Fit for Frailty: An innovative approach to maintaining independence Sarah Pask (RGN) Llinos James (RGN) Lowri Davies (MPharm)

The “F” word......Frailty Syndrome or distinctive health state related to the ageing process. Multiple body systems gradually lose their inbuilt reserves A person becomes vulnerable to sudden changes in health triggered by a small event eg a minor infection or change in medication. A person loses their resilience.

Setting the scene Highest proportion of elderly patients of all the clusters in Hywel Dda. Language barriers Recruitment difficulties in rural Wales. Rural location. Adopting a proactive approach

Issues: High proportion of GP home and care home visits requested Unnecessary admissions to hospital Cultural tradition and coping mechanisms Patients living longer with multiple co-morbidites. Increasing demands on the GP’s and primary care team

Cluster’s response to the problem “A local approach to a local need” The development of a specialist Frailty and Chronic Conditions Team Recruitment took place in 2015 of a full time nurse and two pharmacists on a job share By today we have 2 full time nurses and are currently awaiting our second pharmacist to start.

Aims of our service Promote fitness not Frailty Identify and manage patients who are frail and/ or have chronic conditions Right person , right place, right time, right intervention Avoid unnecessary hospital admissions Releasing GP time

Aims of our service Providing care and support in own environment Improve patients’ self-management of their conditions Improved working and communication with Community Pharmacists Improve GP recruitment and retention through new initiatives Signposting to appropriate services

The Frailty referral process. Patient identified to Frailty Team Full Health MOT and Frailty Assessment Completed including NOTEARS Medication Review . Follow up visits as required Discussion with GP of pertinent issues, medications changed when appropriate and onward referrals and liaison with other members of MDT team

The assessment.... Joint Nurse and Pharmacist visit Pertinent issues- what matters to the patient Assessment includes: Physical Psychological Social Full NOTEARS medication review and medicines optimisation and rationalisation based on current evidence based practice. Agree follow up plan if appropriate

Post assessment... Discussion of issues with appropriate healthcare professionals Update patient’s electronic record and input of observations and QOF parameters Change of medications where appropriate and information sharing with all parties involved Signposting and referral to appropriate services/ teams Ordering of equipment

Key to success Understanding the patient’s perspective Joint realistic goal setting Challenging sedentary behaviour and low morale Increasing physical fitness/ well being Creating a resilient patient Maintaining independence

Challenging public perception : STOP thinking Frail/ Elderly....START thinking living well with frailty

Challenges so far...... Duplication of roles Inter- county working: Different documentation needed Different referral processes 7 practices- 7 different ways of working 2 different clinical systems : Vision and EMIS

Our stories....Diabetes

Our stories...Opioids

Our stories.....Warfarin

Our stories..... Falls

Outcomes to date...patients 240 Care Home health assessments 286 Care Home NOTEARS Medication Reviews 170 Frailty home visits by Frailty Nurse 57 home visit NOTEARS medication reviews 1823 clinical interventions by Pharmacist 172 medications which are at risk of causing falls stopped/ reduced after NOTEARS review (? Reduced hospital admissions)

Outcomes to date .....GP specific 40.4 days of GP time saved by Pharmacist doing NOTEARS medication reviews in their place

Outcomes to date ....£££ The actual cost saving of stopping medications is £30, 731.40 Estimated value of the clinical interventions done by pharmacist stands at £905,700 Non-quantifiable savings by nursing interventions which may have prevented admissions/ expatiated discharge .

Team developments Urinary tract infection prevention, identification and urinalysis training Delirium UTI audit Pressure sore prevention and skincare training Falls prevention workshops in conjunction with Occupational Therapy and Physiotherapy service Pharmacist led Inhaler Technique training for carers.

Team developments Close working or joint visits with other specialist nurses and over phone liaison Full training and on-going MDT case working with the Clinical Psychology service New innovations eg Electrocardiography (ECG) in the home Health promotion talks to local groups Raising awareness of Frailty

Evaluation Feedback from Care home managers and practice managers Compliments and complaints Monthly figures kept including : referral source numbers of unplanned admissions. Date of referral and date of visit Monthly figures , cost savings, number and type of clinical interventions recorded by Pharmacist.

The future...ideas and wish list Admiral Nurse to support the team with dementia patients Physiotherapist and Occupational Therapist attached to the team Falls clinic supported by a Geriatrician/GP with special interest. Interests groups and social networks for patients who are isolated and lonely – social prescribing Investment in more third sector provisions Share good practice..... Challenge the “F word” and remain Fit for Frailty.

Any Questions?