Frailty identification and management North Sydney Local Health District and Sydney North Primary Health Network Cynthia Stanton: General Manager, Primary Care Advancement & Integration SNPHN Chanelle Stowers: Integrated Care and HealthPathways Redesign Project SNPHN Lyn Olivetti: Service Development Manager: Chronic & Complex Medicine, Rehabilitation & Aged Care NSLHD

Problem Statement Frailty is a common syndrome effecting 25-27% of the popn aged 70+ (approx. 35,000). It is associated with vulnerability and poor health outcomes. Frail older people have increased risk of falls, longer length of hospital stay, decline in function, increased chance of institutionalisation, and death Early identification and targeted intervention can reduce frailty, avoid inappropriate hospital admissions, and improve health outcomes for people who are frail.

Mission We will work together with patients and providers to ENABLE… ONE PERSON (AND THEIR CARER/S) Supported by people working as ONE TEAM From organisations behaving as ONE SYSTEM

Aim and Objective Aim: To optimise the wellness of (socially isolated/older) people who are frail in the Northern Sydney region. Objectives: Work as one team to deliver supporting and integrated care Reversal of frailty in some cases Reduced adverse patient outcomes whilst in hospital Increase hospital avoidance Reduced length of hospital stay To increase patient satisfaction with health delivery system

Analysis

Approach Aligned with current evidence and the 2017 Asia Pacific Guidelines: Implementation of a simple screen to identify frailty (FRAIL Scale) in Acute care, ED Hospital Inpatient Primary Care Enable referral to relevant management options; Physical activity plan Address polypharmacy Nutrition plan for weight loss with appropriate supplements Addresses self reported exhaustion Vitamin D deficiencies

Diagnostic Phase Actions Socialise the idea with stakeholders Community needs assessment Define scope (eg, socially isolated) Establish project governance group More robust data analysis to inform problem definition Community (and provider) engagement Source patient stories March 2018 Diagnostic Phase July 2018 Implementation Strategy Value Case Agree Vision and mission Communication Plan Evaluation Framework Ensuring mutual October Implementation

Timeline April – May 2018 July 2018 Aug-Sep 2018 Oct 2018 Dec-Jan 2019 Diagnostic Value Case, agree vision, mission and strategy Communication & generate support Pilot Evaluate impact Refine Scale April – May 2018 July 2018 Aug-Sep 2018 Oct 2018 Dec-Jan 2019 Feb 2019 March onwards 2019