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Transforming Services for Older People
Developing a Frailty Pathway Bournemouth & East Dorset
Population of Older People in Dorset
• Higher than average population for over 85 in Dorset • 36% of the Dorset workforce is aged over 50 compared with
28% in England • Over 65's population projected to grow by 50% over the next
25 years • 28 % population over age 65-69 (comparison of 18% in other
counties) • Increasing pressure on adult services in local authorities • Services for older people accounts for 55% of the adult social
care budget
• 48% of people over 85 die within one year of hospital admission Imminence of death among hospital inpatients: Prevalent cohort study David Clark, Matthew Armstrong, Ananda Allan, Fiona Graham, Andrew Carnon and Christopher Isles, published online 17 March 2014 Palliat Med
• 10 days in hospital (acute or community) leads to the equivalent of 10 years ageing in the muscles of people over 80
Gill et al (2004). studied the association between bed rest and functional decline over 18 months. They found a relationship between the amount of time spent in bed rest and the magnitude of functional decline in instrumental activities of daily living, mobility, physical activity, and social activity.
Kortebein P, Symons TB, Ferrando A, et al. Functional impact of 10 days of bed rest in healthy older adults. J Gerontol A Biol Sci Med Sci. 2008;63:1076–1081.
If you had 1000 days left to live how many would you
chose to spend in hospital?
Challenges at Royal Bournemouth Hospital
• Older people presenting to hospital with increasing levels of frailty
• 6 Medical Wards for Older People (168 beds)
• 50% of beds occupied by older people medically stable for discharge
• Delayed transfers of care running at 5.5%
• Acute Trust supports patients living in Bournemouth, East Dorset & Hampshire:
• 2 Clinical Commissioning Groups
• 3 Local Authorities
How we started our journey…
• Understanding the situation and our potential outcomes?
• Understanding our fears and our hopes • What we were willing to sacrifice and what we
were not willing to sacrifice • What is the best course of actions that would
meet all of this
Beds aren’t capacity ‘Beds are where patients wait for the next thing to happen’
How many red days?
An example of a patient journey… need for change
8
Mrs Andrew’s Story
https://www.youtube.com/watch?v=Fj_9HG_TWEM
Older Persons Medicine: Our Vision
Safe compassionate care for older people living with frailty: “Care needs to be just as important as treatment. Older people should be properly valued and listened to, and treated with compassion, dignity and respect at all times. They need to be cared for by skilled staff who are engaged, understand the particular needs of older people and have time to care” Government response to the Francis Report (November, 2013).
10 principles of delivering a frailty pathway
• Ensure early identification of people with frailty
• Initiate CGA within 1 hour
• Initiate a rapid response system
• Adopt a silver phone system
• Adopt clinical professional standards to reduce unnecessary variation
10 principles of delivering a frailty pathway
• Strengthen links inside and outside of the hospital
• Introduce appropriate education and training
• Adopt a measurement mind set
• Clinical change champions, collaborative leadership approach
• Support from an executive sponsor and project management
How we are doing this?
• An integrated frailty pathway • Frailty Unit – short stay (5 days LOS) • Older Persons Medical Unit (10 days LOS) • Locality Hub in Bournemouth & Christchurch • Admission Avoidance • Discharge to Assess • Expertise of health, social care and third sector
services • Developing professional standards in discharge
planning
ED Attender ED
Observation admission
Admission to AMU
PTWR Triage EACM Transfer
OPM Ward
ED Attender or GP admission Transfer to Frailty Unit Discharge or transfer to Older Persons medical
ward
The current pathway for older people involves unnecessary: • transfers • handover • late moves leading to poor experience and increased length of stay The new frailty pathway will ensure the right patient is in the right place at the right time…….
Current pathway for older people
Frailty Pathway September 2016
Emergency Department
Admissions
GP Admissions
Older Persons Assessment Unit
25 beds
12 hours LOS
Short Stay Unit : Wards 24&25
50 beds
5 days LOS
Medical Unit – Wards 4&5
50 beds
10 days LOS
Admission Avoidance
via Locality Hub
or
Discharge to Assess
via Locality Hub
Simple Rules and doing what is known to work each day every day
DISCHARGE TO ASSESS
INTERMEDIATE CARE
INTERIM TEAM
REABLEMENT
ROAMING NIGHT SERVICE
THIRD SECTOR
SERVICES
OPAC
CONSULTANT NURSES
COMMUNITY MENTAL HEALTH TEAM
Locality HUB
ADMISSION AVOIDANCE
SAFEGUARDING GERIATRICIANS SILVER PHONE DAY HOSPITAL SOCIAL WORKERS OCCUPATIONAL THERAPISTS PHYSIOTHERAPISTS DISTRICT NURSES VOLUNTEERS VIRTUAL WARDS
STEP DOWN BEDS VIA COMMUNITY HOSPITALS
OR INTERIM CARE HOMES
STEP-UP BEDS VIA COMMUNITY HOSPITAL
OR INTERIM CARE HOMES
VISION OF THE HUB • Admission Avoidance & Discharge to Assess as expectation rather than
exception
• Integrating factors: single assessment process, single record, trans disciplinary roles (NHS England: associated with improved outcomes and added value with only small investment)
• Identifying patients at the right time – proactive rather than reactive, (impact of two day wait).
• Exploration of other options for discharge to assess: interim bed arrangements and extra care housing opportunities
• Putting the needs of the patient before the needs of the service
• Eliminating ‘hand-offs’
• Simplifying decision-making
• Increasing efficiency
• Access to Geriatrician via silver phone
Stranded Patients
0
10
20
30
40
50
60
70
80
90
100
03
/08
/20
15
10
/08
/20
15
17
/08
/20
15
24
/08
/20
15
31
/08
/20
15
07
/09
/20
15
14
/09
/20
15
21
/09
/20
15
28
/09
/20
15
05
/10
/20
15
12
/10
/20
15
19
/10
/20
15
26
/10
/20
15
02
/11
/20
15
09
/11
/20
15
16
/11
/20
15
23
/11
/20
15
30
/11
/20
15
07
/12
/20
15
14
/12
/20
15
21
/12
/20
15
28
/12
/20
15
04
/01
/20
16
11
/01
/20
16
25
/01
/20
16
01
/02
/20
16
08
/02
/20
16
15
/02
/20
16
22
/02
/20
16
29
/02
/20
16
07
/03
/20
16
14
/03
/20
16
21
/03
/20
16
28
/03
/20
16
04
/04
/20
16
11
/04
/20
16
18
/04
/20
16
25
/04
/20
16
02
/05
/20
16
09
/05
/20
16
16
/05
/20
16
23
/05
/20
16
30
/05
/20
16
06
/06
/20
16
No
. of
Pat
ien
ts
Date Report Run
Number of Over 14 Day Stay PatientsGeriatric Medicine
Stranded Patients Mean (Ave) Lower Control Limit Upper Control Limit
Significant reduction in number of patients with a length of stay of over 14 days. Evidence of early success with stranded patient reviews.
Occupied Bed Days
100
120
140
160
180
200
220
01/0
3/20
1603
/03/
2016
05/0
3/20
1607
/03/
2016
09/0
3/2
01
611
/03/
2016
13/0
3/20
1615
/03/
2016
17/0
3/20
1619
/03/
2016
21/0
3/2
01
623
/03/
2016
25/0
3/20
1627
/03/
2016
29/0
3/20
1631
/03/
2016
02/0
4/2
01
604
/04/
2016
06/0
4/20
1608
/04/
2016
10/0
4/20
1612
/04/
2016
14/0
4/2
01
616
/04/
2016
18/0
4/20
1620
/04/
2016
22/0
4/20
1624
/04/
2016
26/0
4/2
01
628
/04/
2016
30/0
4/20
1602
/05/
2016
04/0
5/20
1606
/05/
2016
08/0
5/20
1610
/05/
2016
12/0
5/20
1614
/05/
2016
16/0
5/20
1618
/05/
2016
20/0
5/20
1622
/05/
2016
24/0
5/20
1626
/05/
2016
28/0
5/20
1630
/05/
2016
01/0
6/20
1603
/06/
2016
05/0
6/20
1607
/06/
2016
09/0
6/20
16
No
. of
Occ
up
ied
Bed
Day
s
Date
Occupied Bed Days - Geriatric MedicineAll Wards
OBDs.MeanLower Control LimitUpper Control Limit
Average: 194Upper Control Limit: 206Lower Control Limit: 183
Number of Beds occupied by patients has significantly reduced – by an average of 20 beds per day.
% Bed Occupancy
75%
80%
85%
90%
95%
100%
105%
01/0
3/20
1603
/03/
2016
05/0
3/20
1607
/03/
2016
09/0
3/20
1611
/03/
2016
13/0
3/20
1615
/03/
2016
17/0
3/20
1619
/03/
2016
21/0
3/20
1623
/03/
2016
25/0
3/2
01
627
/03/
2016
29/0
3/20
1631
/03/
2016
02/0
4/20
1604
/04/
2016
06/0
4/20
1608
/04/
2016
10/0
4/20
1612
/04/
2016
14/0
4/20
1616
/04/
2016
18/0
4/20
1620
/04/
2016
22/0
4/2
01
624
/04/
2016
26/0
4/20
1628
/04/
2016
30/0
4/20
1602
/05/
2016
04/0
5/20
1606
/05/
2016
08/0
5/20
1610
/05
/20
16
12/0
5/20
1614
/05/
2016
16/0
5/20
1618
/05/
2016
20/0
5/20
1622
/05/
2016
24/0
5/20
1626
/05/
2016
28/0
5/20
1630
/05/
2016
01/0
6/20
1603
/06/
2016
05/0
6/20
1607
/06
/20
16
09/0
6/20
16
% o
f B
eds
Occ
up
ied
Date
% Bed Occupancy - Geriatric MedicineAll Wards
% Occ.
Mean
Average: 96%Upper Control Limit: 101%Lower Control Limit: 91%
Discharges Before Midday
0%
5%
10%
15%
20%
25%
30%
35%
01/0
6/20
1508
/06/
2015
15/0
6/20
1522
/06/
2015
29/0
6/20
1506
/07
/20
15
13/0
7/20
1520
/07/
2015
27/0
7/20
1503
/08/
2015
10/0
8/20
1517
/08/
2015
24/0
8/20
1531
/08/
2015
07/0
9/20
1514
/09/
2015
21/0
9/20
1528
/09/
2015
05/1
0/20
1512
/10/
2015
19/1
0/2
01
526
/10/
2015
02/1
1/20
1509
/11/
2015
16/1
1/20
1523
/11/
2015
30/1
1/20
1507
/12/
2015
14/1
2/20
1521
/12/
2015
28/1
2/20
1504
/01/
2016
11/0
1/20
1618
/01/
2016
25/0
1/20
1601
/02
/20
16
08/0
2/20
1615
/02/
2016
22/0
2/20
1629
/02/
2016
07/0
3/20
1614
/03/
2016
21/0
3/20
1628
/03/
2016
04/0
4/20
1611
/04/
2016
18/0
4/20
1625
/04/
2016
02/0
5/20
1609
/05/
2016
16/0
5/2
01
623
/05/
2016
30/0
5/20
16
% o
f P
atie
nts
Dis
char
ged
Week Commencing
Geriatric MedicinePercentage of Patients Discharged before Midday
% Disch Before MiddayAverage (Mean)Lower Control LimitUpper Control Limit
Evidence shows that increasing discharges before midday facilitates improved patient flow.
Questions…
Vanessa Mason Associate Director for Older Persons Medicine & Integrated Care [email protected] Cherry McCubbin Older Persons Service Manager [email protected] Twitter @MMOT_2