

Daily Admissions.................................................................................................................................. 13

The Dorset Care Plan ........................................................................................................................... 14

CGA ...................................................................................................................................................... 21

Outcome measures ............................................................................................................................. 22

Mild Frailty / E-learning ....................................................................................................................... 23

Case Study, Acknowledgements & References ....................................................................................24

Appendix 1: eFI formulae .................................................................................................................... 25

Appendix 2: Pareto chart .................................................................................................................... 26

Appendix 3: DCP additional examples ................................................................................................27

Appendix 4: Frailty Leaflets ..................................................................................................... 28, 29,30

Appendix 5: Frailty Poster ................................................................................................................... 30

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GPPractice-MDTMeetingsMDTmeetingsarerecommendedtoberunmonthlywithanidentifiedlistofpatientsfromriskprofilingandpatientsofconcernputforwardbyclinicians.

StructureofanMDT

ToensureanMDTmeetingissetuptoenableallteammemberstocontribute,thefollowingarerecommended:-

• AsuitablesizedroomtoseatallMDTmembers• GPSystemaccessavailableinthemeeting• AprojectortoenableallMDTmemberstoviewGPsystemandrelevantrecords• AnuptodatelistofalllinkworkersattendingthesurgeryMDTrepresentingtheirservice• MDTdatesagreedayearinadvancetoensurealllinkworkersplantheirdiariesand

guaranteeattendance• TheriskprofilingdatashouldbesenttoGPpracticesandlinkworkersaweekinadvanceof

theMDTtoallowadequatetimetogatheranybackgroundinformationthatmaybehelpfultothediscussion

• Allattendeesmustsignaconfidentialdeclaration• TheMDTtermsofreferenceshouldbesenttoalllinkworkers• AllsurgeriesshouldhaveanMDTcoordinator• Anominatedscribemustbeavailableinthemeetingtorecordtherelevantpointsonthe

MDTdiscussiontool-Thisshouldnotbethechairofthemeeting• TheChaircanbeaGPoracompetentalternative

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MDTProcessChartThefollowingchartdemonstratestheprocessfromriskprofilingtoMDToutcome

7/8dayspriortomeeting...theriskprofilingteam•RuneFIandHubreferralsreport•Provideclinicaltranslationofdata•ProducemanageablelistofpatientswhowouldbenefitfromMDTdiscussionormoredetailedreview&assessment

1weekpriortomeeting...LinkWorkersReviewdatasentbyriskprofilingteam&highlightanypatientstheywishtodiscuss

MDTCoordinatorForwarddatatoGPs/relevantPracticestaffCollatelistofpatientsidentifiedfordiscussionbyotherMDTmembers

MDTMeeting...•UseMDTdiscussiontooltemplatetoguideandrecorddiscussion•Makeuseofthebroadestrangeofprofessionalsasappropriate•Discussidentifiedpatients•Eachpatientdiscussedmusthaveaclearoutcomewithanamedpersonresponisiblefortheaction•MDTCoordinatortofollowupactions2weeksaftermeeting

SenddatatoSurgeryMDTCoordinator

&linkworkers

SendidentifiedpatientstonamedGPsforanyprep

work

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PrimaryCareMDT-TermsofreferenceThepurposeoftheMDTmeetingis:

• Toprovideamulti-disciplinaryforumforthediscussionandmanagementofrelevantpatients

• ToensurethatthepatientisatthecentreoftheMDTdecisionmakingprocess• Toensurethatthediscussionaroundeachpatientcoversallrelevantpoints,whichcan

befacilitatedbytheuseofaMDTdiscussiontooltemplate• Tomaintaincommunicationbetweenallorganisationsmakingupthemulti-disciplinary

teaminordertopromotebestpracticeandtoensuretimely,holisticindividualisedcare• Toagreeaplanofactionbasedonintendedoutcomesforthepatient.

Attendance:

• GPs• NursePractitioners/ECP’s• Communitymatrons• Districtnurses• Health&SocialCareCoordinators

(H&SCCO)• Palliativecarenurses

• ICRTmembers–physiotherapy/OT• CMHT–adultandolderpeoples• SocialServices• Administrationstaff/MDTCoordinator• Thirdsectorrepresentativeforappropriate

partsoftheMDT(Theyshouldnotbeinattendancewhendiscussingpatientsnotontheircaseload)

Expectationsofthechairperson:

• Thechairpersonmaybeaclinicalornon-clinicalteammember• Toensurethemeetingcommencesandfinishesontime• Tohavecollatedandreviewedinadvanceofthemeetingallrelevantdatasourcesincluding

(butnotexclusively):palliativecarepatients,admissionsdata,frailtyandhubreportsprovidedbytheH&SCCoordinatorandidentifiedpatientsfromanyofthemulti-disciplinaryteamsmembers

• ToreviewpreviousactionplansfromthelastMDTmeeting• Toeffectivelymanagethemeeting,takingintoconsiderationtimeconstraints,preventing

repetitionandensuringthatteammembersremainfocused,succinctandrelevanttoMDTworking

• Torelayanyrelevantinformationtothewiderteamonbehalfofanypersonsunabletoattend

• Toensurethatanyactionsgiventoabsentteammembersareconveyedtotheminatimelyandclearmanner

• Tosummarizethedecisionsandactionplanandensuretheyarerecordedaccurately.

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Expectationsofattendees

• Membersareexpectedtoattendandbepreparedtocontributebothactivelyandconstructivelytothemeeting

• Presentationofpatientsshouldclearlyandconciselyspecifythemainissuestoenableconstructivediscussiontotakeplace.Discussionshouldbepresentedwithobjectivity,brevityandwithclearpurpose

• Memberswhoareunabletoattendshouldsendtheirapologiesandanupdatetotheadministrator/chairpersonpriortothemeeting

• Toshowrespectforothersknowledgeandvalueequallytheinputofallinattendanceo Onlyonegroupmembertospeakatatimeo Tobemindfuloflanguageusedwhendescribingpatients,theirsignificantothers

andotherprofessionalso Tonotinterruptinappropriatelyo Tolisteno Topromoteasupportiveenvironment

• Toberesponsibleforthesafekeepingofanyidentifiableinformationprintedforthepurposeofthemeeting,andifnotrequired,tobehandedbacktotheadministrator/chairpersonforconfidentialdisposal

• Laptops/handheldelectronicdevicesareallowableonlyiftheyarenecessaryforinformingthemeeting

• AgenciesshouldbewillingandabletoacceptreferralsdirectlyfromtheMDT• Attendancefromserviceswillbemonitored.

Recordkeeping:

• AnominatedadminsupportpersonwillcirculatemeetingdatespriortothemeetingandwillcirculateallrelevantdocumentationtoallmembersoftheMDTatleast48hoursbeforethemeeting

• Ensurearegisterofattendeesiskeptalongwithrelevantconfidentialitydeclaration• Torecordthediscussioninanappropriateformatinthepatientsrecordsandbyuseofe.g.

MDTdiscussiontemplate• Torecordthedecisionsandactionplanassummarizedbythechairperson• Torecordthenominatedprofessional(s)tocompletetheactionplan.

Processes:

• MDTmeetingswilltakeplacemonthly,thedurationtobedecidedbytheindividualsurgery• PreparationfortheMDTmeetingwilltakeplaceaspertheMDTprocessesflowchart• PatientsfordiscussionwillbesubmittedtothesurgeryMDTadministratororchairpersonat

least24hoursinadvanceofthemeeting• Thechairpersonwilldeterminetheorderofdiscussioninvitingrelevantmulti-professional

teammemberstopresenttheiridentifiedpatients.

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MDTDiscussionToolTheMDTdiscussiontoolisrecommendedtobeusedduringthePrimaryCareMDTdiscussiontoenabletheconversationregardingthepatienttoberecordeddirectlyintotheir

notes.ItoffersaguidetosteertheMDTdiscussionensuringactionsandoutcomesarerecorded.

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IfaDorsetCarePlanhasbeen

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EFIRiskprofilinginstructionsforRPTAdministrator–EFItool

SYSTMONE:

Tofind/runtheElectronicFrailtyIndexreport….

• OpentherequiredGPPracticeSystmOne

• Select‘Reporting’• Select‘MiscellaneousReports’• Select‘ElectronicFrailtyIndex

Report’• Goto‘Showtop’typein

percentageofpopulationyouwishtosearchandensurethat‘Percent’isselected(forriskprofilingyouwillneedtoincludeallpatientswithascoreof0.13orabove–thiscanbeachievedbysearchingfor100%ofpopulationanddiscardingthosenotrequiredorbyworkingoutapproximate‘frail’populationsforyourPractices)

• Select‘RunReport’• Oncethereporthasbeen

populatedrightclickonanypatient,select‘Table’then‘OpenasCSV’whichwillexportthetabletoanExcelSpreadsheetallowingdatatobemanipulated.

• OncedocumenthasopenedscrolldowntobottomofEFIlistanddeleteanypatientswithascorebelow0.13.

• DonotclosethePracticeSystmOneasyoumayneeditagainlater

• ***IfyouhaveaGPS1thatservesmultiplePracticeMDTsyouwillneedfurtherinstructions***

SystmOneEFIscoreguidance:

• Fit0–0.12• Mildfrailty0.13–0.24• Moderatefrailty0.25–0.36• SevereFrailty>0.36

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RiskProfilingRiskprofilingisaprocessofidentifyingpatientsthroughastructuredmethod;ensuringpatientswhoareatriskduetoanincreaseintheirfrailtyscoringarehighlighted.

TheElectronicFrailtyIndex(eFI)isanevidencebasedtoolrecommendedbytheBGStobeusedtoidentifyfrailtyinanidentifiedpopulation.TheeFIusesasetof36deficitsthatmayindicatefactorswhichincreaseapatient’schanceoffrailty,basedonReadcodesrecordedinaGPpractice.

TheeFIistheminimumstandardrequiredforriskprofilingyourpopulation.Toenrichthisprocesswerecommendyoualsoriskprofileusingadmissiondatafromyoursecondarycareservices,thisdataanalysiswillalsoassistcommunityteamstosatisfytheCQUINNtargetof‘Supportingproactiveandsafedischarge’whichaimstoreducelengthofstaytounder7daysforover65s.Admissiondataalsoallowsyoutolookforspecificconditionsthatrepresent‘frailtysyndromes’identifiedin‘FitforFrailty’asfalls,immobility,delirium,new/worseningincontinenceandsusceptibilitytosideeffectsofmedication.Datafromreferralstolocalityhubs/virtualwardcanalsobeusedtoaddvaluetoGPMDTs.Instructionsonhowtodothisareincludedinthetoolkit.

GPpracticeresponsibility

Fromthe1stJuly2017theGeneralMedicalService’scontractwillrequirepracticestoroutinelyidentifymoderateandseverefrailtyinpatientsaged65yearsandover.TheNHSFiveYearForwardViewidentifiesolderpeoplelivingwithfrailtyasoneoftheareaswheretheNHSfacesparticularchallenges.Practiceswillberequiredtouseanappropriatetoolandrecordtheappropriatediagnosisofmoderateorseverefrailtyinthepatientrecords.

Thisriskprofilingprocessisnotdesignedtogenerateanentirefrailtyregister.Itisamethodofidentifyingpatientswhoareincreasinginriskandmayrequireinputtoimplementproactive,preventativecarethanmayreduce,orinsomecases,reversetheirfrailtydeficits.

RiskProfilingTeam

ThefollowingguidancewillprovideinformationforHealth&SocialCareCoordinatorsorotherappropriatepracticebasedstaffmemberonhowtorunthenecessaryreportstoriskprofileapopulation.InadditiontothisitprovidesguidanceforCommunityMatronsorotheridentifiedclinicianstotranslatethedatawhichaddsvaluetousinganelectronictoolandbringsclinicalreviewintotheprocessasnoriskprofilingtoolis100%sensitive.

Theriskprofilingteam(RPT),dependingonyourchosenapproachoflocalityorpracticelevelcoordinationshouldbemadeupofthefollowingteammembers:

Localityteam

Surgeryteam

• Health&SocialCareCoordinator(RPTadministrator)

• CommunityMatron/OtherClinician(RPTClinician)

• SurgeryMDTCoordinator

• GP/PracticeAdvancedNursePractitioner(RPTClinician)

• SurgeryMDTCoordinator(RPTadministrator)

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• OpentheEFIspreadsheet

• YouwillnoticethatcellsF&GonCurrentEFIlisttabarealreadypopulatedDONOTamendthesecellsastheycontainformulaewhichmakeyourjobmucheasier!

• PleasenotethatthefirsttimeyouruntheEFIyouwillonlyneedtocopyandpasteyour

S1/Emislistinto‘CurrentEFIlist’tab

• Select‘PreviousmonthEFIlist’tabandclearcontentsofpreviousEFI

• Select‘CurrentEFIlist’tab(ensurethat‘Diff’columnfilterisremoved)selectcolumnsA-E,

copyandpasteinto‘PreviousmonthEFIlist’thenclearcontents

• GobacktoyourspreadsheetthatcontainsyournewlypopulatedEFIlistandcopyand

pasteinto‘CurrentEFIlist’tabyouwillnoticethatthecolumnsF&Ghavepopulated

themselves

• Alwayscheckthattheformulaearecorrect-pleaserefertotheformuladocumentin

Appendix1• Filter‘Diff’columnanddeselect‘0’andanyminusscoresthenclick‘OK’

• CopyandpastethepatientsintoanewtabandrenameittoreflectMDTmonth.Youwill

onlyneedtoincludepatientswitha‘severe’ormoderate’score

• Younowhaveatablethatonlyshowspatientswheretherehasbeenachangesincethe

lastMDT

• Savedocument.

• IfyouhaveaVirtualWardSystmOneandMDTcaseloads…o Registerpatients

o Select‘Other’asReferralsource

o Select‘MDT–Frailty’asPrimaryReferralinReason

o SelectappropriatePracticeMDTasCaseload

o WhencompletingInfoGathering&ReferralScreeningtemplateensurethatyou

recordIncreasedEFIscoreasreasonforreferralandincludeifthepatienthasa

careplan,whatfrailcategorytheyareinandwhethertheyhaveincreasedby

category

o InformRPTclinicianoncepatientsareregisteredtoS1andreadyforclinical

input.

• IfyoudonothaveaVirtualWardSystmOne…o InformRPTclinicianthatEFIspreadsheetiscompleteandensurethattheyhave

accesstodocumentsotheyareabletorecordtheirclinicalinput.

ItisrecommendedthattheRPTadministratorEFIinputiscompleted8dayspriortoMDT.

FollowingclinicaltranslationofdatathenextdayRPTadministratortorunHubreferralsreport.

EFISPREADSHEETEXAMPLE/INSTRUCTIONS

YouwillbeprovidedwithaspreadsheetthatyoureFIlistcanbetransferredintothat

will identify patients with an increased eFI score using the VLOOKUP function and

utilisesconditionalformattingtocolourcodescoresaccordingtofrailtycategories.It

canalsobesetuptoidentifypatientswithcareplans/incarehomesetc.

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• OpentheEFIspreadsheet

• YouwillnoticethatcellsF&GonCurrentEFIlisttabarealreadypopulatedDONOTamendthesecellsastheycontainformulaewhichmakeyourjobmucheasier!

• PleasenotethatthefirsttimeyouruntheEFIyouwillonlyneedtocopyandpasteyour

S1/Emislistinto‘CurrentEFIlist’tab

• Select‘PreviousmonthEFIlist’tabandclearcontentsofpreviousEFI

• Select‘CurrentEFIlist’tab(ensurethat‘Diff’columnfilterisremoved)selectcolumnsA-E,

copyandpasteinto‘PreviousmonthEFIlist’thenclearcontents

• GobacktoyourspreadsheetthatcontainsyournewlypopulatedEFIlistandcopyand

pasteinto‘CurrentEFIlist’tabyouwillnoticethatthecolumnsF&Ghavepopulated

themselves

• Alwayscheckthattheformulaearecorrect-pleaserefertotheformuladocumentin

Appendix1• Filter‘Diff’columnanddeselect‘0’andanyminusscoresthenclick‘OK’

• CopyandpastethepatientsintoanewtabandrenameittoreflectMDTmonth.Youwill

onlyneedtoincludepatientswitha‘severe’ormoderate’score

• Younowhaveatablethatonlyshowspatientswheretherehasbeenachangesincethe

lastMDT

• Savedocument.

• IfyouhaveaVirtualWardSystmOneandMDTcaseloads…o Registerpatients

o Select‘Other’asReferralsource

o Select‘MDT–Frailty’asPrimaryReferralinReason

o SelectappropriatePracticeMDTasCaseload

o WhencompletingInfoGathering&ReferralScreeningtemplateensurethatyou

recordIncreasedEFIscoreasreasonforreferralandincludeifthepatienthasa

careplan,whatfrailcategorytheyareinandwhethertheyhaveincreasedby

category

o InformRPTclinicianoncepatientsareregisteredtoS1andreadyforclinical

input.

• IfyoudonothaveaVirtualWardSystmOne…o InformRPTclinicianthatEFIspreadsheetiscompleteandensurethattheyhave

accesstodocumentsotheyareabletorecordtheirclinicalinput.

ItisrecommendedthattheRPTadministratorEFIinputiscompleted8dayspriortoMDT.

FollowingclinicaltranslationofdatathenextdayRPTadministratortorunHubreferralsreport.

EFISPREADSHEETEXAMPLE/INSTRUCTIONS

YouwillbeprovidedwithaspreadsheetthatyoureFIlistcanbetransferredintothat

will identify patients with an increased eFI score using the VLOOKUP function and

utilisesconditionalformattingtocolourcodescoresaccordingtofrailtycategories.It

canalsobesetuptoidentifypatientswithcareplans/incarehomesetc.

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7. Lookinthetabbedjournaltoestablishanycontactoverthepastmonth8. Identifyanyadmissions,infections,falls,delirium,exacerbationofLTC,deteriorationinconditionor

increasedfrailty9. Reviewmedicationstoidentifyriskofpolypharmacy(specifymedstoreviewifrelevant),identify

weightloss,newdiagnosis,increaseincareneeds10. CheckifaDorsetCarePlanrequirescompletingorupdating.Thisshouldincludeaclearescalation

plananddescriptionofpatient’sbaseline11. Reviewanyletterfromaspecialistthatprovidesinformationwhichmayaddtothecurrentpicture12. HighlightifaRockwoodscoreneedstobecompleted13. Recordanythingsignificantbyclickingon‘hubdashboard’followedby‘quicknote’andsummarise

yourfindings14. IfthepatientdoesnotrequireanMDTdiscussion–Save,admintemplate,endreferral,usualplaceof

residence,treatmentcompletedthensaveandrefreshlist15. IfthepatientdoesrequireanMDTdiscussion,save,admintemplatethensave16. Whenyouhavelookedthroughthewholelist,youwillhaveoneshorterlistofpatientsthatrequire

MDTdiscussion17. EmailRPTadminmembertonotifythatthistaskhasbeencompleted18. Theywillthencompileanemailwiththenamesofpatientstobediscussedalongwiththecomplete

listofpatientswhohavebeenraisedthatmonthduetotheirEfi,anadmissionorreferraltothehub.ThiswillbeattachedtoinformationsenttothePractice.theGPpracticeinformation.

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ClinicianGuidanceontranslatingdata

Allocatingtimeforriskprofiling–Theidentifiedclinicianwillneedtoallocatetimewithintheirdaythese

pointsareguidanceonhowthiscanbedone

• KeeparecordofallriskprofilingpreparationdatesandyourlinksurgeryMDTdates• Blockouttimeinyourdiarytocompletethedataanalysisonthepreparationday• Theadministrationmemberoftheriskprofilingteam(RPT)willensureyouhavethedatainyour

inboxthedaybefore• Aimtoreturnthedatacompletedtoadministrationmemberoftheriskprofilingteambymiddayon

thesameday.

Howtotranslatethedata/riskprofilingforEfiIfyouareNOTusinghub

module

Monthly

1. TheadministrationmemberoftheRPTwillhaveprovidedyouwithalistofdataforyoutotranslatedrawnfromtheElectronicFrailtyIndex(Efi)

2. Thedataincludespatientswhohave‘risen’orare‘new’onthelist.Itisbrokendownintomild(green),moderate(yellow)andsevere(red)frailtycategories.Thecolourcodingwillhelpidentifypatientswhohave‘jumped’upacategoryorwhohave‘risen’withintheircategory

3. AccesstheGPmodulesforyourpracticesandlookupthepatient4. Lookinthetabbedjournaltoestablishanycontactoverthepastmonth5. Identifyanyadmissions,infections,falls,delirium,exacerbationofLTC,deteriorationinconditionor

increasedfrailty6. Reviewmedicationstoidentifyriskofpolypharmacy,identifyweightloss,newdiagnosis,increasein

careneeds7. CheckifaDorsetCarePlanrequirescompletingorupdating.Thisshouldincludeaclearescalation

plananddescriptionofpatientsbaseline8. Reviewanyletterfromaspecialistthatprovidesinformationwhichmayaddtothecurrentpicture9. HighlightifaRockwoodscoreneedstobecompleted10. Recordanythingsignificantintheappropriatecolumnonthedatasheets11. Highlightpatientsthathavesignificantchangesthatwouldbenefitfrombeingdiscussedatthe

surgeryMDT.

HowtotranslatedataviathehubmoduleinSystmOne

1. YouwillreceiveanemailfromtheadministrationmemberoftheRPTtellingyouyourEficaseloadisreadytoviewonthehubmodule

2. Logintothehubmodule3. Clickoncaseloads4. LookundertheMDTcaseloadforyoursurgery–hereyouwillfindthelistofpatientswhohave

increasedinfrailtyoverthepastmonth(seepoint2inthesectionabove)5. Workdownthelistandretrievetherecordsforeachpatient6. TheAdminRPTmemberwillhaverecordedinthepatientnotesiftheyare‘moderate’or‘severely’

frail,iftheyhavejumpedacategory,iftheyhaveaDorsetCarePlan(ornot)andiftheyareanin-patient

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DailyAdmissionsRiskprofilingadmissiondataensurespatientsadmittedduetofrailtysyndromesarebeingidentifiedinaproactivetimelyway.ThefollowingcriteriaisbasedonacuteadmissiondatabetweenApriltoMarch2015/16&2016/17andfocusesonthetopreasonsforadmissionthatrelatetofrailty*SeeAppendix2

RiskProfilingCriteria:

Ø Over65andoneofthefollowing:Ø AdmissionforafallorUTIØ 2ormoreadmissionsinthepastyear

RiskprofilinginstructionsforRPTAdministrator–DailyAdmissions

Youwillneedtohaveaccesstodailyadmissionsalertsemail,acutehospitalsystemandtheHubS1tocompletethistask.(IfyoudonothaveaHubs1thenyoucanstillcarryouttaskbutwillneedtocreateaspreadsheettokeepyourdata)

• Opendailyadmissionsalertsemailandenableediting(saveasrequired)• Select‘Data’tabandclickon‘Sort’buttonthenselectSortbyDOBandok• Onlyover65’sneedtobeincludedsoallotherpatientrowscanbedeleted.In2017a65y/owould

havebeenbornin1952• SelectColumnCthenselect‘ConditionalFormatting’,‘HighlightCellRules’,‘DuplicateValues’then

‘OK’• DeleteduplicateNHSnumbersonly–donotdeleteentirerow• Filter‘Admissionspreviousyr’columnanddeselect‘0’&‘1’• RegisterpatientstoS1

o Select‘Other’asReferralsourceo Select‘MDT–Frailty’asPrimaryReferralinReasono Select‘Admissions’asCaseload

• Gobacktodailyalertsheetandun-filter‘Admissionspreviousyr’column• Filter‘InitialComplaint’columnandselect‘FALL’and/or‘UTI’• Repeatabovestepsforthesepatients,theydonotneedtoberegisteredtwiceifalreadyonfor2+

admissions• OpenandlogintoacutehospitalsystemtofindrelevantinformationtoberecordedinInfoGathering

&ReferralScreeningtemplateensuringthatyourecordtheadmissioncriteriaasreasonforreferral.

Thisdatawillbeanalyseddailybytheriskprofilingteam.

Ø Ifthepatientisstillanin-patientthewardiscontactedtoseeif:-thehubcanfacilitatedischarge,toaddinformationalreadyknowaboutthepatientortoidentifyreasonforongoingadmission

Ø Alinkisestablishedwithourserviceandthewardandrequestedthatwearekeptupdatedifanongoingadmissionisrequired

Ø IfthepatientisalreadyathometheRPTclinicianwillreviewdischargeletterandcontactpatient/carertoensurepatientisrecoveringwellandarrangeavisitwithin48hoursifappropriatetorevieworasurgentifrequired

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Hubreferrals/MDTdataHubreferrals/MDTinstructionsforRPTAdministrator-YouwillneedaccesstotheLocalityHubSystmOnemoduleandbeabletoaccessClinicalReporting

PleasenoteifyoudonothaveaccesstoHubS1,youwillnotbeabletocompletethisstageandinsteadwillneedtosendyourEfi&admissionsdatatoGPPracticeandlinkworkers.

TocreateanMDTHubreferralsreport…

• Select‘Reporting’• Select‘ClinicalReporting’• Select‘LocalReports’• Select‘New’• NameyourreportandcreatenewcategorycalledMDT• Openthe‘Registration’folder• Select‘GP’then‘RegisteredGPpracticeattimeofevent’andsearchforthePracticerequired.• Select‘RegistrationStatus’andensurethat‘Deceased’‘Active’andDeducted’areallticked• Openthe‘Clinical’folder• Select‘EventDates’then‘Eventdate’andentertheappropriatetimeperiod• Select‘ReferralsIn’then‘Areferralinexists’andensurethat‘Bothnewandre-referrals’and‘Limittoreferralsto

here’areticked• Select‘Ok’atbottomofscreenandyourreporthasbeencreated

Tofind/runtheMDTHubreferralsreport….

• OpenHubSystmOne• Select‘Reporting’• Select‘ClinicalReporting’• Select‘LocalReports’andclickonthetriangletotheleft-handside• Select‘MDT’• RightclickontheappropriatePracticereportandselect‘Amend’• Scrolldownto‘EventDates’andchangetheeventdateto‘After’thedatethepreviousreportended• Changethenameofthereporttoreflectthetimeperioditnowshows(reportwillonlyincludedaterecorded

before5pmthefollowingday)• Select‘Ok’• Rightclickonyourreportandselect‘Run’• Oncegreentickhasappearednexttoreportitisreadytoview(ifthisistakingawhilethenclickon‘Refresh’)• Rightclickonyourreportandselect‘BreakdownResults’• Dropdown‘ReferralsIn’listandtick‘ReferralID’&‘Reasonforreferral’thendropdown‘Registration’listand

tick‘RegisteredGP(GMS)’• Select‘Refresh’andthen‘Close’• Rightclickonyourreportandselect‘Showpatients’• Select‘SaveallpagestoCSV’whichwillopenaspreadsheet• OpenMDTdatadocument• OpenandrenameanewtabtoreflecttheMDTmonthyouareworkingon.• Copyandpasterelevantinformationfromyour‘Showpatients’spreadsheetintoMDTdatadocument• Ifapatientappearsonlistmorethanonce,condenseinformationintoonerow.• Highlightpatientsidentifiedasneedingfurtherdiscussioninred.(PatientsidentifiedwillbethoseleftinHub

MDTcaseloadorsenttoyoubyCommunityMatrons)• SendMDTdatatoGPPracticeandlinkworkers

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ThepagenumbersandscreenshotsrefertothePrimaryCareSystmOneversionoftheDorsetCarePlan.HoweverthisisavailableforPrimaryCareEMISsystemsandforDorsetHealthCareCommunitySystmOnemodules.Thedescriptionsandexamplesarerelevanttoallversions.

PAGE3:SummariesandFunctionalStatus

Patients/carersperspective

Recordtheviewsofthatpatientand/orcarer–whataretheirprioritiesandhowwouldtheydescribetheirhealth?Theirprioritiesmaybenon-medical.Dotheywantalltreatmentsaimedatprolongingtheirliferegardlessofoutcome,oristheirprioritycomfortandqualityoflife?

e.g.Bobfeelsthatalthoughhedoesgetseverechestinfectionsattimes,hisqualityoflifeisgoodin-betweentheseandheisstillabletodomostofthethingshewantstodo.Ifhebecomesseverelyunwellhewouldwantadmissiontohospitalforanyintensivetreatmentaimedatprolonginghislife.

PAGE1:CoreCarePlan

RecordnamedGP,admissionavoidancecareandreviews,otherprofessionals

involved.

PAGE2:Carers&Relationships

Carers,occupationandnextofkindetails

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TheDorsetCarePlan

TheDorsetCarePlan(DCP)isadetailedtemplatewhichcanallowrecordingofacomprehensivemanagementplanandbackgroundhistoryforanypatient(althoughitisparticularlyrelevanttofrailorcomplexpatients).Itwasdevelopedtoallowastandardisedapproachtoadmissionavoidance/advancemedicalcareplanninganditcanincludeanyorallofthefollowinginformation:thepatient’sprioritiesforcare,asummarybaselineforthatpatient,anadvancecareplan,atreatmentescalationplanandself-managementadvice.Thefieldscloselylinktotheenhancedsummarycarerecord(highlightedonthetemplate)allowingittobesharedeasilywithotherHealthCareprofessionalsusingdifferentITsystems.

ThingstothinkaboutwhenconsideringwhetherapatientissuitableforaDorsetCarePlan:

• DoesthispersonhavecomplexneedswhereaDCPwouldhelpanexternalpersonmanagethoseneeds?

• Doesthispersonneedinstructionstohelpthemmanagelongtermconditionsintheformofasharedcareplan?

• Isthisperson’sconditionlikelytodeteriorateorchangequicklyanditisimportantthatbaselineinformationisknown?

• Isthereaclearnonescalatoryplanthatisessentialtoshare?

WhencompletingaDorsetCarePlan,byclickinginanyofthefields,itispossibletoseewhatdatahasalreadybeenenteredlinkedtothatcode(inthewindowonrightsideofscreen).Thisallowsdifferenthealth-careteammemberstocompletedifferentpartsofthecareplan.Ifthelastentryontherighthandsideiscompleteandaccurate,thereisnoneedtore-enterthisinformationinthecareplan.Ifthelastentryisincompleteorhaschanged–eitherre-enterallnewdataorrightclickontheentryandpressctrl+C.Thenclickinthedataentryboxandpressctrl+V–theentrywillbecopiedacrossandcanthenbeamendedasrequired.RememberthatthemarkedreadcodeslinktotheeSCRandeveryentryisvisible.Onlyre-enterdataifthereisachangeornewinformation.Theprintablecareplangeneratedattheendofthetemplatewillpullinthelastentryintoitregardlessofwhenitwasadded.

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PAGE4:AdmissionAvoidanceCarePlan(Pleasenotepages4&5areonthesamepageontheDHCversion)

Clinicalescalationplan

Thiscantakeavarietyofformsdependingonthepatientandtherisks.Considergivingguidancerelatedtochronichealthproblemsandsuggestedactions.Considerlikelyscenariosfordeterioration(includingbutnotexclusively–stroke,MI,infection,fall,suddenunexpecteddeteriorationinhealth,poororalintake)andthelevelofcareapatientwouldwantinthatsituation.Youcouldusethefollowingcategoriesofcare–Intensive(allacuteinterventionsincludingintensivecareifnecessary),Hospital(admissiontohospitalforanyinterventionsapartfromITU/HDU),Home(careinthehomeonlyincludinganytreatmentsthatarepossibleinthecommunity),Comfort(palliativemanagementratherthanactivetreatment).Considermajorhealthproblemsthatmayneedintervention.

e.g.Bobpreferstobetreatedinhishomewhensafetodoso,butheisacceptingofhospitaladmissionifitisclinicallynecessaryandappropriate.

Heisatriskofchestinfections/infectiveexacerbationsofCOPD.Heisawareofsignsofdeterioration(increasedcough/sputum,increasedshortnessofbreath).ThesesometimesrespondwelltooralAmoxicillinandashortcourseofPrednisolone,howeversometimeshedeterioratesrapidlyandwillneedconsiderationofhospitalisationifhissatsdrop(hisusualsatsare93-95%)orifheshowssignsofsepsis.Heisagreeablefortreatmentwithintravenousantibioticsandconsiderationofnon-invasiveventilationsupportifthisisnecessaryandappropriate.

Hehasoccasionalfalls(relatedtoposturalhypotension&residualweaknessfromapreviousCVA).Ifhefallsandcan’tgetup,hehasaCareline.Suspectedfracture/woundswillneedassessmentandappropriatetreatmentinA&E.

HehashadaCVApreviouslyresultinginmildresidualrightsidedweakness.HewouldwanthospitaladmissionforafurtherCVA,althoughhewouldnotwantartificialfeedingandhasanadvancedirectivetorefusetreatmentrelatingtothisscenario.

Atrialfibrillation–rateiscontrolledwithlowdosebisoprololandheisanticoagulated–atpresentthebenefitsoutweightherisks,butthismayneedreconsideringiffallsincreaseinfrequency/resultinsevereinjury.

Intheeventofasuddenunexpecteddeteriorationinhealth–hospitaladmissionwouldbeacceptedifhecouldnotbesafelyinvestigatedortreatedathome.

Hyponatraemia–previousepisodeofsymptomatichyponatraemiasecondarytoomeprazole.ConsidercheckingU&Esurgentlyifhedevelopssignsofrecurrenthyponatraemia.

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PAGE3:continued

HealthProfessionalssummary

Abriefdescriptionofthepatient–wheredotheylive,howmuchsupportdotheyneedtomeettheircareneeds(ifany),whatarethemainriskstodeteriorationofhealth?

e.g.Boblivesinhisownbungalowwiththesupportofhisdaughterwhohelpswithshopping,cleaningandcollectingmedication.HeisstillmanagingtocompleteallotherADLsindependentlybutthisisgettingharderandhemayneedasmallcarepackageinthenextfewmonths.HehasCOPDandhasbeenadmittedtohospitaltwiceinthelastyearwithexacerbations,despiteprompttreatmentwithhisrescuemedication.Earlytreatmentdoeshoweverpreventsomeadmissions.

FunctionalStatus

Usethisboxtodescribethepatient’sabilitytoself-care–considerany/allofthefollowingareas-mobility,continence,abilitytowashanddress,abilitytoself-feed,skinintegrity

e.g.Bobisindependentlymobilewithoneortwosticks,heisfullycontinent.Heisindependentwithshoweringanddressing,butisstartingtofindthisquitedifficultandisconsideringthathemayneedacarertoassisthim.Heeatsanormaldietandisabletoreheatreadymeals,butnottoprepareamealhimself.

Furtherinformation–tickboxes&clickonpenciltorecordfurtherinformation

Rockwoodfrailtyscore(PleasenotethisisnotontheDHCversion)ClickonthisboxandtheRockwoodscoring(andguidance)willpopup–chooserating1-9andifappropriatemild/moderate/severefrailtyfromdropdownbox.

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(PleasenotethePEACEinformationisnotontheDHCversion)

LinktoPEACEform(thresholdsofcareforpatientsincarehomeswithandwithoutcapacity–alotofthisinformationcouldberecordedintheclinicalescalationplan,butitisalsoincludeshelpfulguidancenotesforcarehomere:Intensive/Hospital/Home/ComfortthresholdsofcareandhowtoachieveHomeandComfortoptions).Thisisausefuldocumentforanursinghomeandgivesstructuretodecisions,howeveritdoesnotuploadorlinktotheenhancedSummaryCareRecord.

PAGE5:AllowaNaturalDeathdecisions&ADRT

Optionstorecorddecisionsrelatingtoresuscitationandadvancedirectivesto

refusetreatment.

PAGE6:Palliativecare

ToensurethatthepalliativecaresectionisaddedtothecompletedCarePlandocument,

tickthis‘anticipatorypalliativecare’boxhighlighted.

OptionstorecordGSFstatus,preferredplaceofdeath,linkstocreatepalliativecaredrugcharts,

specialmessageformsforoutofhours/ambulanceservice,prescribingfor

anticipatorymedication.

PAGE7:Dementia

Youmusttickthe‘dementiacareplanagreed’boxtoincludethisinthe

completeddocument

RecorddetailsaboutDOLS,Powerofattorney&capacityhere

Page|18

PAGE4:continued

Self-managementplan

ThisisguidancefromHealthCareprofessionaltothepatient/carers.Whatsymptoms/signsshouldtheylookoutfor,whatshouldtheydoifaparticularsymptomstarts.Whenshouldtheycallforhelpandwhoshouldtheycall?

e.gBob–ExacerbationofCOPD–ifyoudevelopyourusualsignsofachestinfection(increasedcough/sputum/breathlessness)–thenstartyouremergencyantibioticsandprednisolone.Re-orderfromGPsurgery.IfnotimprovingasusualoryoursymptomsareworsethanusualthenmakeanemergencyappointmentwithGP/requestvisit/outofhourscall111.

Foranyotherurgenthealthproblems-makeanemergencyappointmentwithGP/requestvisit/outofhourscall111

Forroutinehealthproblems–makearoutineappointmentwithyourGP

Ifyouhaveaseveresymptomandfeelyourlifemaybeatriskfromit,thencall999orpressyourCarelinebuzzer

Ifyoufallandcan’tgetup,thencall999orpressyourCarelinebuzzer.

Whatistheirpreferredplaceofcare?(dropdownbox)

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ComprehensiveGeriatricAssessmentThegoldstandardforthemanagementforfrailtyinolderpeopleistheprocessofcareknownasComprehensiveGeriatricAssessment(CGA).Itinvolvesaholistic,multidimensional,interdisciplinaryassessmentofanindividualbyanumberofspecialistsofmanydisciplinesinolderpeople’shealthandhasbeendemonstratedtobeassociatedwithimprovedoutcomesinavarietyofsettings(BGSJune2014)

Notallpatientsrequireassessmentsfromeverymemberofthemultidisciplinaryteamandonwardreferralsmayberequiredfollowingtheprocess.TheassessmentiscommonlybuiltupoveraperiodoftimewithinputfromdifferentmembersofthemultidisciplinaryteamandthisiswhyasharedtemplateacrossthevariousHealthCareservicesisidealtoachievethisandtoreduceduplication.

TheoutcomeoftheCGAprocessistheformulationofapatient-centredlistofneedsandissuestotackle(anactionplan)andanindividualisedcareandsupportplan(e.gtheDorsetCarePlan)andarecommendationforfrequencyofreview.

ComponentsofaCGA

� PhysicalSymptoms� MentalHealthsymptoms� Leveloffunctionindailyactivityforpersonalcareandlifefunctions� Socialsupportnetworkscurrentlyavailable(formalandinformal)� Livingenvironment� Levelofparticipationandindividualconcerns/anxieties–whatisimportanttothem� Compensatory mechanisms and resourcefulness the individual uses to respond to

havingfrailty.

OutcomesofaCGA

� Formulation of a patient-centred list of needs and issues to tackle includingmedicationreview(anactionplan)

� Individualisedcareandsupportplan(e.gtheDorsetCarePlan)� Recommendationforfrequencyofreview.

FitforFrailty(BGS2014)recognisesthatresourceswouldnotallowallpatientswithfrailtytohaveafullCGAassessment,butsuggeststhatallpatientswithfrailtyshouldatleasthaveaholisticmedicalreviewbytheirGPbasedontheprinciplesofCGAwiththesameoutcomesasafullCGA(actionplanandDorsetCarePlaninthismodel).

Page|20

PleasenoteontheDHCversiontherewillbeanadditionalboxtoticktostateconsenthasbeen

gainedforthepatient’srecordstobesharedontheenhancedsummarycarerecord.Therewill

alsobeanautomatedtasksenttotheGPwhentheDCPhasbeenamendedorcompletedinthe

communitysettingastheGPistheonlyprofessionalwhocanchangeapatientsconsentsettings

Throughoutthecareplantemplatethereareoptionstoopenupadditionalformsforcompletionwhenrelevantandextraguidance

e.gSAILform,STOPPSTARTtool

*PleaseseeAppendix3forfurtherexamplesonhowtocompletetheDorsetCarePlan

PAGE8:Problems,medication

Anopportunitytoreviewmedicationandproblemlist–medicationscanbealteredfromthisscreenandproblemlistcanbeeditedifsomeproblemsneedtobemovede.gmajoractivetomajorinactive

Recorddetailsaboutabilitytomanagemedication

PAGE9:ConsenttoShare

Codingpageforconsenttoshareandconsent(ordissent)forcoreandenhancedsummarycarerecord

PAGE10:PrintCarePlan&FinalSteps

FinalpagetoallowcreationofapersonalisedDorsetCarePlandocument(bytickingthebox)

Page|23

MildFrailty/E-Learning

AlthoughtheBritishGeriatricSocietyadvisesagainstpopulationscreeningforfrailtyduetolackofevidenceofpositiveoutcomes,weneedtobemindfuloftheearlywarningsignsofdevelopingfrailtyandbeabletoachievethegoalof'assessingindividualsforfrailtyateveryHealthCareencounter.'DorsetHealthCarehasafrailtymodulethatisrecommendedtobecompletedbyallstaffandcanbeaccessedbytheE-hub.Itprovidesabasiclevelofinformationtoincreasetheknowledgeofallstaffmemberswhocomeintocontactwithpatientswhoarepotentiallyincreasinginfrailty.

ThismodulehasnowalsobeenmadeavailableontheCCGintranet,GPpracticesareencouragedtopromotethecompletionofthismodulebyallreception/adminandclinicalstaff.Thiscanbeaccessedbyhttps://intranet.dorsetccg.nhs.uk/localities/frailty-elearning.htm.

Wehaveprovidedaseriesofleafletsonlivingwithfrailty,assessingforfrailty(usingavalidatedtoolcalledPRISMA7)advancecareplanningandearlyself-help.Thesepatientscanbewellsupportedbythirdsectorearlyhelpandofcourseexerciseandbalanceclassesaretheonlyinterventionthathasshownadefiniteabilitytopartiallyreverseorslowtheprogressionoffrailty.Wehopethatthesetoolswillgiveyousomeadditionalresourcestohelpdeveloppracticeandlocalityspecificsupportandidentificationofthemildlyfrail.*PleaseseeAppendix4

Page|22

OutcomeMeasures

Aim

Theaimofthisworkistoreduceunplannedadmissionsforpatientsover65identifiedasbeingmoderateorseverelyfrail

ProcessMeasures–Thesemeasuresdefinetheprocessimplementedtoachievetheintendedoutcome

• Patientsidentifiedasmild/moderateandseverelyfrail• Rockwoodscore• CGA• DorsetCarePlan

Outcomemeasure–TheseoutcomemeasurescanbecollectedbyrunningreportsontheGPsystemorfromdailyacuteadmissiondatefromsecondarycare

• Numberofunplannedadmissions• Lengthofstay• Preferredplaceofcareachieved• GP/OOHContacts• Toallowforquantitativedatafriendandfamilyauditscanalsobeincluded

Page|25

Appendix1–eFIformulaeIfthereiseveraproblemwithanyofyourformulapleasecheckthissheetsoyoucancorrectanyerrorsthatmayhaveoccurred.

PleasenotethathighlightedcellnumbermaynotalwaysbeA2–itwillbewhichevercellcontainsthefirstNHSnumberinyourlist

Ifyouneedtoamendformulamakesureyoudragtheformuladownsoitamendsallcellsnecessary

PrevMDTscore=IFERROR(VLOOKUP(A2,'PreviousmonthEFIlist'!A:E,5,FALSE),"Notonlist")

Diff=IFERROR(SUM(E2-F2),"-")

Page|24

CaseStudy

NHSEngland.“Nowwehavehelp”https://www.youtube.com/watch?v=Y9hYaD201rI

Acknowledgements

Authors

DrLauraGodfrey–WeymouthElderlyCareService

EmmaWinterburn–CommunityMatron/ProjectLead

KatieScourfield–Health&SocialCareCo-ordinator

WewouldliketoextendourthankstoDorsetHealthCareUniversityFoundationTrust,DorsetClinicalCommissioningGroup,TwoHarboursHealthCare,theWeymouth&PortlandFrailtyProjectTeamandHealthEducationWessexfortheirsupportandcontribution.

References

BritishGeriatricsSociety.Fitforfrailty-consensusbestpracticeguidanceforthecareofolderpeoplelivingincommunityandoutpatientsettings.www.bgs.org.uk/press-3/resources/campaigns/fit-for-frailty/fff-guidance-downloadOxfordacademic.Developmentandvalidationofanelectronicfrailtyindexusingroutineprimarycareelectronichealthrecorddata.https://academic.oup.com/ageing/article/45/3/353/1739750/Development-andvalidation-of-an-electronicNHSEmployers.Technicalrequirementsfor2017/18GMScontractchanges.www.nhsemployers.org/gms201718NHSEngland.FiveYearForwardView.www.england.nhs.uk/five-year-forward-view

To download Frailty Tool Kit please visit: www.dorsetccg.nhs.uk/frailty

Page|26

Appendix2–Paretochart

0

50

100

150

200

250

300

350

400

450

500

RespiratorySystem

CardiacSurgeryandPrimaryCardiac

Conditions

MusculoskeletalSystem

UrinaryTractandMale

ReproductiveSystem

DigestiveSystem NervousSystem Immunology,Infectious

DiseasesandothercontactswithHealth

MouthHeadNeckandEars

Skin,BreastandBurns

EndocrineandMetabolicSystem

HepatobiliaryandPancreaticSystem

Haematology,Chemotherapy,Radiotherapyand

SpecialistPalliative

MultipleTrauma,Emergency

MedicineandRehabilitation

VascularSystem EyesandPeriorbita

RadiologyandNuclearMedicine

Acuteadmissiondata2016/2017ApriltoMarchOver75s

Page|28

Appendix4–FrailtyLeaflets

1 Are you more than 85 years?

Yes No

2 Male?

Yes No

4 Do you need someone to help you on a regular basis?

Yes No

3 In general do you have any health problems that require you to limit your activities?

Yes No

5 In general do you have any health problems that require you to stay at home?

Yes No

6In case of need, can you count on someone close to you?

Yes No

7Do you regularly use a stick, walker or wheelchair to get about?

Yes No

IDENTIFYINGFRAILTY

We would like to extend our thanks to Health Education Wessex for funding the project and providing support throughout and to Dorset Healthcare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.

Acknowledgments

To download this leaflet please visit:www.dorsetccg.nhs.uk/frailty

AcknowledgmentsWe would like to extend our thanks toHealth Education Wessex for funding the project and providing support throughout and to Dorset HealthCare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.

We want to ensure all our patients receive the best possible health care. Part of this includes looking for problems early before they develop into something more serious. As we get older, we become at risk of developing a health condition called ‘frailty.’ This is not just a description, but a condition where you start to lose your bodies inbuilt reserves. This can show itself in different ways and is not always easy to recognise. This can often be mistakenly put down to an inevitable part of getting older, whereas there are sometimes things we can suggest to slow this process down or improve the symptoms.

There is a brief questionnaire that can help us tell if you are developing this health condition. Please can you complete it and hand it back to reception. If you score 3 or more on this questionnaire, we can arrange for one of the healthcare team to review you (either in the surgery or in your own home if you struggle to get to the surgery). This will allow us to work out if there are things that we can suggest which will help to slow down this process and help you remain healthy for longer.

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Appendix3–DCPadditionalexamplesPatients/carersperspective

e.g.Jillhasadvanceddementiaandsheneverwantedtobecomeasunwellasshenowisandwouldhavebeenveryupsettohavebeenunabletomanageherownhygieneneeds.Shestronglydislikeshospitalsandtakingmedication.Thepriorityismaintaininghercomfortanddignityinthefamiliarsurroundingsofhercarehomeandensuringthathospitaladmissionisavoided.

HealthProfessionalssummary

e.g.JillhasadvanceddementiaandmovedintoanursinghomeinJanuary2017whenitbecametoodifficulttomeethercareneedsathome.Sheneedsallnursingcare.Shecanbecomeagitatedandaggressivewithinter-currentinfectionandsheexperiencesrecurrentUTI.Ifsheneedsanymedicationthenitshouldbeliquidordispersibleformulationduetoswallowingdifficulties.

FunctionalStatus

e.g.Jillhasnoactivemobilityandneedshoistingfortransfers.Sheisdoublyincontinentandneeds2carerstomanagepersonalcare,washinganddressing.Sheneedstobefedandneedsstage1thickenedfluidsandapureeddiet.Sheisatriskofpressuresoresandneedsregularchangesofpositiontoavoidthis.

Clinicalescalationplan

e.g.Jillhasadvanceddementiaandingeneralhercareneedsarebestmetinafamiliarsettingwithfamiliarcarers.AbestinterestsdecisionindiscussionwithhernextofkinhasagreedthatwheneverpossiblehercareshouldbemanagedinthenursinghomewithsupportfromherGPsurgeryoroutofhoursservice.Theonlyexceptionwouldbetraumaorifsymptomaticcontrolcouldnotbeachievedinthecommunity.

SheisatriskofUTIandchestinfections.Theseusuallyrespondtooralantibiotics(liquidformulation).Anyinfectionsshouldbetreatedinthenursinghomesettingonlywithoralantibioticswhensheisabletoswallow.Ifshebecomesunabletoswallowthenmanagementshouldbepalliative.

Dementia–shehasadvanceddementiaandcandisplaysomebehavioursthatchallengerelatingtoaggressivebehaviourwithinterventions.Thesecanbemanagedwithbehaviouralstrategiesgenerally.Ifthereisachangetobehaviourthenconsiderreversiblecausese.g.pain,infection,constipation.Managedeteriorationrelatedtodementiainthenursinghomewiththeprioritybeingsymptomcontrol.NocurrentCMHTinvolvement.

Fallsriskislowduetoherimmobility.IfthereistraumathenassessinA&Eonlyforsuspectedfractureorunmanageablewoundsandreturntonursinghomeassoonaspossible.

Heartfailure–symptomscurrentlycontrolledwithdiuretics,thesemayneedadjustmentifshedevelopsworseningperipheraloedemaorshortnessofbreath.

Intheeventofanysuddendeteriorationinhealthe.g.CVA–manageinthenursinghomesymptomaticallywithsupportofGPsurgery/outofhoursservice.

Self-managementplan

e.g.Jill-Theaimisformanagementinthenursinghome,soforanyunexpecteddeteriorationinhealththencontactGPsurgery/outofhoursservicetoadvise/review.

Foranynon-urgentproblemthenawaitroutineweeklyGPsurgeryvisit

999onlyfortraumaoraseveredistressingsymptomthatcannotawaitGPadvice/assessment.

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Appendix5–FrailtyPoster


AcknowledgmentsWe would like to extend our thanks to Health Education Wessex for funding the project and providing support throughout and to Dorset HealthCare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.

For certain of our frailer patients or patients at

high risk of hospital admission, we can complete a

Dorset Care Plan. This not only gives you a chance

to tell your GP what your wishes are, but allows a

record of these wishes and plans to be available to

the out of hours services and paramedics too.

These are in addition to the documents listed

below, but could contain information from any or

all of them. If you feel that you should have a care

plan and do not yet have one, then don’t hesitate

to let your GP know.

For an overview of advance care planning and all it

entails please visit

DorsetCare Plan

http://www.nhs.uk/planners/end-of-life-care/

documents/planning-for-your-future-care.pdf

AdvanceCare PlanThis is a booklet that you can fill in to let other

people know what your wishes are in certain

situations e.g. if you got very poorly, whether you

would want to go into hospital or be cared for

at home.

We have copies of these available in the surgery, or

you can download a copy at:

http://www.dorsetccg.nhs.uk/Downloads/

aboutus/CCP/Cancer%20and%20end%20of%20

life/201309_Dorset_Advance_Care_Planning_

Guide.pdf

What wouldhappen if...Have you ever thought about what would happen if you or

a relative became seriously ill or disabled?

Regrettably we often fail to address these issues until it is

too late to do anything about them.

For example, if you (or a relative) lost the ability to make

decisions about your finances or health – do you know

what would happen?

Another situation is resuscitation – lots of people have

quite clear views that, when the time comes, they want to

be allowed ‘to go naturally’ – however if this not clearly

documented then resuscitation will always be attempted.

These are difficult subjects to think and talk about for

many people, and that is both completely understandably

and acceptable.

If however you do want to think about this, then we’ve

listed some areas to consider, and some helpful links too.

LastingPower of AttorneyThis is a legal document that lets you nominate

one (or more) people to make financial or health

decisions for you, if you loose the ability to

do so. This is particularly relevant for people

who develop dementia, but can apply in other

situations too.

This has to be completed whilst you still have the

‘capacity’ to do so. So it’s never too early to think

about it. And remember, no matter how early you

make this, the people you nominate can only make

decisions for you if you no longer can.

https://www.gov.uk/power-of-attorney/

overview

If you have a clear view that you would not want

resuscitation to be attempted, then you can discuss this

with your GP, who can complete the relevant form.

Please remember that making a decision to allow a natural

death does NOT mean that your regular medical treatment

will stop. Your healthcare team will continue to ensure

that you get the highest level of care regardless of

this decision.

‘Allow aNatural Death’

Advance decisionto refuse treatmentIt is possible to make an advance decision to refuse a

specific treatment, in specific circumstances e.g. if you had

a stroke and were unable to eat/drink – you could refuse to

have a feeding tube fitted.

http://www.ageuk.org.uk/money-matters/

legal-issues/living-wills/advance-decision/

Appendix 4 - Frailty Leaflets

Page I 29

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My Life My Care‘visit Age UK for help, information and advice’.

They are able to provide advice, enable independence e.g. exercise classes, and combat loneliness e.g. befriending services

0800 678 1174 www.ageuk.org.uk

Citizens Advice Bureau‘Information, advice and support to help you find a way forward whatever the problem’ Includes benefits, income maximization, debt, housing, employment. Health & care, family & relationships, legal, immigration, consumer, education, tax.

0344 2541219 (any queries)

0845 4900042 (Macmillan support – living with cancer)

01929 775500 (energy advice)

www.citizensadvice.org.uk


Acknowledgments

We would like to extend our thanks to Health Education Wessex for funding the project and providing support throughout and to Dorset HealthCare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.

Appendix 4 - Frailty Leaflets

Page I 30

There are many different options available to help maintain your independence and allow you to live in your own home for as long as possible. However it is sometimes difficult to know what options are available, whether there is a cost, if help with costs is available and where to go for advice.

This leaflet includes a list of local and national options available to help you to work out what you need. Some of this information you can find yourself online, some services can be contacted by telephone or email to access advice that way or to arrange face to face meetings. All of these services are free to contact and access, although some of the services they may be able to guide you to may have a cost.

Dorset Popp Wayfinders‘Wayfinders are individuals who live and work locally who are able to meet you and provide information and signposting to support and services for adults in their local community’

‘They work primarily with any adults who have an identified need or a concern that is reducing their ability to maintain their independence or quality of life whilst living in their own homes for as long as they wish to’

01305 548111 www.helpandcare.org.uk

My Life My Care‘if you find it difficult to live safely and independently in your own home, you can find help here. Our solutions offer information and advice to help you make informed choices about living the life you want’

01305 221016 www.mylifemycare.com

My Health My Way‘access free support with your health...helping you cope and feel more confident living with a health condition’

0303 303 1053 [email protected] www.myhealthdorset.org.uk

SAIL - Safe And Independent Living‘SAIL offers Dorset residents a wide range of free support, services or information to help keep people safe and independent in their own homes’

Health professional to complete 0800 0382323 ‘Safe and Well’ advice line

Complete online www.mylifemycare.com/Safe-and-independent-living

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We would like to extend our thanks to Health Education Wessex for funding the project and providing support throughout and to Dorset HealthCare University Foundation Trust, Dorset Clinical Commissioning Group & Two Harbours Healthcare for working together and allowing this to be a truly integrated project. Particular thanks are given to all members of the Weymouth & Portland frailty project team for their hard work and contribution.

Use of Dorset Care Plan has remained consistent but there has been a marked improvement in the detail recorded and the template is now also available to community health services.

Use of both the Rockwood score and the frailty readcodes has continued to rise throughout the project. Note that significant increase in use of frailty readcodes between April and August will have in part been due to the GP contract requirements of July 2017.

No results recorded on the use of CGA as this is still in development.

RESULTS

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WO

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SCO

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British Geriatrics Society. Fit for frailty - consensus best practice guidance for the care of older people living in community and outpatient settings. www.bgs.org.uk/press-3/resources/campaigns/fit-for-frailty/fff-guidance-download

Oxford academic. Development and validation of an electronic frailty index using routine primary care electronic health record data. https://academic.oup.com/ageing/article/45/3/353/1739750/Development-andvalidation-of-an-electronic

NHS Employers. Technical requirements for 2017/18 GMS contract changes. www.nhsemployers.org/gms201718

NHS England. Five year forward view. www.england.nhs.uk/five-year-forward-view

ACKNOWLEDGMENTS

REFERENCES

The Dorset Care Plan was developed in Weymouth & Portland in primary care to encompass the patient’s priorities for care, admission avoidance including treatment escalation and advanced care planning.

The DCP links with the enhanced summary care record providing OOH/Paramedics with this valuable information. As part of the frailty project Dorset Health Care have developed an equivalent version enabling Community and Primary care to input into a shared document ensuring the patients records are up to date and accurate and completed by the most appropriate clinician at the time.

The Dorset Care Plan (DCP)

In October 2016 Weymouth & Portland received funding from Health Education Wessex to focus on developing services for frailty.

The aim was to support the goals of Integrated Primary and Community Services ensuring a joined-up approach, reducing duplication and enhancing patient care.

OBJECTIVES

INTRODUCTION ABOUT FRAILTY

For people living with frailty the state for an individual is not static; it can be made better and worse.

Frailty is a spectrum condition that spans from mild to severe.

In Dorset about 17,000 people would fall within this definition. Of Dorset’s estimated population of 765,700 some 173,000 are aged 65 and over. Of these around 6,200 are 85 or over; a figure which is said to rise to 9,300 in the next 25 years.

The pilot for this project focused on Weymouth and Portland and developed an integrated model with excellent GP and Community services engagement. A toolkit

was designed to enable the model to be rolled out to other localities

TOOL KIT INCLUDES

Whilst the rollout of the Dorset Frailty Toolkit provides the bulk of the projects education, other developments have been made. Dorset Healthcare had a pre-existing frailty e-learning module that has now, through the work of the frailty project, been made available to the Dorset CCG providing a basic level of information to increase the knowledge of all staff members who come into contact with patients who are potentially increasing in frailty. A series of leaflets on living with frailty, assessing for frailty & advance care planning and early self-help were also developed during the project.

Education

MULTI-DISCIPLINARY MEETINGS IN GP PRACTICES

LOCAL CONTEXT

Population of Dorset Are 85+ and are frail

Frailty is not an inevitable part of ageing; it is seen as a long term condition in the same way as diabetes or Alzheimer’s disease

Fit the definition of frail

For patients identified as frail - to develop a frailty framework, underpinned by a standardized assessment approach

To agree a standardized approach to the identification and stratification of frailty across health and social care services within Weymouth and Portland Locality

To develop a training and education package to enablel the above to be consistently delivered, reviewed and monitored across Dorset.

DEVELOPING FRAILTY SERVICES IN DORSET

Recommended structure for MDTs

Terms of Reference

MDT discussion tool example

Instruction on how to risk profile using the Efi, Admissions and hub data

Detailed instructions on completing a Dorset Care Plan

Introduction to CGA

Recommended outcome measures

Information on the E-Learning frailty Module

Patient leaflets – Planning future care, self & early help resources and Prisma 7 questionnaire/mild frailty

The Toolkit provides a step by step guidance on how to get the best value out of a GP MDT.

Risk profiling of frail patients using the Electronic Frailty Index and admission data is analysed prior to MDTs to ensure the patients who are in most need are discussed. The MDT discussion tool is used in the meeting to help guide the discussion and formulate a clear action plan.

PATIENTS IDENTIFIED AS MILD/ MODERATE AND SEVERELY FRAIL

COMPLETED ROCKWOOD SCORE

COMPLETED CGA

COMPLETED DORSET CARE PLAN

To monitor the engagement and uptake of the model the following process measures have been implemented:-

THE ROLL OUTThe model and toolkit has been adopted by Dorset health Care and the Dorset Clinical Commissioning Group. It is being rolled out as the gold standard of frailty work to be implemented in all localities over the next year

What next?

We plan to create a shared Comprehensive Geriatric Assessment (CGA) template between primary and community services to reflect and enable the following:-

The gold standard for the management for frailty in older people is the process of care known as Comprehensive Geriatric Assessment (CGA)

Holistic, multidimensional, interdisciplinery assesment of a individual by a number of specialists of many disciplines in older peoples health

The CGA has been demonstrated to be associated with improved outcomes in a variety of settings (BGS June 2014)

Number of unplanned admissions

Length of stay

Preferred place of care

GP / OOH contact

The following Outcome Measures will be used to measure the impact of this project:-

8 / 7 days prior to meeting.... the risk profiling team•Run eFI and Hub referrals report •Provide clinical translation of data•Produce manageable list of patients who would benefit from MDT discussion or more detailed review & assessment

1 week prior to meeting.... Link Workers Review data sent by risk profiling team & highlight any patients they wish to discuss

MDT CoordinatorForward data to GPs / relevant Practice staffCollate list of patients identified for discussion by other MDT members

MDT Meeting•Use MDT discussion tool template to guide and record discussion

•Make use of the broadest range of professionals as appropriate

•Discuss identified patients•Each patient discussed must have a clear outcome with a named person responisible for the action

•MDT Coordinator to follow up actions 2 weeks after meeting

Send identified

patients to named GPs for any prep

work

Send data to Surgery MDT Coordinator

& link workers

A1 version.indd 1 31/10/2017 12:23:05

Use of Dorset Care Plan has remained consistent but there has been a marked improvement in the detail recorded and the template is now also available to community health services.

Use of both the Rockwood score and the frailty readcodes has continued to rise throughout the project. Note that significant increase in use of frailty readcodes between April and August will have in part been due to the GP contract requirements of July 2017.

No results recorded on the use of CGA as this is still in development.

RESULTS

DEC

EMB

ERA

PRIL

AU

GU

ST

123715031811

RO

CK

WO

OD

SCO

RE

DEC

EMB

ERA

PRIL

AU

GU

ST

7149321854

FRA

ILTYR

EAD

CO

DES


British Geriatrics Society. Fit for frailty - consensus best practice guidance for the care of older people living in community and outpatient settings. www.bgs.org.uk/press-3/resources/campaigns/fit-for-frailty/fff-guidance-download

Oxford academic. Development and validation of an electronic frailty index using routine primary care electronic health record data. https://academic.oup.com/ageing/article/45/3/353/1739750/Development-andvalidation-of-an-electronic

NHS Employers. Technical requirements for 2017/18 GMS contract changes. www.nhsemployers.org/gms201718

NHS England. Five year forward view. www.england.nhs.uk/five-year-forward-view

ACKNOWLEDGMENTS

REFERENCES

The Dorset Care Plan was developed in Weymouth & Portland in primary care to encompass the patient’s priorities for care, admission avoidance including treatment escalation and advanced care planning.

The DCP links with the enhanced summary care record providing OOH/Paramedics with this valuable information. As part of the frailty project Dorset Health Care have developed an equivalent version enabling Community and Primary care to input into a shared document ensuring the patients records are up to date and accurate and completed by the most appropriate clinician at the time.

The Dorset Care Plan (DCP)

In October 2016 Weymouth & Portland received funding from Health Education Wessex to focus on developing services for frailty.

The aim was to support the goals of Integrated Primary and Community Services ensuring a joined-up approach, reducing duplication and enhancing patient care.

OBJECTIVES

INTRODUCTION ABOUT FRAILTY

For people living with frailty the state for an individual is not static; it can be made better and worse.

Frailty is a spectrum condition that spans from mild to severe.

In Dorset about 17,000 people would fall within this definition. Of Dorset’s estimated population of 765,700 some 173,000 are aged 65 and over. Of these around 6,200 are 85 or over; a figure which is said to rise to 9,300 in the next 25 years.

The pilot for this project focused on Weymouth and Portland and developed an integrated model with excellent GP and Community services engagement. A toolkit

was designed to enable the model to be rolled out to other localities

TOOL KIT INCLUDES

Whilst the rollout of the Dorset Frailty Toolkit provides the bulk of the projects education, other developments have been made. Dorset Healthcare had a pre-existing frailty e-learning module that has now, through the work of the frailty project, been made available to the Dorset CCG providing a basic level of information to increase the knowledge of all staff members who come into contact with patients who are potentially increasing in frailty. A series of leaflets on living with frailty, assessing for frailty & advance care planning and early self-help were also developed during the project.

Education

MULTI-DISCIPLINARY MEETINGS IN GP PRACTICES

LOCAL CONTEXT

Population of Dorset Are 85+ and are frail

Frailty is not an inevitable part of ageing; it is seen as a long term condition in the same way as diabetes or Alzheimer’s disease

Fit the definition of frail

For patients identified as frail - to develop a frailty framework, underpinned by a standardized assessment approach

To agree a standardized approach to the identification and stratification of frailty across health and social care services within Weymouth and Portland Locality

To develop a training and education package to enablel the above to be consistently delivered, reviewed and monitored across Dorset.

DEVELOPING FRAILTY SERVICES IN DORSET

Recommended structure for MDTs

Terms of Reference

MDT discussion tool example

Instruction on how to risk profile using the Efi, Admissions and hub data

Detailed instructions on completing a Dorset Care Plan

Introduction to CGA

Recommended outcome measures

Information on the E-Learning frailty Module

Patient leaflets – Planning future care, self & early help resources and Prisma 7 questionnaire/mild frailty

The Toolkit provides a step by step guidance on how to get the best value out of a GP MDT.

Risk profiling of frail patients using the Electronic Frailty Index and admission data is analysed prior to MDTs to ensure the patients who are in most need are discussed. The MDT discussion tool is used in the meeting to help guide the discussion and formulate a clear action plan.

PATIENTS IDENTIFIED AS MILD/ MODERATE AND SEVERELY FRAIL

COMPLETED ROCKWOOD SCORE

COMPLETED CGA

COMPLETED DORSET CARE PLAN

To monitor the engagement and uptake of the model the following process measures have been implemented:-

THE ROLL OUTThe model and toolkit has been adopted by Dorset health Care and the Dorset Clinical Commissioning Group. It is being rolled out as the gold standard of frailty work to be implemented in all localities over the next year

What next?

We plan to create a shared Comprehensive Geriatric Assessment (CGA) template between primary and community services to reflect and enable the following:-

The gold standard for the management for frailty in older people is the process of care known as Comprehensive Geriatric Assessment (CGA)

Holistic, multidimensional, interdisciplinery assesment of a individual by a number of specialists of many disciplines in older peoples health

The CGA has been demonstrated to be associated with improved outcomes in a variety of settings (BGS June 2014)

Number of unplanned admissions

Length of stay

Preferred place of care

GP / OOH contact

The following Outcome Measures will be used to measure the impact of this project:-

8 / 7 days prior to meeting.... the risk profiling team•Run eFI and Hub referrals report •Provide clinical translation of data•Produce manageable list of patients who would benefit from MDT discussion or more detailed review & assessment

1 week prior to meeting.... Link Workers Review data sent by risk profiling team & highlight any patients they wish to discuss

MDT CoordinatorForward data to GPs / relevant Practice staffCollate list of patients identified for discussion by other MDT members

MDT Meeting•Use MDT discussion tool template to guide and record discussion

•Make use of the broadest range of professionals as appropriate

•Discuss identified patients•Each patient discussed must have a clear outcome with a named person responisible for the action

•MDT Coordinator to follow up actions 2 weeks after meeting

Send identified

patients to named GPs for any prep

work

Send data to Surgery MDT Coordinator

& link workers

A1 version.indd 1 31/10/2017 12:23:05

Page I 31

dorset frailty toolkit - nihr clahrc wessex · 2017-12-08 · first dorset frailty toolkit a model...

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