Frail & Older People

What is an outcome and why are they important?3

Journey of the Event

Introduction & Context1

David Cryer

Jim Dodsworth

Terms of Art2

Identifying Our Outcomes4

Prioritising Our Outcomes5

Value Agenda Overview6

Exploring the Value Agenda

& Next Steps 7

Frail & Older People

Outcomes for each Borough

Barnet

Haringey

Camden

Islington

Enfield

Anne Schlattl

Ben Ellis

Celia Smith

David Cryer

Fran Gertler

Fredrik Johansson

Helen Dunford

Inti Khan

Mousumi Basu-Doyle

Nadia Raja

Naser Turabi

Pramod Prabhakaran

Sam Jones

Stuart Mackay-Thomas

Suzanne Joels

Tracy Brown

Adam Webber

Graham MacDougall

Jennie Bostock

Naheed Rana

Nasrin Hafezparast

Paul Allen

Rachna Chowla

Sian Therese

Ann Mount

Irina Goodluck

Jean Aldous

Juliana Bersani

Karen Spooner

Martins Charters

Muyi Adekoya

Tim Bowler

Andy Murphy

Clare Henderson

Clarissa Murdoch

Dan Windross

David Davis

Liz Brutus

Martin Kuper

Michelle Wheeler

Sue Newton

Tina Jegede

Sheena Nixon

Susanna Dale

Catherine Herman

Delia Thomas

Greg Battle

Helen Joyce

Helen Pelendrides

Helen Taylor

Jonathan Carmichael

Liz Evans

Maurice Cohen

Nicole Klynman

Rachel Lissauer

Rosaire Gray

Sherry Tang

Shirley Ip

Frail & Older People

Older People with Frailty

Cohort definition

Included Excluded

All people aged

75+ years

and

pre-frail and frail

A. Patients under end of life care

B. Patients with organ system failure (eg end

stage renal failure, end stage heart failure)

C. Patients who require specialist care teams

(e.g. immediate care following acute event

(e.g. MI), surgery related care, psychiatric

care, all cancer care)

D. Patients who are not frail

Local context: current provider landscape

Providers whose services for 75 years+ are in scope for the patient cohort in 2015/16

Estimated frail and pre-frail population number 6,955

Primary care

Core contract

Primary Care

Haringey x 4 localities

Acute Providers

North Middlesex

Royal Free (BCF)

Whittington Health

Community Care

Whittington Health

Social Care

Domiciliary Care

Adult Social Care, LBH

Other

Housing

Third Sector

Care HomesUCLH

Barnet Enfield and Haringey

MHT

IPU design proposal

Assessment

& case

management

UNDERPINNED BY:

Infrastructure issues such as co-location, shared records,

workforce development, 7 day working etc

Primary and Community

Management and

risk stratification including

low level prevention

Single Point of Access

To The Hub

GPs Patient/family/carersSocial Services Acute Trusts

Diagnostics and treatment

Specialist functions to

help assess, care plan,

case manage and deliver

Short or medium-term acute

& community interventions,

including self-management

intermediate care,

enablement &

Rapid response functions

Care co-ordinator

& The Patient

Outcomes Shortlist: Older people with frailty