1. Elderly Frailty Project in Teesside
Helen Howe – Advanced Nurse Practitioner, Project Lead (South Tees)
Gemma Pickering – Advanced Nurse Practitioner, Project Lead (North Tees)
Mani Krishnan Consultant in Old Age Psychiatry

2. Introduction Background Rationale for the project
Funding – time scales for project
Aims / Objectives
Outcomes

3. Staffing
Five band 6 nurses have been appointed to work across both sites
Piloting an 8-8 service working 7 days per week

4. Multidiciplinary Team
Consultant Geriatrician
Junior Medics
Nurse Practitioner
Nurses
Therapists
Psychiatric Liaison nurses
Social Worker

5. Inclusion Criteria
Over 75 years of age with either or all of the following presentations
Urinary tract infection
Lower respiratory tract infection
Delirium
Reduction in normal mobility associated with intercurrent illness
Dehydration or poor oral intake
Recurrent falls (more than 2 in last month)
New or worsening incontinence

6. Exclusion Criteria GI bleed
Suspected stroke (FAST positive) – stroke pathway
COPD
Unstable / deteriorating patient
Alcohol Excess (and confusion – suspected withdrawal)
Requiring telementary

7. Assessment Process Proforma Outcomes Screening – sharing information

8. Flow Chart

9. Workshop Case scenario
Discuss considerations in order to plan a safe discharge
Discuss barriers and how they would be overcome

10. Considerations Mr A Cognitive assessment Collateral history
CT Head & Memory Clinic Bloods
Capacity
Therapy assessment
Physical review (Ensure the infection has resolved)
Safeguarding – (his wife feels frightened, he can be volatile)
DoL’s
Wife’s Mental State (Consideration of a referral to MH services)
Future Care Provision
RISK

11. Barriers Mr A
On-going confusion, unresolved infection – may exceed 72 hours
a back of house bed or period of recovery
Acute trust pressure for beds
discharge location
delirium bed (limited resources)
Delirium Clinic (limited resources)
waiting for care homes to assess before they accept
Social support
Single point of referral
Discharge on psychotropic medication
Pressure on Community Teams, Community Mental Health Teams and Intensive Community Liaison Services

12. Considerations Mr B
Has Mr B got capacity to refuse food/drink/medication and does a DOLS need to be considered.
Dietician referral due to recent weight loss and does he need IV fluids.
Covert medication plan.
Delirium pathway – may need 0.5mg haloperidol BD to manage symptoms.
Regular liaison assessment/monitoring.
Good collateral history from wife regarding onset of illness and her thoughts around discharge.
CHC to be completed by the ward for allocation of social worker to assess needs – package of care/24 hour care as wife is struggling to cope.
Ward to implement diet/fluid/bowel chart.
Mental health OT assessment to support safe discharge planning.
Consultant review to consider psychotropic medication.
Referral to CMHT for monitoring of mood and medication on discharge.
Does ICLS need to be involved in the short term.
Does patient require an inpatient assessment when medically fit.

13. Barriers Mr B
Barriers.
Timely social care assessment within 72 hours as this can not be requested until the patient is medically fit.
Is the wife happy to have Mr B home and would this be a safe discharge.
Bed availability at respite/assessment/rehabilitation placements as they have long waiting lists.
24 hour care placements – current lack of placements locally and long waiting lists.
Will medical team be happy to discharge within the 72 hours and can antibiotic treatment continue and be monitored in the community.
How to overcome the barriers.
Can Mr B be transferred to a delirium/time to think bed.
Can the intensive community liaison service support Mr B on discharge in addition to the CMHT.
Social worker to allocate alternative placement in the community if there are no beds in respite/assessment/discharge to prevent a delayed discharge.
Does Mr B require an inpatient admission to manage the risks safely?

14. Consideration Mrs C Are bloods within normal range.
Is she medically fit for discharge.
Dietician input given low BMI.
Diet/fluid/bowel charts.
Are there any safeguarding concerns around the son/what are the problems?
Is she managing at home independently or does she require social support.
Suicidal intent/risk assessment.
Is she on any psychotropic medication.
Does she require a psychiatric admission to hospital or can the risks be monitored in the community.
Does she have capacity and she will she consent to an informal admission or does a MHA assessment need to be considered.
Collateral information from family.

15. Barriers Mrs C Unresolved physical health problem.
Low BMI and appearing very physically frail, will medical staff be happy to discharge and will psychiatric ward be happy to admit.
Resources limited with regards to bed locally and she may need to go out of area.
Refusing hospital admission.
Getting the required social support in a timely manner.

16. Vision for the Future Delirium ward / unit in the community
Intensive post discharge liaison follow up
Expand Delirium Clinic
Community resources – intensive care teams to prevent unnecessary admission
Timely referal’s to Community Mental Health Teams – in the absence of delirium.