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 vanessa.mason@rbch.nhs.uk Cherry McCubbin Older Persons Service Manager cherry.mccubbin@rbch.nhs.uk Twitter @MMOT_2