1. Workforce and education initiative to support the delivery of better care to frail patients in West Southampton
Team: Dr Harnish Patel
Rachel Everett & Pippa Collins – Advanced Clinical Practitioners in Frailty
Start date: April 2017

2. Aims of CLAHRC funded frailty project
Two ACP’s (1.3 WTE) to identify frailty and implement the comprehensive geriatric assessment process.
Establish a Frailty Pathway from admission, across the hospital and through to discharge and home.
Identify education needs within the MDT both within UHS and in the community, and develop sustainable training resources.
Implement frailty scoring and utilise to identify patients for CGA and evaluate if score predicts outcomes.

3. Initial findings
Frailty inconsistently recognised and poorly understood.
No frailty pathway through acute care and out into the community.
Where recognised clinicians struggle with what to do next – need for leadership, education and training.
No comprehensive holistic assessment routinely in place for people with frailty.
When in place CGA’s are not easily accessible in either the community or UHS.

4. First initiatives
Established prevalence of frailty patients in cluster 1 and 2 by CFS scoring.
Developed multi professional proforma for assessment of all MOP patients in AMU – start of the CGA process.
Inclusion/exclusion criteria defined using frailty score data to select patients that benefited from CGA process during first PDSA cycle.
Post discharge visits undertaken – quantitative and qualitative data collected.
Identified that CGA’s were time consuming, often re admitted prior to CGA (3-4/52).

5. First initiatives (cont’d)
Started collating LoS and re-admission data post CGA – recognised the post d/c dip.
CGA template developed to standardise output.
Internal links made with geriatricians, older people’s practitioners, CEDT, therapy teams.
External links made with virtual ward, ambulance service, Urgent response and community geriatrician.
Strong links made with AFN project team to ensure working toward same goals.

6. Evaluation of first initiatives
Two surveys of use of proforma to develop effective form. Used 75% of time (not replenished in AMU).
83 % Estimated discharge dates on proforma not met but mainly not for medical reasons.
Skills are present in pockets but not joined together.
No one person has oversight of the patient; plans are profession specific, often contradictory and do not include the views of the patient and family.
Professions are risk adverse but do not recognise themselves as such.
Clinicians feel powerless to effect change and feel they are “doing it already”.

7. Evaluation of first initiatives (cont’d)
With higher levels of frailty the risk of rapid readmission or poor outcomes is high.
Discharge of the frail patient is a stressor event causing a mental and physical dip that is not recognised.
Links with the community, whilst there, are not sufficient to support the patient in the immediate post discharge period.
Anticipatory care plans vary in quality and are not consistently used.
CGA format not consistent across practitioners and not visible to community and UHS.
Initial findings are that readmissions are being reduced following CGA but will only be fully evident over time.
Patients unclear of plan when discharged

8. Patients and their families are not being involved from the start
Patients and their families are not being involved from the start. Plans are often made without them.

9. Next stage (3/12)
Utilisation of findings from first stage to educate clinicians.
Concentrating solely on Cluster 1. This is producing a patient case- load that can be followed and influenced from the AMU and out into the community.
Continue to reinforce use of proforma and why using, including decreasing duplication of effort.
Clear emphasis on what the patient and family want from admission and for discharge.
All patients CFS scored to provide data on outcomes.
Clear referral criteria for virtual ward.

10. Next stage (3/12)
All patients in cluster 1 who meet the inclusion criteria will be managed by an ACP, through the wards and back home – what intensity of input is needed?
This will include an immediate post d/c visit to address issues such as medication, dip in physical or cognitive functioning, family and patient anxiety.
Able to investigate what is happening along the pathway and target education accordingly.
CGA on system 1.
Standardising anticipatory care plans.
Continue to collect patient stories.

11. Evaluate outcome metrics
Critique roles of involved practitioners with evidence for what does/does not work at all stages of the pathway.
Patient perspective and experiences.
Breakdowns; failures; overlaps; quality; patient perspective.
Comparison of outcomes of CGA process for Cluster 1 against baseline data.
Readmission rates and LOS.

12. Education initiatives
Level 1 training for all staff: What is frailty; how to recognises it; what to do when identified.
Level 2 training for medics, AHP,s and nurses: Role of CGA; putting the patient at the centre; importance of recognition and implications for clinical practice.
Level 3 training: based on findings from data analysis.
Link in with dementia
Workplace facebook platform
PDSA cycles – proforma, our roles; where we can best make an impact