Complex care and frailty multidisciplinary meeting Dr Stuart Mackay-Thomas Clinical Lead for Frailty

Frailty and complex care in Camden Camden’s population is approximately 230000 There are an estimated 3000 frail / complex care patients in Camden The CCG definition of frail / complex care patients: >75 years with 1 or more LTCs and 1 or more non-elective hospital admissions per year <75 years with complex health and social care needs where a patient’s GP has identified they would benefit from a case management approach

Rationale for the frailty & complex care pathway Prevention of avoidable hospital activity Patients aged 64+ non elective admissions 2011/12 - 5,900 2012/13 – 6,000 42% resulted in stays of 2 days or less Improving outcomes and patient experience through better co-ordination of care 35% of older people admitted to hospital are discharged in a poorer functional state than on admission Continuity of GP care can prevent emergency admissions (Baker et al 2012)

Camden’s model for those with complex needs Hospital Mental health services central Hub MDT Social services local GP and Integrated Primary Care team

Camden’s model for those with complex needs Hospital Mental health services central Hub MDT Social services local GP and Integrated Primary Care team

Comprehensive geriatric assessment The gold standard for the management of frailty in older people is the process of care known as Comprehensive Geriatric Assessment (CGA). It involves an holistic, multidimensional, interdisciplinary assessment of an individual by a number of specialists of many disciplines in older people’s health and has been demonstrated to be associated with improved outcomes in a variety of settings.

Camden’s current model for those with (very) complex needs Hospital Mental health services central Hub MDT Social services local GP and Integrated Primary Care team

Camden’s current model for those with (very) complex needs Hospital Mental health services central Hub MDT Social services local GP and Integrated Primary Care team

has home NIV - ?compliance Name Co-Morbidities Current Mediaction / (Include strength and dose Problems For Discussion Patient's name Hypoventilation and nocturnal hypoxaemia Ramipril (d) 5mg PO ON recurrent admission   Hypertension Bisoprolol (d) 7.5mg PO OM Date of Birth: AF Digoxin (d) 125 micrograms PO OM concern regrading medication compliance- Reported by ward staff pt tend to hide medications on her food CRT-D in situ4. NIDDM Atorvastatin (d) 20mg PO ON CKD- baseline creatinine 112 Glicazide (d) 160mg PO BD optimise hear failure; LV EF 10-15% NHS No: Schizophrenia Metformin (d) 500mg PO BD XXXXXXXXXXX Left mid cerebral infarct 2013; Right sided weakness Spironolactone (d) 50mg PO OM has home NIV - ?compliance Dilated cardiomyopathy EF 10-20% Rivaroxiban (d) 20mg PO 18pm Main Carers full name: ECG: old LBBB Ivabradine (d) 5mg PO BD Carers name (son) Chronic type 2 respiratory failure. Mixed pathology, pulmonary and severe LVSD Bumetanide (d) 3mg PO OM 7577319156 MI 2009 Bumetanide (d) 2mg PO 14pm GP Name: Flupenthixol 60mg IM every 3 weeks Continue Continuing next due 01/04/2015 Dr X Senna 7.5mg PO BD PRN GP Practice: Abbey Medical Centre 85 Abbey Rd NW8 0AG Presented by: Ivy Macalino RFH-Resp Frailty Score: Has this patient given their consent to view the GP records? verbal consent yes 14/4/15 Does this patient have capacity sufficient to make decisions around own care? yes Email to: nekeisha.henry@nhs.net

Hub MDT Weekly Multidisciplinary meeting GP Geriatrician / secondary care Complex care nurses Therapists (eg OT) Social workers Mental health consultant Pharmacist Camden Carers Palliative care team Age UK Camden

Hub MDT communication Access to EMIS web community i.e. the full GP records (if consented). Allied EMIS web community records e.g. community renal team, or community diabetes. Framework-I (social work database). Mental health consultant uses RiO. Camden Integrated Digital Record - web-based access to EMIS, secondary care data, community nursing, mental health and social work databases. Videoconference facility – currently with one practice.

Hub MDT example care plan Dear Doctor, Ms X was discussed by the Multidisciplinary Team for frailty at South Camden Centre for Health today. 15-Apr-2015 Case conference (South Camden Centre for Health) MACKAY-THOMAS, Stuart - GP (Dr) Problem Chronic obstructive pulmonary disease (Review) [X]Schizoaffective disorders (Review) Type 2 diabetes mellitus (Review) Left ventricular failure (Review) Atrial fibrillation (Review) History Has been discharged from hospital recently, and it is reported that patient missed her medication for 3 days (by Percy the heart failure nurse). Rebecca Broadhurst is the allocated social worker. Plan Dr Mackay-Thomas to contact Percy re: meds. Dr Mackay-Thomas to contact Rebecca Broadhurst re: adult safeguarding. Hub to review next week. GP - please consider rechecking HbA1c.

Hub MDT outcomes Recent data from an evaluation has shown reduction in unscheduled care by 50% in those managed at the Hub. At a time when A&E admissions increasing ~ 10% per year 47.7% reduction in accident and emergency attendances; and 32.9% reduction in first and follow up outpatients’ appointments. 30% of patients referred into the MDT spent more time at home following their intervention than in the 6 months previous.

Hub MDT Outcomes Data illustrates a 32% reduction in A&E 6 months after an MDT intervention.

Hub MDT Outcomes 18% reduction in emergency beddays in the 6 months following an MDT intervention

Hub MDT Outcomes MDT has also led to financial efficiencies around A&E and emergency admissions

Further reading De Lepeleire et al. (2009) Frailty: an emerging concept for general practice BJGP 59 (562) e177-e182 Clegg A et al. (2013) Frailty in elderly people. Lancet 781: 352-362 Sayer, C. (2014) Improve frail elderly care with evidence, not intuition. HSJ http://m.hsj.co.uk/5070273.article Fit for frailty – British Geriatrics Society 2014 http://www.bgs.org.uk/index.php/fit-for-frailty