Dr Dai Roberts Programme Development Lead Farah IrfanKhan Project Manager Health Innovation Manchester Falls amp Fractures the facts Falls and fractures in people aged 65 and over account for over ID: 1048562
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1. Frailty, Falls & Fragility Dr Dai Roberts -Programme Development LeadFarah Irfan-Khan – Project ManagerHealth Innovation Manchester
2. Falls & Fractures - the facts Falls and fractures in people aged 65 and over account for over four million hospital bed days each year in England aloneThere are ~65,000 hip fractures in the UK each yearCosting the health and social care £2 billion a year£33% of people >65 will suffer a fall rising to 50% for people >85 Hip fractures account for 4000 inpatient bed days daily
3. Greater ManchesterHospital admission rate for falls averages at 44% across GM Expected annual costs for falls£62,275,961£Around 10% of people aged over 65 years have frailtyNWAS data shows that 11% ambulance call outs were for falls
4. Ambition for frailty… ‘Everybody should know what to do next when presented with a person living with frailty and/or cognitive disorder’
5. Frailty is not good for you
6. Emergency bed days by ageIf the 08/13 years and 12/17 years are compared by age (under 65 vs over 65s), the biggest changes are for those who are over 65 years.Whilst the pattern is essentially the same for the two groups, the biggest absolute changes are for those age 65+.Bed days have been split for the under 65’s and those aged 65 years and over.
7. Greater Manchester Strategic Case Reducing the number of falls is a key priority articulated in the GM HSCP Sustainability and Transformation Plan ‘Taking Charge’Reducing 2750 serious fallsGM HSCP Five Transformation Themes
8. Project aimTo reduce falls and fractures related to frailty across Greater Manchester through early identification, treatment and management of patients at risk
9. Tameside & Glossop Neighbourhood Frailty MDT Model This MDT model aims to identify, review and manage severely frail patients at risk of falls and fractures using the electronic Frailty Index (eFI), Fracture Risk Assessment Tool (FRAX) and Falls Risk Assessment Tool (FRAT)92. Risk stratification using FRAT & FRAXNeighbourhoods across Tameside & GlossopeFI1. Collect baseline data on severely frail patients using eFIKey enablers to support T&G Transformation Programmes
10. The model eFIFRATFRAX
11. Potential InterventionsThis project aims to reduce falls and fractures related to frailty across Greater Manchester through early identification, treatment and management of patients at riskCommunity physiotherapyMedicines optimisation of bone sparing therapy drugsFalls programmeRelevant local authority, domiciliary care and voluntary services Community Response ServiceComplete Summary Care Record Social dimensionsSocial isolationShort form questions –to impact on resilience and adherence to treatments –e.g. local community groups for referral on toE.g De Jong Gierveld
12. OutcomesThis project aims to reduce falls and fractures related to frailty across Greater Manchester through early identification, treatment and management of patients at riskEarly identification, treatment and management of patients at risk:Reduction in hip and fragility fracturesDecrease in mortality rates due to hip fracturesEarly and increased identification of osteoporosis and high risk patients Reduction in non-elective admissions related to falls and fracturesBetter outcomes for patients with a reduced risk of disability and loss of independence
13. Milestones achievedStalybridge Frailty MDT pilot launched on 31 January 2018Data Sharing Agreement produced for Frailty MDT which has been approved by the West Pennine LMCOpportunity to deploy population health toolkit, Vision Outcomes Manager, being progressed Engagement with:Martin Vernon, National Director for Older People, NHS EnglandIndustry partners Bury GP FederationNorthern AHSNs as part of the wider ‘Bone Health Programme’Stalybridge Neighbourhood TeamPublic Health Trafford Council
14. FinancesIT costsCost for FRAX licensing is £20,000Deployment of Vision Outcomes Manager is available via the GP Systems of Choice contractual framework No costs associated with integrating FRAT Frailty MDT model costsThe cost to backfill a GP/team for Frailty MDT is £300 per practiceTransformation Funding to Stalybridge Neighbourhood Predictive ROI: £3,925,276
15. Risks and Challenges Delays in approval of Data Sharing AgreementsLow uptake of the Vision Outcomes ManagerContinued variation, falls & fractures!Establishing baseline data for each Locality Engagement with Localities to take up project will be challenging due to increasing demands on general practice