1. Complex care and frailty multidisciplinary meeting
Dr Stuart Mackay-Thomas
Clinical Lead for Frailty

2. Frailty and complex care in Camden
Camden’s population is approximately
There are an estimated 3000 frail / complex care patients in Camden
The CCG definition of frail / complex care patients:
>75 years with 1 or more LTCs and 1 or more non-elective hospital admissions per year
<75 years with complex health and social care needs where a patient’s GP has identified they would benefit from a case management approach

3. Rationale for the frailty & complex care pathway
Prevention of avoidable hospital activity
Patients aged 64+ non elective admissions
2011/ ,900
2012/13 – 6,000
42% resulted in stays of 2 days or less
Improving outcomes and patient experience through better co-ordination of care
35% of older people admitted to hospital are discharged in a poorer functional state than on admission
Continuity of GP care can prevent emergency admissions (Baker et al 2012)

4. Camden’s model for those with complex needs
Hospital
Mental health services
central
Hub MDT
Social services
local
GP and Integrated Primary Care team

5. Camden’s model for those with complex needs
Hospital
Mental health services
central
Hub MDT
Social services
local
GP and Integrated Primary Care team

6. Comprehensive geriatric assessment
The gold standard for the management of frailty in older people is the process of care known as Comprehensive Geriatric Assessment (CGA).
It involves an holistic, multidimensional, interdisciplinary assessment of an individual by a number of specialists of many disciplines in older people’s health and has been demonstrated to be associated with improved outcomes in a variety of settings.

7. Camden’s current model for those with (very) complex needs
Hospital
Mental health services
central
Hub MDT
Social services
local
GP and Integrated Primary Care team

8. Camden’s current model for those with (very) complex needs
Hospital
Mental health services
central
Hub MDT
Social services
local
GP and Integrated Primary Care team

9. has home NIV - ?compliance
Name
Co-Morbidities
Current Mediaction / (Include strength and dose
Problems For Discussion
Patient's name
Hypoventilation and nocturnal hypoxaemia
Ramipril (d) 5mg PO ON
recurrent admission
Hypertension
Bisoprolol (d) 7.5mg PO OM
Date of Birth: AF
Digoxin (d) 125 micrograms PO OM
concern regrading medication compliance- Reported by ward staff pt tend to hide medications on her food
CRT-D in situ4. NIDDM
Atorvastatin (d) 20mg PO ON
CKD- baseline creatinine 112
Glicazide (d) 160mg PO BD
optimise hear failure; LV EF 10-15%
NHS No:
Schizophrenia
Metformin (d) 500mg PO BD
XXXXXXXXXXX
Left mid cerebral infarct 2013; Right sided weakness
Spironolactone (d) 50mg PO OM
has home NIV - ?compliance
Dilated cardiomyopathy EF 10-20%
Rivaroxiban (d) 20mg PO 18pm
Main Carers full name:
ECG: old LBBB
Ivabradine (d) 5mg PO BD
Carers name (son)
Chronic type 2 respiratory failure. Mixed pathology, pulmonary and severe LVSD
Bumetanide (d) 3mg PO OM
MI 2009
Bumetanide (d) 2mg PO 14pm
GP Name:
Flupenthixol 60mg IM every 3 weeks Continue Continuing next due 01/04/2015
Dr X
Senna 7.5mg PO BD PRN
GP Practice:
Abbey Medical Centre
85 Abbey Rd NW8 0AG
Presented by:
Ivy Macalino
RFH-Resp
Frailty Score:
Has this patient given their consent to view the GP records?
verbal consent yes 14/4/15
Does this patient have capacity sufficient to make decisions around own care?
yes
to:

10. Hub MDT Weekly Multidisciplinary meeting GP
Geriatrician / secondary care
Complex care nurses
Therapists (eg OT)
Social workers
Mental health consultant
Pharmacist
Camden Carers
Palliative care team
Age UK Camden

11. Hub MDT communication
Access to EMIS web community i.e. the full GP records (if consented).
Allied EMIS web community records e.g. community renal team, or community diabetes.
Framework-I (social work database).
Mental health consultant uses RiO.
Camden Integrated Digital Record - web-based access to EMIS, secondary care data, community nursing, mental health and social work databases.
Videoconference facility – currently with one practice.

12. Hub MDT example care plan
Dear Doctor,
Ms X was discussed by the Multidisciplinary Team for frailty at South Camden Centre for Health today.
15-Apr-2015
Case conference (South Camden Centre for Health) MACKAY-THOMAS, Stuart - GP (Dr)
Problem
Chronic obstructive pulmonary disease (Review)
[X]Schizoaffective disorders (Review)
Type 2 diabetes mellitus (Review)
Left ventricular failure (Review)
Atrial fibrillation (Review)
History
Has been discharged from hospital recently, and it is reported that patient missed her medication for 3 days (by Percy the heart failure nurse).
Rebecca Broadhurst is the allocated social worker.
Plan
Dr Mackay-Thomas to contact Percy re: meds.
Dr Mackay-Thomas to contact Rebecca Broadhurst re: adult safeguarding.
Hub to review next week.
GP - please consider rechecking HbA1c.

13. Hub MDT outcomes
Recent data from an evaluation has shown reduction in unscheduled care by 50% in those managed at the Hub.
At a time when A&E admissions increasing ~ 10% per year
47.7% reduction in accident and emergency attendances; and
32.9% reduction in first and follow up outpatients’ appointments.
30% of patients referred into the MDT spent more time at home following their intervention than in the 6 months previous.

14. Hub MDT Outcomes
Data illustrates a 32% reduction in A&E 6 months after an MDT intervention.

15. Hub MDT Outcomes
18% reduction in emergency beddays in the 6 months following an MDT intervention

16. Hub MDT Outcomes
MDT has also led to financial efficiencies around A&E and emergency admissions

17. Further reading
De Lepeleire et al. (2009) Frailty: an emerging concept for general practice BJGP 59 (562) e177-e182
Clegg A et al. (2013) Frailty in elderly people. Lancet 781:
Sayer, C. (2014) Improve frail elderly care with evidence, not intuition. HSJ
Fit for frailty – British Geriatrics Society