Integrated Care for Older People with Frailty and Multimorbidity Helen Lyndon, Nurse Consultant, Clinical Lead Frailty, NHS England Lucy Watson, Director of Quality, Safety and Governance, Somerset Clinical Commissioning Group Dr Mike Pearce, General Practitioner, Somerset Clinical Commissioning Group
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Integrated care for older people with frailty and multimorbidity, pop up uni, 12.00, 3 september 2015
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Integrated Care for Older People with
Frailty and Multimorbidity
Helen Lyndon, Nurse Consultant, Clinical Lead Frailty, NHS England
Lucy Watson, Director of Quality, Safety and Governance, Somerset Clinical Commissioning Group
Dr Mike Pearce, General Practitioner, Somerset Clinical Commissioning Group
Our session today • Introduce the concept of frailty and multimorbidity in older people.
• To update the on the work NHS England is undertaking to promote
the concept of frailty as a long term condition including products
that can support service development within a community and
primary care setting.
• Implementation in practice - information from Somerset CCG to
embed the frailty pathway in Symphony data and collaborative working pilots and Unplanned Admissions Direct Enhanced
Service.
Where is frailty?
“ I know it when I see it but what I see may not be the same as what everyone else sees” Community dwelling adults aged 65+ = 7% - 12% Community dwelling adults aged 85+ = 25% - 50%
The Frailty Paradox Not recognised
Not diagnosed
Not recorded
Chen, X, Genxiang, M, Sean X (2014) Frailty Syndrome: an overview . Clinical Interventions in Aging
2014:9 433–441
Frailty – a complex syndrome
of increased vulnerability
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Life course determinants: Biological Genetic Psychological Social Environmental
Decline in physiologic reserves + Multiple long term conditions
Primary care electronic Frailty Index (eFI): survival plots (n=227,648; >65y)
Fit Mild frailty Moderate frailty Severe frailty
5 yrs
Implementation of a pathway of care for older
people living with frailty – NHS England Guidance
If frail older people are supported in living independently and understanding their long-term conditions, and educated to manage them effectively, they are less likely to reach crisis, require urgent care support and experience harm.
This document summarises the evidence of the effects of an integrated pathway of care for older people and suggests how a pathway can be commissioned effectively using levers and incentives across providers.
http://www.england.nhs.uk/ourwork/pe/safe-care/
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Healthy active ageing and supporting
independence
Living well with long term
conditions
Living well with complex
comorbidities and frailty
Rapid support close to home in
crisis
Good acute hospital care when needed
Good discharge planning and
post-discharge support
Good rehabilitation
and reablement
High quality nursing and
residential care home care
Choice, control and support
towards the end of life
Cross-organisational standards
Commissioning intentions CQUINNS Frailty toolkit
Frailty Toolkit for Primary Care
Includes: • Case finding tools and advice • How to populate frailty registers and
read coding • Comprehensive geriatric assessment • Care coordination • Care planning • Medication review in frail older
people http://www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/long-term-conditions-improvement-programme/house-of-care-toolkit/national/commissioning/tools-and-levers/enhanced-services-resources.aspx