Following Frailty

[Phil Wood]

Pathway%201.1.pptx

We all want to improved choice, care and support, quality and timeliness of pathways or models of care that support frail older people as the Health and Wellness system interacts with them.

I attach a 'map' of where such models may fit in.

What will hopefully be helpful is to have a broader range of examples that are in service around New Zealand, or at least in the planning  / review stage. We can all learn a lot from each other.  It's not a competition!

We should also not be afraid of some commentary, hard questions, and request for good evidence wherever possible.

Whether it is an acute demand pathway, or a long term support approach, feel free to post examples and who is the best person to talk to about this. NB no emails / Phone numbers please

[Pat Flanagan]

Hi Phil, I'm very interested in the social and community aspects of elderly care; given the growing evidence around loneliness and social isolation being risk factors for premature deterioration and death. I am attaching a link to an article describing a cross generational Residential home initiative in the Netherlands. I was wondering how we can encourage such initiatives here in New Zealand? There has to be a number of opportunities in the community for such initiatives.......

[Phil Wood]

The concepts of mixed housing developments suitable for a true community as well as avoiding the ghettoising of older folk is a "work in progress".

There is nothing on paper, but it certainly is of interest especially where there is considerable housing shortfalls, e.g. Auckland.

Having students "living in" is a novel idea, and it probably could work in some circumstances. Proximity to transport to universities et cetera would be only one part of the need. In general there are more examples of younger folk visiting, perhaps even performing some light duties, reducing social isolation and loneliness, and maybe receiving some compensation for this. There may be considerable implications for safety, security et cetera that would have to be put in place to support this.

Has anyone else seen or know of such examples in NZ  or elsewhere?

[Deborah Callahan]

...especially given the cost of student housing in Auckland!

[Karen Day]

Nice diagram Phil. I would argue that the home (the image in the middle) should dominate rather than appearing to be equal to/smaller than the health service icons. There doesn't appear to be an icon for social support in this model, i.e. it seems quite clinical. 

What are your thoughts on emphasising the time not in care, i.e. the proportion of independent/self-care? 

[Phil Wood]

Yes, the diagram has been through various iterations, depending on audience. Ideally there would be a HUGH and dominant home but  practical matters precludes this. I'll boost the home size when I get  to use it again. 

I can see where you're coming from with regards social services. The diagram was more to do with pathways of movement/activity rather than support mechanisms that underpin or promote such movement or stability.

Representations of such diagrams could reflect a variety of perspectives, with Treasury particularly interested in the flow of $! Time in health versus time in ill-health would in general be in another representation.

The audience in the past has been largely clinical/funding and planning, hence speaking in that language.

We have to consider how to reflect the "Positive Ageing Strategy" under MSD, Office of Senior Citizens. It talks more to the social context of wellness/well-being. It would be interesting to see how this "diagram" would be remodelled in that context.

[Ruth Haynes]

Hi Phil and Pat,

what about a Ministry For Loneliness? UK now has.

Having just completed a test of change with our local ambulance service to inform the service of acute demand pathways available to them for the elderly they are called to, we are now working together as nursing clinicians and ambulance officers, referring at risk elderly to community nursing services, falls programs etc.

[Deborah Callahan]

Social connectedness is a very important part of health and wellbeing and under-recognised in many of our medical models. We know in COPD that anxiety is both caused by and drives exacerbations, and that personal touch at the moment of calling for an ambulance is important in reducing unnecessary ED presentations. 

[Anna Skinner]

Health%20of%20Older%20People%20Hospice%20Presentation%20Anne.pptx

I'm attaching a slightly old powerpoint about the HOP team running at our practice. Our DHB also has good pathways for assessing frailty on Map of Medicine and an Interface Geriatrician daily in ED.

[Pat Flanagan]

Karen, Ruth Anna, service integration and social support themes coming through. Just providing a link to a section on the Health Navigator website about social support and social prescribing

As part of the self management support project we pulled together and developed a range of resources and training. This work on developing a tool to map peoples social networks is interesting - Any thoughts

Pat

[Phil Wood]

Hi All, I'm not getting back to this site often enough,. Great comments and ideas out there. I'll get onto individual comments, but rest assured, other will be reading and can always feel free to respond. Getting like minds together is what this all about.

[Phil Wood]

I like to direct you to a "Interdisciplinary Approach to Frailty at the Front Door" an abstract to the Internal Medicine Society of Australia and New Zealand due in, March 2019. I'm not sure why it is visible this early as the program isn't published! It's worth the short read.

So what else is being explored in New Zealand by a similar process focusing at the hospital setting?

http://www.imsanzconference.co.nz/emma-green--rosie-winters.html

See also 

http://www.bgs.org.uk/june-2016/newsletter/news-jun16/jun16-identif...;

[Phil Wood]

Last year I travelled back to one of my old haunts in the UK. I worked in Leicester for about 5 years in various capacities last century. One role was at the Royal infirmary as a co-admitting acute admission consultant. I knew they had moved on a lot and become very influential in Frailty pathways in Acute care. It is a big hospital of around 1,000 beds, and they have a couple of unitis / wards supporting acutely unwell frail older people. below is an abstract about the service. It is planning to evolve again with a specially built part of the ED unit. While this example is beyond the needs of most NZ hospital (it's an economy of scale issue) the principles and processes are generic to making things more suited to the frail older patient. After 7 years of various alterations etc it is still very much an integral part of the Hospital and has a very stable staff.

Leicester, UK: In early 2011, a 12 bed “Emergency Frailty Unit” (EFU) was established within the ED of the Leicester Royal Infirmary, focusing on older patients who were likely to be discharged home within 24hrs, by embedding a comprehensive geriatric assessment pathway within the ED [4]. The business case for the EFU was predicated on reducing the proportion of elderly patients presenting to ED who go on to be admitted for on-going hospital care (the ED ‘conversion rate’). Geriatricians provided complete medical cover for the service from 8am-6pm, 7 days a week. Secondary/primary/community care pathways were developed and strengthened; for example, the EFU assessment was able to be used as the admission assessment and management plan in community rehabilitation facilities.
A historical cohort evaluation of the impact of the EFU over its first 2 years, showed a significant reduction in the number of older people aged >85yrs requiring hospital admission (ED conversion rate falling from 69.6% to 61.2%). This was despite an 18% increase in the number of >85 yr old patients attending the ED during the intervention period (rising from 638 per month in 2010 to 753 per month in 2012). The 90 day readmission rate following discharge from the ED also fell from 26.0% to 19.9%. However, the mean length of inpatient stay was increased (from 8.9days to 11.1 days); possibly explained by only the sickest of elderly patients being admitted to hospital. ED conversion rates fell across all age groups and are thought to be related to the time freed up for emergency physicians to care more comprehensively for younger patients