1. The State of Medicine of the Elderly

2. What are the key challenges for MoE in the next 20 years?

3. Projected change in the age structure of Scotland’s population, 2004-2031

4. The Kerr Report

5. Key Drivers The ageing population Reshaping Care for Older People
1 in 6 living now will live to age 100
Reshaping Care for Older People
Change Fund £70M
Live Well in Later Life 2018

6. Live Well in Later Life 2018 – Progress
96% reduction in delayed discharge
133% increase in intensive home care
10X increase in older Telecare service users
Reduction in orthopaedic lengths of stay
New care homes + day centres
Reduction in inpatient bed days and admissions

7. Emergency bed usage: What the numbers tell us King’s Fund
70% bed occupied by emergency admissions
10% admissions have LoS>14d account for 55% of bed days
80% of admissions with LoS>14d are aged>65
Reducing LoS has greatest potential for reducing hospital bed use

8. What are our goals? To develop integrated health and social care
To look after more frail older people at home
To reduce admissions at the ‘front door’?
To provide access to CGA in varied settings
To reduce occupied hospitalised bed days

9. Why do patients get admitted to hospital?
Majority are sick and need hospital
Need investigation
Limited access to intermediate care services
Uncertainty around anticipatory care planning
Maximum PoC in place but no longer enough
Earlier, unsorted, sicker, care home discharges
Readmissions

10. We have to change

12. Comprehensive Geriatric Assessment
A multi-disciplinary assessment to
determine an individuals problems across
multiple domains and construct an
individualised plan for treatment,
rehabilitation and follow up.

13. The Sepulveda GEM Study:
Randomized Trial of a Hospital Geriatric Evaluation & Management Unit
 Mortality 24% vs 48% at 1 yr  NH Use 27% vs 47%; 26 vs 56 days  Rehosps 35% vs 50%; 17 vs 23d  Costs $22,000 vs $28,000 /yr surv  ADL 42% vs 24% improved at 1yr  Morale 42% vs 24% improved at 1 yr
The Sepulveda GEM Study (a randomized trial of a hospital geriatric evaluation) showed obvious benefits with a significant reduction of Mortality, NH Use, re-hospitalizations and Costs.  
Comprehensive Geriatric Assessment improves outcomes
Ref: Rubenstein, et al, NEJM 1984; 311:1664

14. What works? Nairn Identification of at risk patients
Provide an anticipatory care plan
To allow patients to express their wishes for care prior to sudden deterioration in health
Proactive case management
Associated with reduction in unscheduled admissions (40%) and reduced bed days usage in comparison to standard care

15. Better than CGA? Hospital at home admission avoidance
Sasha Shepperd1,*, Helen Doll1, Robert M Angus2, Mike J Clarke3, Steve Iliffe4, Lalit Kalra5, Nicoletta Aimonino Ricauda6, Andrew D Wilson7 Cochrane Library

16. ASSET: Admission Avoidance and Hospital at Home
Age > 75 Exc. stroke, fractures, chest pain, surgical
Assessment within 1 hour of referral
Access to reablement and equipment
12% care home residents
76% initially supported at home
5.5% dead at 30 days
Patients and carers happy with service

17. Elderly Care Assessment Team (June 2010)
3 MoE Band 5 Nurses supported by MoE consultants
One nurse 7 days predominantly based at front door
All medical admissions age>65 screened with AHP
Defined ECAT criteria
Short focussed triage and assessment
‘High risk’ criteria to guide off site transfers

19. Who is geriatric? Geriatric Syndromes Falls Immobility Confusion,
Impairment of AD
Major co-morbidity
Parkinsons.
n=312
Miller et al EUGM 2012

20. Who is ‘Geriatric?’ Wards Up to 6 months Up to 12 months NNT
(wards overall) 13 20
Needs 6
Age 25 NS

21. ECAT since June 2010
Screened > medical admissions aged >65
Facilitated admission of over 5000 patients
Falls and poor mobility ~50%
Improved cognitive and falls assessment
More than 90% moved straight to a MoE ward
10% admissions to MoE are from care homes
10% admissions have urinary catheter inserted
1. Large number screened. 2. RIE takes admissions from all over Edinburgh (does it have the right bed capcity?) 3. Should we take every older person with falls or confusion? 4. ECAT associated with high admission straight to MoE ward – ‘the right place first time’ in contrast to previous work that showed multiple moves and boarding. 5.Team also see patients identified at front door as ‘fitting’ MoE criteria but taken over for speciality intervention. ECAT proactively follow up at day 3 to ‘pull’ patient into rehab once ready (no more referral delays). 6. Team also seeing rehab referrals. 21

22. Ellis Systematic Review
22 RCTs 10,315 participants in 6 Countries
Primary outcomes with ward Vs team care
For every 100 patients
More alive and in own homes at end of 12m
Wards
Teams
Overall +5
(2-7) -6
( ) +3
(1 – 6)

23. Intermediate care Range of services with ‘care closer to home’
Provide alternatives to hospital admission
Early supported discharge
Day Hospital care equal to CGA in wards
Evidence better for specific condition
Enabling and time limited

25. Lessons from ESDS Expensive initial outlay for small effect
Lack of service integration
Therapy assessment needed changed (40%)
Nursing competencies hospital Vs community
Main delays: awaiting PoC

27. Next steps and implications
Community is the ‘direction of travel’
Admission avoidance
Looking after MoE patients in non-MoE wards
Cannot be at cost of last 20 years progress
Business case to the board for £1.7M
Job plans of the future will include ‘community’