Intro toolkit frailty in primary care 150415 slide pack

WELCOME

Wednesday 15 April 2015 Webinar

Introducing a Toolkit to support the management of Frailty in Primary Care

Introducing a Toolkit to support the

Management of Frailty in Primary Care

Wednesday 15 April 2015

12.30pm – 1.30pm

Helen LyndonNurse Consultant Older People, Clinical Lead Frailty, NHS England

&

Beverley MatthewsLTC Programme Lead, NHS Improving Quality

Beverley Matthews

LTC Programme LeadNHS Improving Quality

[email protected]

LTC Year of Care Commissioning Programme:

• 5 Early Implementer sites

• 35 Fast Followers

• Whole Population Datasets

• Implementation Guide

• Simulation Modelling

• Specialist Support Team

LTC Person Centred CareImprovement Programme:

• 40 Early Implementer sites

• 4 regional learning networks

• Snapshot Survey

• Simulation Modelling

• Specialist Support Team

Long Term Conditions Learning Community

• LTC Dashboard

• Case Studies

• Lunch and Learn Series

• The Bulletin

• Specialist Support Team

@NHSIQ @bev_j_matthews #LTCimprovement #LTCyearofcare

LTC Lunch & Learn Series ….coming soon…

Date Webinar Hosted by Bev Matthews &

17 April 201512.30 – 13.30

Information Standards for End of Life Care (ISB150) supporting the implementation of Electronic Palliative Care Coordination system

Adam Hatherly, HSCIC&

Christine Wike, NHSIQ

29 April 201512:00 – 13:00

Information Sharing for Care Coordination Adam Hatherly, HSCIC&

Christine Wike, NHSIQ

1 May 201512:30 – 13:30

Information as a Therapy Mark DumanMRPharmS DirectorMonmouth Partners

6 May 201512:30 – 13:30

Prevention & Effective Interventions inFrailty

Helen LyndonNurse Consultant Older People, Clinical

Lead Frailty, NHS England

27 May 201512:30 – 13:30

Primary Care Workforce for the 21 Century Webinar

Sharon LeePrimary Care Workforce Facilitator

South Kent Coast CCG

9 June 201512 noon – 1pm

Health 1000 Rob MeakerBarking, Havering & Redbridge

Introducing a Toolkit to support the management of Frailty in Primary Care

• Understanding the concept of frailty as a long term condition.

• Understanding how frailty can be managed effectively in primary care.

• Understand how to access and implement practical tools which can support identification, assessment and care planning for older people living with frailty in primary care.

of Care foundation.

Today’s Learning Outcomes

www.england.nhs.uk

Devon and

Cornwall Frailty

Toolkit.

Helen Lyndon

Nurse Consultant

Clinical Lead for Frailty

NHS England

Lunch and Learn Webinar 15th April 2015

www.england.nhs.uk

• Understand the concept of frailty as a long term

condition.

• Discuss how frailty can be managed effectively in

primary care.

• Access and implement practical tools which can

support identification, assessment and care planning

for older people living with frailty in primary care.

Introducing a Toolkit to Support the

Management of Frailty in Primary

Care

www.england.nhs.uk

Frailty – a complex syndrome of

increased vulnerability

11

Life course

determinants:

BiologicalGenetic

Psychological

Social

Environmental

Decline in

physiologic

reserves

+

Multiple

long term

conditions

Candidate markers:

Nutrition

Mobility

Activity

Strength

Endurance

Cognition

Mood

Adverse Outcomes:

Disability

Morbidity

Hospitalisation

Institutionalisation

Death

Prevent/delay frailty

Primary prevention

Health promotionDelay onset

FRAILTY

Delay/prevent adverse outcomes

Rodriguez-Mañas L, Fried LP. Frailty in the clinical scenario. Lancet. 2014 Nov 6

Reversibility

www.england.nhs.uk

A definition of frailty

• Frailty is not a disease but a combination

of the natural ageing process and a variety

of medical problems.

• It focuses on the loss of reserve, energy and wellbeing.

• A useful definition is: “Multidimensional loss of reserves -

energy, physical ability, cognition and health”

Rockwood et al (2005)

Ageing Fitness

Disease

www.england.nhs.uk

Frailty is a loss of physiological reserve

Clegg, Young, Rockwood Lancet 2013

www.england.nhs.uk

Frailty as a Long Term Condition?

A Long Term Condition is: “A condition that cannot, at present, be cured but

is controlled by medication and/or other

treatment/therapies” (DH 2012)

Frailty is:

• Common (25-50% of people over 80 years)

• Progressive (5 to 15 years)

• Episodic deteriorations (delirium; falls; immobility)

• Preventable components

• Potential to impact on quality of life

• Expensive

www.england.nhs.uk

Proactive interventions in frailty

Ten years ago

Two years ago

One month ago ‘He is a

fall

waiting to

happen

“Dad is

slowing

down”

“I’m not

as steady

on my

feet as I

was”

www.england.nhs.uk

Proportion alive

Time

Primary care electronic Frailty Index (eFI): survival plots (n=227,648; >65y)

Fit

Mild frailty

Moderate frailty

Severe frailty

5 yrs

www.england.nhs.uk

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

www.england.nhs.uk

Questions and

discussion