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

2. 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.

3. 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

4. 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

5. 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.

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

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

13. 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

14. Our stories....Diabetes

15. Our stories...Opioids

16. Our stories.....Warfarin

17. Our stories..... Falls

18. 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)

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

20. Outcomes to date ....£££
The actual cost saving of stopping medications is
£30,
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 .

21. 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.

22. 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

23. 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.

24. 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.

25. Any Questions?