1. Frailty & Palliative Care MDT
CHIN Two Update
Frailty & Palliative Care MDT
Dr Claire Hassan, The Clinic - Oakleigh Road North
Wednesday, 21st November 2018
Working together with the Barnet population to improve health and wellbeing

2. CHIN 2 Membership CHIN 2 Practices Brunswick Park Medical Centre
Colney Hatch Lane Surgery
East Barnet Health Centre (Dr Monkman)
East Barnet Health Centre (Dr Helbitz)
East Barnet Health Centre (Dr Peskin and Dr Hussain)
Friern Barnet Medical Centre
St Andrews Medical Centre
The Clinic – Oakleigh Road North
*Combined list size – 53,450
Working together with the Barnet population to improve health and wellbeing

3. Area of Focus
As of 2011, 13.3% of the borough's population is over 65 - the sixth-highest of London's boroughs.
The number of people aged 65 and over is predicted to increase by 33% between 2018 and 2030, compared with a 2% decrease in young people (Barnet Joint Strategic Needs Assessment)
We know that elderly people are dying in A&E or soon after admission - would they have been better served by caring for them in the community?
QI project carried out for patients from Oakleigh Road HC looking at over 65s admitted with a code of pneumonia or UTI.
Working together with the Barnet population to improve health and wellbeing

4. MDT Rationale QI Data (April 2017-February 2018) Pneumonia UTIs
12 patients admitted (2 patients had multiple admissions)
Average age 87.5 years
5 died during admission
1 died shortly after (death linked to starting NOAC during pneumonia admission)
UTIs
10 patients admitted (4 patients had multiple admissions)
Average age 80.4 years
1 died during admission
2 died at home of unrelated causes
This data was analysed and it was felt that several of the patients would have been better served if they had not had recurrent admissions and/or been involved in advance care planning to discuss their preferred place of care and/or death. It was decided that having an MDT approach would enable appropriate care planning to take place whereas if the GP was left to do this alone there was likely to be reticence regarding some of the difficult decision making. The role of the MDT will be to look at patients who would benefit from care plans (either identified by GPs or members of wider team or after an admission). It was also agreed that a specialist nurse would enhance the role of the MDT but working with the identified patients and ensuring all parties (patients/carers/clinicians) all aware of any plans. It is anticipated that most of the plans will be recorded on Co-ordinate My Care.
Working together with the Barnet population to improve health and wellbeing

5. MDT Membership MDT Extended Team MDT Core Team
Palliative care consultant
Consultant Geriatrician
Consultant Old Age Psychiatrist
Patients and their carers
Case Manager (LAS)
MDT Core Team
GPs
CHIN Specialist Practice Nurse
MDT Administrator
Social care
CLCH Community Nurse
CCG practice-based pharmacist
Age UK (Barnet)
Working together with the Barnet population to improve health and wellbeing

6. Coordinate My Care (CMC)
What is CMC?
Together with their clinicians, patients may record their preferences and wishes within an electronic personalised urgent care plan that also includes clinical information and relevant medical history.
What’s in it?
The urgent care plan contains clinical information about the patient’s diagnosis, allergies, medications and resuscitation status as well as their wishes and preferences on where they would prefer to be cared for and, if appropriate, where they would wish to die.
Who can see it?
The care plan can be seen by all health and social care providers who have a legitimate relationship with the patient – this including patients; doctors; nurses; social care providers; emergency services including the ambulance service, NHS 111 and the out of hours GP service
CMC was discussed about a year ago at a pan-Barnet event, here’s a reminder about what it is.
Working together with the Barnet population to improve health and wellbeing

7. MDT Evaluation
Will be conducted by Dr Ray Sacks (innovative GP for Barnet) with input from Public Health and CCG.
Evaluation Metrics will include:
Reviewing number of care plans developed and the uptake of CMC
Reviewing non-elective admissions and A&E attendances
Deprescribing / Appropriate prescribing
As well as monitoring care plans, non-planned admissions and de-prescribing there will be ongoing assessment as to the effectiveness of using CMC – the plan being for CHIN 2 to assess how easy CMC is to use and how long it takes to write the plans. If this is successful it is hoped that CMC usage will be rolled out CCG wide.
Go live date is …….. we’ll keep everyone informed of our progress over the next 6 months.
Any questions?
Working together with the Barnet population to improve health and wellbeing