Care for Older People Tuesday 14 May 2019 2pm to 4pm Developing - - PowerPoint PPT Presentation

Members’ Event: Integrated Care for Older People

Tuesday 14 May 2019 2pm to 4pm

Dr Sanjay Suman Clinical Co-Director (Medical)

Developing Pathways of Care for Frail Elderly

Therapies and Older Persons Program Medway NHS FT

Alison Streatfield

Clinical Co-Director (Nursing)

April Thompson

Head of Therapies

Agenda

• Introduction- why are we here?
• Where have we come from
• Where are we now
• Where are we going
• Q&A

• What is the programme?
• Who are we?
• What do we want from you….?

Introduction – why are we here?

Frailty is best viewed as a long term condition

Isolated functional decline Progressive functional decline Dependence Disability Incapacitation

Trajectory of Decline

Clinical Frailty Scale: Tool to identify frailty

Medical Functional Social Psychological

Comprehensive Geriatric Assessment (CGA) Gold Standard for frailty management

INDIVIDUAL CARE & SUPPORT PLAN

• How frail is the individual (Trajectory)
• Managing acute illnesses
• Optimising underlying co-morbidities
• Optimising Polypharmacy
• Optimising physical function
• End of Life decision making
• Family meeting / managing expectations
• Ceiling of care
• Criteria for Discharge
• Expected Date for Discharge
• Identifying and meeting care needs

MDT Role

Trust strategy

Our values put our patients first and inspire us to be the B.E.S.T BOLD – We are inspiring and ambitious EVERY PERSON COUNTS – We are respectful and supportive SHARING AND OPEN – We are open and speak up TOGETHER – We are inclusive and responsible

Innovation Financial Stability Our People

Clinical Strategy Quality Strategy Workforce Strategy System Financial Recovery Plan Transformation Programme Culture Programme Integrated Partnership Digital Transformation Continuous Improvement Estates Strategy

Supporting Strategies Key enabling initiatives

HIGH QUALITY CARE

Integrated Healthcare

Where have we come from?

Developments since September 2018

• Dedicated Multidisciplinary

Team (Nursing, Medical, Therapies, Pharmacy, Discharge Team)

• Consultant-Led Unit
• Focus areas:

 Rapid turnaround (<72 hours)  Improvements to the physical space befitting of a frailty unit i.e. Enablement Café, Dementia-friendly garden

ED / Medical Assessment Unit

September 2018

Sapphire Acute Frailty Unit (SAFU)

October 2018

• MDT Embedded: Front Door

Therapist, Frailty Specialist Nurses, Pharmacist)

• Identifying Frailty in ED (Clinical

Frailty Scale applied)

• Consultant led pathway: 7

days, 12 hours

• Comprehensive Geriatric

assessment commenced in ED

• Frail Patients streamed to

Acute Frailty Unit or Frailty Bed Base depending on Expected Date of Discharge

Frailty Flow

November / December 2018

• Establishment of SAFU

Huddles / Board Rounds  Consolidation of Board Rounds and daily Huddles with MDT engagement  Development of Frailty Specialist Nurse roles to support flow directly to SAFU and Frailty bed base (FBB)

• Official opening of SAFU

13/12/18

MFT Frailty Village “Poet’s Wing”

January 2019

• Frailty “stocktake”

workshop held (22/01) to:  Finalise MFT Frailty Village 3- 5 year vision – “Ideal State”  Develop Cycle 1 BBB Improvement programme workstreams (see slides) which includes the Frailty “Hot Clinic” mobilisation for GP rapid access  Introduce the BBB Improvement methodology into Frailty to realise vision

Where we are now? Poet’s Wing:

Medway’s Acute Specialist Frailty Village

Vision Statement “….A specialised acute wing receiving emergency admissions directly into the care of the Frailty Service using evidence-based best practice interventions to support exceptional care for frail patients. Poet’s Wing will provide a comprehensive multidisciplinary assessment and inpatient service for frail people requiring acute, hospital-based support. The wing will also house ambulatory care for unplanned and planned patients requiring non-inpatient support, which is directly accessible from primary and emergency care….”

October 2018

The Butterfly Garden

Poet’s Wing:

Medway Hospitals first dementia friendly therapy garden.

• To reduce the average length of stay (LoS) for frail older patients to an average of 10 days across

the Frailty Bed Base and 72hrs within Frailty Short Stay (SAFU);

• To optimise the number of frail older people returning home on the same day;
• To reduce the pressure on other emergency pathways and services who do not specialise in the

care of frail older people.

• To accelerate the initiation of appropriate clinical interventions for frail patients who do

require admission;

• Reduce avoidable readmissions among the frailty patient cohort;
• Reduce the associated incidences of hospital-related harm and deconditioning for

admitted frail patients;

• To meet the quality standards of the Silver Book to provide CGA for all patients presenting

with frailty syndrome within 2 hours (14-hours overnight);

• Reduce the number of inpatient ward moves and encroachment into other specialty beds;
• Provide a more personalised care approach for all Frail patients and their families / carers

to ensure the acute stay is minimised and patients safely return home as soon as possible Optimise flow Improve safety & quality Enhance patient experience

• To reduce the direct and indirect costs associated with increased length of stay to the

acute trust, community and third sector partners and patients themselves;

• To enhance the Trust’s reputation and become known for providing

exceptional care for frail patients – and thereby be in a position to recruit and retain specialist staff. Improve sustainability

Where are we going?

We are listening to you and investing in a programme to improve our capacity to provide safe, quality, value for money care.

Home unwell present Assess Decision to Admit Admit Place

Inpatient

Treat

Medically Fit

Ready to leave

Awaiting Transfer

• f Care

Transfer

• f Care

Commun ity

We want to lead in Higher Quality Care

Why?

• Because we believe that best care will be achieved by

the right person, in the right place, at the right time.

• ‘There’s no place like home’ and that safe, timely

discharge is our goal.

• We believe that our people deserve the opportunities

and support to arrive at work knowing that they are empowered to contribute to the delivery of high quality care and leave knowing they have delivered.

• We believe that working with partners we can improve

the outcomes and efficiencies for the people we serve across our local health and social care system.

Thank You

SAVE THE DATE! Our next members’ event ‘A taste of Medway’ will be on 9 July 2019.