Clinical Network: Frailty - PowerPoint Presentation

1. Clinical Network: FrailtyClinical Director: Bettina WanProposed Interventions and OutputsTarget Outcomes Target ImpactTalking about frailty: Tailored guidance and professional communications developed to promote understanding of frailty to people whose expression is influenced by socioeconomic deprivation. Report launched with UCLP, Care City and Clinical Networks webinar held as part of proactive promotional campaign. Increased number of referrals to social prescribing schemesIncreased number of referrals to anticipatory care servicesSupport proactive focus on frailty to prevent ill-health and address health inequalities related to frailtyEnhanced workforce competencies on frailty identification and managementTargeted regional communications campaign to improve the completion of frailty e-learning training within priority workforce. This includes staff working in UEC, services managing long-term conditions, elective care and care homesPublish a report on findings of uptake 6 months post launch.Evaluation prepared summarising education and training programme pilot testing phase involving LAS paramedic use of the Clinical Frailty Scale (CFS)Develop scalable hybrid education training programme for LAS across London to support wider application of CFS.Monitor data on uptake of CFS on LAS systems by paramedics.Expand education training  from Paramedics in field to Clinical Advisory Service (CAS) in LAS support call centreIncreased number of existing workforce that can recognise, assess and provide personalised interventions related to frailtyIncreased number of patients aged ≥65 with CFS recorded in ambulance dataset and emergency care datasetIncreased % of patients aged ≥65 screened for frailty within 30 minutes of arrival to emergency department, as per national targetImproved skills and capabilities around recognising, assessing for and providing personalised interventionsImproved crisis recovery for people living with frailty through access to appropriate servicesImproved urgent and emergency care responsiveness through more effective triaging to services such as SDEC, community urgent response, virtual wardsSDEC Falls – DataCollaboratively work with London digital transformation lead and team to explore coding for falls.Test bed in one area to identify a cluster of codes that reflect falls.Utilise codes to explore pathways and patient journey from 999/111 call to treatment.Falls identified by agreed set of data codes to be able to measure weight of demand on services across community and secondary careICSs supported to identify opportunities for improvements in falls pathways, benchmark and monitor progress madeImproved crisis recovery for people living with frailty through access to appropriate servicesImproved urgent and emergency care responsiveness through more effective triaging to services such as SDEC, community urgent response, virtual wardsCommunity Delirium PathwayTask and Finish group mobilised.Develop a community pathway to treat delirium under the umbrella of Virtual ward/ Hospital at Home for Frailty.Ensure stakeholder engagement in pathway developmentCascade new alternative pathway for management of delirium in communityReduction in the number of patients admitted for an inpatient hospital stay for management of delirium that could be supported via virtual ward / hospital at Home pathwaysImproved crisis recovery for people living with frailty through access to appropriate alternative pathways at homeImproved urgent and emergency care responsiveness through more effective triaging to services such as SDEC, community urgent response, virtual wardsIntegrated networking with London Renal NetworkEnsure Clinical Network for Frailty and Palliative and End of Life Care are represented within this newly formed networkIncreased cross collaboration between frailty and renal care specialitiesIdentify gaps in pathway delivery that requires improvementsIncrease recognition of frailty (e.g. use of CFS) within renal care Increase number of patients living with renal conditions and frailty who have a personalised care and support plans relating to their frailty needsImproved quality of life of people living with chronic renal conditions and frailty through frailty assessments and personalised care plans that targets frailty specific needsKeyCommenced activityDevelopment Phase

2. Mental and physical health interface for people living with frailtyRecognition that there is variation in how people at crisis point with both physical and mental health problems receive access to servicesComplete stakeholder engagement to define problem statement Mobilise a task and finish group to define key enablers and solution focussed pathwaysDevelop an ICS recommendations framework to support improved equity of access to most appropriate service or resource at time of crisis. Support coordinated London ICS action to address.Reduced emergency department attendance/ hospital admissions/ length of stay of people with frailty and mental health diagnosesImproved crisis recovery for people living with frailty who have both physical and mental health needs Medicines related and role of community pharmacistsExplore over prescription of medications that are high risk for people living with frailtyIdentify where there is variation in prescription linked with sub-segmentation of frailty using eFI index and prescriptionExplore and capture any potential variation in medicines optimisation  and annual review checks.Identify key enablers to support de-prescription were appropriateReduced average number of medicines prescribed for people living with frailtyReduced % of people living with frailty on pre-defined high risk medicationsReduced number of emergency department attendance/ admission related to medication side effectsImproved use of resourcesImproved quality of life of people living with frailty Frailty as part of Virtual ward/ Hospital at Home pathwayMobilise wider system leadership for change and establish a phased approach to implementing frailty virtual wards across LondonAlignment of established leadership, funding, staffing resources and existing programme activity enables rapid mobilisation, removes duplicated effort and optimises use of finite resourcesSupport phase 1 development of frailty virtual ward for care home residents in London in collaboration with EHCH, Rapid response teams and community pharmacyEstablish remote monitoring requirements for frailty virtual wardsCreate a mutually supportive learning environment where good practice and immediate insights from Test Bed delivery is shared openlyCollaboration with other SCN’s such as Dementia, PEOLC and DiabetesReduced pressures in acute hospitals, including:​Reduced emergency department attendance​Reduced bed days​Improved patient flowIncreased number of frailty virtual wards operational across London providing agreed and standardised  offerImprove evidence on the value of technologies to support people living with Frailty Improved crisis recovery for people living with frailty through access to appropriate servicesImproved urgent and emergency care responsiveness through more effective triaging to services such as SDEC, community urgent response, virtual wards ​Frailty within Perioperative servicesIdentify a test bed surgical pathway in one acute Trust Explore frailty screening in line with the CPOC guidelines on frailty screeningIncreased number of patients receiving a frailty screen pre-operativelyIncreased number of patients on a peri-operative pathway who have a frailty measure Increased number of patients who have targeted personalised care plans put in place in line with CGA.Improved elective care that better meets the need of people living with frailty Population health managementDevelopment of a CHImE dashboard that reflects data for frailty and health inequalities.Maturity Matrix shared and helps set frailty ambitions for each ICS.ICS supported to address areas of inequity and variationImproved regional, ICS, Borough and PCN level understanding of where there are health inequalities linked with frailtySupport ICS commissioning to understand frailty related priorities and enable improvementsSupport proactive focus on frailty to prevent ill-health and address health inequalities related to frailty