2. Frailty – Fall Prevention Programme Dr Haydn Williams

NHS Long Term Plan for Older People Improve NHS care in care homes. Identify and provide proactive support to older people living with frailty in the community. Enhance rapid community response at times of crisis. The aim is to support people to age well and to stay independent at home for longer. The Personalisation Plan aims to change the way NHS services and health professionals work to give everyone living with long term conditions more choice and control over their care. 

A Framework for Frailty in Luton: Ambition Older People: Over 65’s The main aim of this programme is to promote healthy ageing, to case find frail elderly, proactively manage their care and reduce the need for older people, those aged over 65, to be urgently admitted to hospital. This will be achieved through system-wide agreement, development and implementation of a Framework for Frailty in Luton; clearly describing the interventions and services across health & social care that will support older people with healthy ageing and to remain in their own home for as long as possible. And where this is no longer possible, ensuring that the best possible care is provided for older people in residential & nursing settings. The framework describes the offer for each frailty cohort; fit, mild, moderate and severe.

Ageing Well: Falls Prevention A joint health & social care Falls Prevention Campaign with underpinning material that supports people getting older to stay stable, strong and safe.   The campaign focuses on encouraging self-care through increased awareness of risk and establishing pathways that enable individuals to make informed choices. A postcard has been developed that includes fall prevention tips and healthy ageing advice. Stakeholders across the whole of Luton have agreed to participate in the postcard campaign and a series of roadshows after the Summer, in preparation for Winter. After the initial launch, the campaign will sustain messages to the population of Luton by ensuring the Falls Prevention Tips postcard is issued to people routinely, shortly after their 65th birthday. Outcomes: The programme was launched in September 2018, with postcards being sent to all people aged over 65 – providing them with tips on how to prevent themselves from falling. In 2017, long term users of adult social care indicated their biggest fear was the possibility of falling. Proportions reporting a ‘fear of falling’ are down in 2018 compared to 2017 – and this may be attributed to our local Falls Prevention Programme. Carole Gillespie, Head of Commissioning Development, Luton CCG

Ageing Well: Healthy Ageing Programme Outcomes: The programme started in July 2018. 11 community voluntary organisations across Luton have been awarded grants to deliver 13 different targeted exercise classes (from ballet to boxercise) in local community venues – that focus on improving the balance, stamina and co-ordination for the mildly frail population in Luton. Over 2000 people have been contacted by their GP Practice and offered the opportunity to benefit from free exercise classes to improve their health and wellbeing. Over 350 people have been assessed and taken up some form of exercise. The programme is underpinned with a ‘Luton Healthy Ageing Booklet’ that supports and encourages the continuation of healthy ageing activities. Evaluation by the University of Bedfordshire has started to provide robust evidence of the impact of the programme on preventing frailty (Report expected end October 2019). Carole Gillespie, Head of Commissioning Development, Luton CCG

Moderate and Severe Frailty At home first - integrated care – systematic Multi-disciplinary Team (MDT) reviews of Moderate / severe frail based on Electronic Frailty Index (EFI) score, with sharing of care plan. Cambridge Community Services (CCS) redesign with enhanced rapid response of frail elderly, daily huddle to review discharged and deteriorating patients, access to consultant MDT and advice. Nursing Home Local enhanced service – GP alignment to nursing homes with enhanced palliative provision in 2 homes enabling rapid discharge from hospital. All Care homes have had systematic medication reviews with significant reduction in drug wastage and polypharmacy.