The West Lothian Frailty Programme Jacquie Campbell, Site Director The West Lothian Frailty Programme Large scale improvement programme covering: health care, Mental Health, social care, and all related sectors and provision across West Lothian processes and pathways quality cost available capacity skills / who does what where and when  

Led by West Lothian executive team and subject experts who will now: Set the scene Give a background to Frailty Describe role development Describe a discharge example Discuss pathways and vision

Setting the scene: The West Lothian Pathways Collaborative (WELPACT) Dr. Karen Adamson Consultant Physician and Associate Director of Medical Education

The Impact of WELPACT SJH, Medical readmissions Source: Tableau / Lothian Analytical Services

Key points for success:   Consultant engagement Consultant review of 474 cases Numbers of readmissions are incorporated on the daily print-outs MDTs led by a Geriatrician Discharge Hub implementation COPD Discharge Bundle KIS and ACP Communication, understanding and relationships across sector boundaries: WELPACT events Integration & Education Events (IEEs) Interface Group

Consultant Physician and Geriatrician Dr. Maria Corretge Consultant Physician and Geriatrician

Paradigm shift in Geriatric care Previously… Discharge “when ready” Weekly, long MDT SW not integrated part of discharge planning Now Early discharge Rehabilitation and sometimes assessment to be completed in the community Daily short huddles, shortened MDT SW integrated in patient’s admission

Drivers to change in paradigm Economic Hospital bed availability Demographic Social Human ?Medical – Evidence of intermediate care outside hospital

Frail Elderly: What are the standards Quality standards: OPAH Quantitative standards: Time waiting for rehabilitation or intermediate care Time spent in hospital as a delayed discharge Access to Comprehensive Geriatric Assessment

Rapid Elderly Assessment and Care in Hospital (REACH) Louise McKay

Everyone ≥ 65 years old is seen Monday - Friday If positive to any one of these then an initial assessment is completed Recommendations made on robust collateral history Referred for Comprehensive Geriatric Assessment

Intervention examples Discussions with family Early assessment for mobility aids / physio assessment Early assessment for discharge Joint working with Discharge Hub, Mental Health, REACT and Templar day services Reablement, Unmet Needs Team, Community Hospitals, Nursing Homes Voluntary and Third Sector

MAU data for those >65yo Starting to reduce the median LOS Starting to reduce the Occupied Bed Days Whilst ward admissions are static

Christine Owen

Consultant Physician and Geriatrician Dr. Jane Rimer Consultant Physician and Geriatrician

Frailty Syndromes

Safe for discharge Screen all >65 FRAILTY PATHWAY: Inpatient journey REACT Acutely unwell frail older person Screen all >65 Safe for discharge A&E SJH Front door PAA MAU REACH nurse OPD Discharge hub Templar Day Hospital Rehab ward Med. IP Adm. GP care + agreed plan GP Aims: to improve the care of frail elderly patients within SJH: Right patients in the right place, looked after by the right people Supported discharges where possible Medical ward - MOE input Rest of SJH Referral or via MDT Subacute care Consultant Geriatrician Single Point of Contact

Alternatives to admission: ‘The vision’ Specialist MOE clinic REACH nurse Referral to MOE: daily triage Comprehensive Geriatric Assessment Templar Day Hospital REACT Acute Rehab Home is best CGA:  A multidimensional, interdisciplinary diagnostic process to: 1. Determine the medical, psychological and functional capabilities of a frail elderly person 2. Develop a co-ordinated and integrated plan for treatment and long-term follow up Iterative. Cochrane review published 2011 of >10,000 patients: Less likely to be institutionalised, More likely to experience improved cognition, 30% chance of being alive and in their own homes at 6 months Frailty Clinic Rapid Access Geriatrician led Same day MDT assessment Pro-active post acute care Community Follow up

OBEYA: Big room Timely MDT assessment Anticipating care needs with advance care planning Rapid access to care and close liaison with social services From the Japanese word meaning ‘big room’, Toyota have developed an approach to both design and manufacturing termed Obeya. This seeks to identify all possible problems and resolve them early in the process, with one experienced engineer present from each division working together towards a common solution. Bringing all the people into one room to make critical decisions – co-location, reduce paper referrals, regular discussions Access to transport where needed Responsive inter-disciplinary IT

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