1. 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

2. 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

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

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

5. 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

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

7. 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

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

9. 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

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

11. 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

12. 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

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

14. Christine Owen

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

16. Frailty Syndromes

17. 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

18. 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

19. 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

20. QUESTIONS