Winstanley GP PCN CD West Kent GP lead for Frailty and Local Care Owen Ingram Consultant Geriatrician MTW Amy Heskett Associate Specialist in Geriatrics Home Treatment Service ID: 933301
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Slide1
Managing Frailty
Ginny
Winstanley
(GP, PCN CD, West Kent GP lead for Frailty and Local Care)
Owen Ingram
(Consultant Geriatrician MTW)
Amy
Heskett
(Associate Specialist in Geriatrics, Home Treatment Service)
Deirdre McCauley, Helen Terrell, Jenny Brown
(Frailty GPs, West Kent Primary Care)
Slide2Agenda
West Kent Frailty service update - Proactive and reactive services and the plan for West Kent
Frailty GPs - how can they help you?
Prescribing and frailty
Treatment escalation planning
KMCR- What is it and why should we use?
Q+A
Slide3National Context
Long Term Plan & Ageing Well Programme
An overview: Ageing Well Programme
More joined up, coordinated care with a much stronger emphasis on proactive care
Deliver integrated, personalised care in communities via three key focus areas
Care makes sense to people and they get what they need when they need it
Slide4Local Context
West Kent has c. 11,100 people with high or very high levels of frailty
The growth in the severe frail population between 2020 and 2030 is expected to be 24.6% in West Kent, (or an additional 2,741 people).
The expected increase in numbers with multiple and complex needs is more modest at 9.8%.
The incidence of dementia is expected to grow by 17% between 2020 and 2030
Slide5What can we do?
RECOGNITION! Identify and code
Comprehensive Geriatric Assessment
Multicomponent, Multidisciplinary assessments
Medical, Drugs, Cognition, Psychiatric, Mobility, Functional, Continence, Advanced care plans,Doctors, Nurses, PAs, OT, Physio, SALT, Pharmacy, Social servicesAnticipatory Care planning Refer to frailty teams!
Slide6Frailty Definition
Oxford English Dictionary:
The condition of being weak and delicate
Is it normal ageing?
Is it helpful or perjorative?Medical Definition?
Slide7WHO Healthy Ageing
“The process of developing and maintaining the functional ability that enables wellbeing in older age”
meet their basic needs;
to learn, grow and make decisions;
to be mobile;to build and maintain relationships; andto contribute to societyIt requires ‘intrinsic capacity’ of the individual and relevant environmental characteristics
Slide8What is frailty?
A syndrome of physiological decline in late life, leading to an increased vulnerability to poor resolution of homeostasis after a stressor event
Slide9Models of frailty?
Phenotype Model (Fried 2001):
unintentional weight loss,
exhaustion,
muscle weakness,slowness while walking, andlow levels of activityThe phenotype model is a precursor to Rockwood’s Clinical Frailty Scale
Slide10Clinical Frailty Scale
Slide11Slide12Models of Frailty?
Frailty Syndrome
Fallers
Patients with delirium
Patients with immobilityPatients with incontinencePatients with polypharmacy / drug side effectsCare home resident
Slide13The Goal
Slide14West Kent Frailty Services
REACTIVE
Acute Frailty Units
Home Treatment Service
Primary CarePROACTIVEFrailty MDTsEnhanced Health in Care Homes
Slide15Acute Frailty Unit - MTW
Maidstone and Tunbridge Wells Frailty Units
2 Acute Frailty Units
Maidstone
9 assessment beds on Whatman WardTunbridge Wells7 bedded assessment area on Ward 2Opening hours8am-8pm Monday-Friday8am-6pm Saturday-Sunday
Slide16Acute Frailty Unit Metrics
TWH
Seeing 60-70 patients per week
50% discharged on the same day
MaidstoneSeeing 50-60 patients per week50% discharged on the same dayRe-admissionsNo increase in re-admissions since AFUs openedSignificant reduction in LOS since AFUs opened
Slide17Pathways
ED pathway to AFU:
All patients >70 screened using CFS by triage / Rapid assessment (RAP)
Direct referral from RAP
clinican to AFUAll patients with Frailty screened by AFU team to see if appropriateSECAM to AFU:Direct referral from paramedics (1-2/day each site)Home Treatment Team / Frailty GPs:Community patients for Admission (or ED) avoidance
Slide18Home Treatment Service
Slide19Home Treatment Service
03000 247111
Slide20PCN Frailty MDTs
Running since Sep 2017
Twice monthly meetings per PCN, via MS Teams
Include:
- MDT Coordinators - Frailty Nurses/Complex Care Nurses - Physiotherapy - MDT pharmacists - Dementia Nurses - Health and Social Care Coordinators - Social Services - Geriatrician - Frailty GPsSupported by : Age UK, Kent Fire and Rescue
Slide21MDT Referrals April 2021 – January 2022
PCN
April
May
June
July
August
September
October
November
December
January
Referrals received
ABC
12
14
13
12
13
19
19
21
17
8
148
Maidstone Central
24
20
28
21
18
20
22
19
25
25
222
Maidstone South
17
15
19
25
5
15
19
29
6
21
171
Malling
10
5
7
7
4
13
7
1571287Sevenoaks24172419172518241722207The Ridge13171091115123990Tonbridge18141920162624212710195Tunbridge Wells44403031443032333229345Weald11212617151116152121174Grand Total1731631761611331701621891551571639
CGAs
Slide22Slide23Slide24Emergency Attendances
Start Date: 1st April 2016
NHS Trust: MTW Only
CCG: West Kent CCG Only
Cohort of patients discussed in MDT: Between 1
st
January 2019 to 31
st
August 2019 Age: 60+
Number of patients: 715
A&E
MIU
Total
Admissions 12m before
2310
30
2340
Admissions 12m after
2026
18
2044
Increase/Decrease of
-284
-12
-296
% of Increase/Decrease
-12%
-40%
-13%
Slide25Slide2678
Respondants
MDT Experience: 78% extremely good/good, 6% poor/extremely poor.
MDT teams and services working well together 80% positive, 5% negative57% respondants felt effectiveness and quality of the MDT meetings improved compared to 12 months ago, 37% felt as though it has remained the samePatient identification: 46% felt as though it was easy, 20% difficult. MDT User Survey June 2021
Slide27What next?
1. Improving Identification of patients
Aim to increase proactive care after reactive episodes. What went wrong? What next?
Improving follow up of patients following unplanned admissions:
- CCNs in board roundsFrailty teams to review lists of over 80s with unplanned admissions Review of care home admissions2. Developing PCN frailty teams to support GPs and streamline working between teamsMove to set meeting days per PCN to allow continuity of MDT staffTriaging of referrals and coordinated approach to assessmentsFrailty GPs to support actions practice EMIS systems3. Additional ServicesDementia Care CoordinatorsIncreased hospice support with care planning
Slide28Frailty
GPwER
project
Since Jan 2020
2 WTE Frailty GPs recruited to support MDTs and pro-active care within PCNs9 GPs working towards accreditation to become frailty GPwERs Weekly meetings to discuss cases with Frailty consultant and Home Treatment ServiceFacilitate admissions to Frailty Unit from primary care. Worked with HTS during pandemicSupporting training of ANPs working with MDTs via joint visitsProviding geriatric reviews and care planning for those patients unable to get to outpatients or GP surgeriesAim to work alongside dementia GPwERs to support dementia diagnosis and treatment in the communityChampions for KMCR within primary care, aiming for rapid adoption and in sharing MDT outcomes and and care planning with acute and out of hours providers
Slide29Frailty GP
Slide30Frailty GP service
7 GPs
7 hrs per week per PCN
Weekly supervision to discuss difficult cases
Integrated into community teams via MDT and HTS
Integrated into hospital teams via the frailty unit
Slide31What we do
Slide32How can we help you
Most referrals from MDT
Review of the more complex medical problems.
Support with care planning discussions
Discussions around capacity and adult safeguarding
Arrange investigations via the frailty unit for pts unable to access through usual routes
Slide33Pharmacology and Frailty
Dr Owen Ingram
Consultant Geriatrician and Physician MTW
Frailty Lead Consultant
Slide34Objectives
To understand the principles of safe prescribing for the older patient
The increased use of drugs in elderly patients and the increase on adverse drug reactions
The effect of the ageing process on pharmacokinetics and pharmacodynamics
Factors affecting compliance The rules for rational prescribing for elderly people
Slide35Polypharmacy
Defined as:
Taking 5 or more regular medications
Or as
'Appropriate Polypharmacy' vs 'Problematic Polypharmacy'
Slide36Slide37Polypharmacy
in the Elderly
16% of over 65s taking >10 medications
Elderly patients in hospital
Average take 6 regular medicationsIncrease by 3 medications on dischargeElderly patients in nursing homesAverage 8 regular medicationsTrials often don't include frail, elderly patients with co-morbidities
Slide38Adverse drug reactions
Each additional medication increases the risk of errors
A nursing home study showed 70% of residents were exposed to a drug error
Adverse drug reactions cause:
6.5% of hospital admissions (increasing to 10% in the over 65s)Median length of stay 8 days0.15% mortality rateCommonest implicated medications:Aspirin, NSAIDs, anticoagulantsDiureticsDiabetic drugs
Slide39Pharmacokinetic implications of Ageing
Route of Administration
Distribution
Metabolism
AbsorptionElimination
Slide40Pharmacokinetic implications of Ageing
Route of Administration
Distribution
Metabolism
AbsorptionElimination
Dysphagia, Delirium, Compliance
Inflammation /
Polypharmacy
Low albumin, low body water
Reduced liver function / I and IsReduced eGFR
Slide41Factors hindering safe prescribing:
Heterogenic
cormorbid
patient groupIncreasing prevalence of polypharmacyLimited applicable evidence and trials in this cohortHigh incidence of adverse drug reactionsUnpredictable pharmacokinetics complicated by polypharmacyCompliance and cognitive impairmentHealthy ageing vs frailty
Slide42Prescribing advise in the elderly
Is the indication still relevant?
Concentrate on QOL not disease specific prescribing
Start slow and low
Avoid starting 2 drugs simultaneouslyAvoid co-prescribing antagonistic drugsConsider non-pharmacological options or other routesInclude drug side effects in the differential diagnosisTry not to treat drug side effects with extra drugs
Slide43Preventative Medicine
Avoiding side effects
Slide44Indicators that a medication review is required?
Adverse drug reaction
>10 regular medications
Falls:
Increased incidence of falls in those >4 medicationsMedication review shown to reduce falls riskMarkers of frailtyNew palliative diagnosis
Slide45Validated tools to review
polypharmacy
Beer's Criteria
Recommended list of drugs to avoid in elderly people – with reasons
http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdfSTOPP / START criteriaScreening tool of older persons potentially inappropriate prescriptionsScreening tool to alert to right treatmentDeprescribing.orgAlgorithms for safely deprescribing PPIs, benzos and antipsychoticsAnticholinergic risk scaleScale categorising anticholinergic burden of specific drugs
Slide46Clinical Scenario
Mrs RC is a 94yo nursing home resident with a past history of stroke, hypertension and dementia. Her regular medications are:
Aspirin 75mg OD Dipyridamole 200mg OD
Atorvastatin
80mg OD Amlodipine 10mg ODBendroflumethiazide 2.5mg OD Donepezil 5mg ODAmitripylline 10mg OD 2 weeks ago she developed abdominal pain, urinary incontinence and agitation. She was started on:Oxybutinin 2.5mg OD Risperidone 0.5mg BDOn review today she is drowsy and her oral intake has reduced. What could have been done differently to avoid this deterioration?
Slide47Clinical Scenario Take 2
Mrs RC is a 94yo nursing home resident with a past history of stroke, hypertension and dementia. Her regular medications are:
Clopidogrel 75mg OD
Dipyridamole 200mg OD
Atorvastatin 20mg OD Amlodipine 10mg ODBendroflumethiazide 2.5mg OD Donepezil 5mg ODAmitripylline 10mg OD 2 weeks ago she developed abdominal pain, urinary incontinence and agitation. She was started on:Oxybutinin 2.5mg OD Risperidone 0.5mg BDMovicol 1 sachet once dailyA bowel and bladder chart with PRN laxativesParacetamol 1g QDSToday her agitation has resolved and she has occasional accidents
Slide48Compliance in the elderly
50% of prescribed medications not taken
Why?
Patient Factors
Medication FactorsHealthcare FactorsCognitive impairmentPolypharmacyPatient educationSensory deficitsPoor labellingRegular follow upLack of caregiver
Side effectsPatient involvement
Slide49Techniques to aid compliance
Educate and empower patients
Simplify drug regimes
Discuss regimes with carers
Inform of early side effectsEncourage use of drug diariesUse large print on bottles, that are easy to openMonitored Dosage SystemsTelemedicineCovert administration
Slide50Slide51Top tips and common pitfalls - Bladder
Anticholinergics for overactive bladder:
Avoid if possible unless clear benefit and consider mirabegron
Stop if dementia / delirium
Don’t co-prescribe with donepezilConsider non-pharmacological management of incontinenceStop if history of urine retention or catheterisedTamsulosinLong term catheter negates need for tamsulosinIf postural hypotension consider finasterideRecurrent UTIAvoid long term AbxConsider topical oestrogens
Slide52Top tips and common pitfalls - BP
Nitrates and Nicorandil in fallers
Do they still suffer with angina? Have they had a recent cardiac event?
Do they really still need the vasodilators?
Swollen legs and furosemide didn’t help?Maybe its venous insufficiencyCould we stop his amlodipine?Digoxin 250mcg is a red flag – drop it 125mcgSupine hypertension with postural hypotensionNo right answer, no good evidenceInvolve the patient in decision on continuing antihypertensivesAccept a higher BP target
Slide53Top tips and common pitfalls – Blood thinners
Dual antiplatelets
Has a year gone by since their MI
Aspirin and
dipyrimadoleSwitch to clopidogrelAnticoagulation and antiplateletIs this a specialist recommendation or did the physician on call forget to stop the aspirin when they diagnosed them with AFAnticoagulation and fallsIn general patients need to be falling a lot before you consider stopping their anticoagulation….I get worried when its >1 per week
Slide54Top tips and common pitfalls – Brain drugs
Benzodiazepines
Avoid and try and stop – consider melatonin if sleep a concern
Antipsychotics in dementia with BPSD
Avoid if possibleDeprescribe if symptoms improve (don’t just continue ad infinitum)Antipsychotics in schizophrenia / psychotic depressionWhen did they last have a major psychotic episode?Is it worth asking an old age psychiatrist if its time to reduce the dose?Phenytoin and barbituratesIf their last seizure was before you graduated medical school its time to ask the neurologist if we can reduce / stop itAmitriptyline – surely there is a cleaner drug for the job
Slide55Top tips and common pitfalls – Miscellaneous
Betahistine
Unless they truly do have Meniere’s try not to use it long term
Are you sure they don’t have BPPV?
StatinsIs it primary or secondary prevention?Are they in the last year of their life with severe frailty?NSAIDsAvoid at all costsInsulin and oral hypoglycaemics, in advanced dementia / frailty with variable oral intakeOften requirements reduceAim to avoid hypos and symptomatic hyperglycaemia (not HbA1C)
Slide56Any Questions?
Slide57References
The King's Fund:
Polypharmacy
and medicines optimisation 2013
Adverse drug reactions as cause of admission to hospital: Prospective analysis of 18 820 patients. Pirmohamed et al 2004A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Alhawassi 2014Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Mangoni et al 2004Assessment of Renal insufficiency in patients with normal serum creatinine levels undergoing coronary angiography Mujtaba et al 2010Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes NICE 2015Deprescribing.orgIdentifying Medications that Older Adults Should Avoid or Use With Caution: the 2012 American Geriatrics Society Updated Beers CriteriaADHERENCE TO LONG-TERM THERAPIES Evidence for action. WHO 2003Caring for older people: Aids for Compliance with medicationEnsuring appropriate use of monitored dosage systems: reducing unnecessary pharmacy workload. Nice Quality and Productivity 2015Medicines Management in Care Homes: NICE Guidelines 2015
Slide58TREATMENT ESCALATION PLANNING
WHAT?
WHY?
WHEN?
HOW?
Slide59Slide60WHY DO A TEP?
To avoid acute admissions for those living with frailty or long term conditions.
If
in line with a person’s goals in place of their choosing.To provide practical support to allow the above
Slide61WHEN TO DO A TEP?
Multiple admissions associated with a reduction in function
When care needs are hard to replicate in a hospital
Person expresses a desire to avoid admission
In context of frailty or multiple long-term conditions
Slide626%
11%
24%
RISK OF DEATH DURING HOSPITAL ADMISSION BASED ON DEGREE OF FRAILTY
Slide63BE BRAVE
BE KIND
BE CURIOUS
ALLOW TIME
HOW TO DO A TEP?
Slide64-
What makes a good day?
-If you were very poorly what should we focus on?
-if you were so unwell and you could not speak- what would your wishes be?
Slide65Hospital could be an option if:
SEE AS A MENU!
-heavy bleeding
-broken bone
-if carers/family are not able to support care needs-if worsening despite treatment at home-hospital based investigations required
Slide66Slide672AM TEST…….
WOULD THIS TEP BE USEFUL AT 2AM FOR A PARAMEDIC CREW?
Slide68List common scenarios
Slide69ReSPECT
Document
Slide70ReSPECT aims to:
put each individual at the centre of the conversation
shared understanding between person and clinician
focus on treatments to be given, not just one to be withheld record agreed clinical recommendations be recognised across all boundaries
Slide71How was
ReSPECT
developed?
Many individual stakeholders
(e.g. patients, doctors, nurses, ambulance clinicians) Representatives of many stakeholder organisations Integrated ethical and legal best practice
Responded to feedback from users
Support from Resuscitation Council UK
Continued evolution in response to feedback
Slide72https://www.youtube.com/watch?v=SdkncGjihG0
Slide73KMCR
Slide74Slide75KMCR
Key Benefits in management of patients with frailty and complex care:
Shared electronic record of Treatment escalation plans
Shared record of MDT meetings
Shared record of frailty assessments
Slide76KMCR
Slide77What is KMCR?
The Kent and Medway Care Record (KMCR) will give staff access to shared patient information from across health and social care by providing a shared care record solution.
The KMCR contains data from multiple health and social care systems, joins it up at patient level, and displays the information in one place for the benefit of staff and citizens. The KMCR includes data from:
GPs Acute Trusts Community Trusts
Local Authorities
Mental Health Trusts
Out of Hours Services
Ambulance Services
HospicesThe information available in your instance of KMCR depends on local preferences and maturity of the project within your organisation.
The system access you have will be determined by the RBAC (Role Based Access Control) role you have been assigned by your organisation, this will either an Admin or Clinical Role.
Slide78Integrated Health and Social Care for Kent & Medway
Slide79EMIS SSO Login
The screenshot below is an example of an EMIS SSO login with screenshots from a GP Practice. Always make sure you are in the Care Record before accessing KMCR.
Slide80Slide81Contingency plan 1/2
Slide82Contingency plan 2/2
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Slide86Epaccs
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Slide89Q+A