Collaborative Summit Thursday 16 May 2019 The Studio Glasgow - - PowerPoint PPT Presentation

Improvement Hub Enabling health and social care improvement

Frailty at the Front Door Collaborative Summit

Thursday 16 May 2019 The Studio Glasgow #ihubfrailty

Housekeeping

• Please put mobile phones on silent
• If you hear a fire alarm, please proceed to the nearest fire exit
• WiFi name: thestudio, password: customerfirst
• Yellow lanyards –here to help
• Sign in at registration if you require CPD/attendance certificate
• Tweet #ihubfrailty

Aims of the day

Aims of the day

• How will you maintain and build:
• Focus?
• Momentum?
• Support?
• Vision?

Agenda

Time Topic Lead 09:30 Registration and coffee 09:45 Welcome Graham Ellis (National Clinical Lead, Older People, Healthcare Improvement Scotland) 10:05 Engaging your Board Calum Campbell (Chief Executive NHS Lanarkshire) 10:35 Evaluation overview Alison Hunter (Improvement Adviser, Healthcare Improvement Scotland) 10:45 Board presentations:  NHS Dumfries & Galloway  NHS Forth Valley Board Leads 11:25 Coffee Break 11:40 Board presentations continued:  Greater Glasgow & Clyde  Lanarkshire  Lothian Board Leads 12:40 Q&A – A chance for boards to answer any questions Graham Ellis (National Clinical Lead, Older People, Healthcare Improvement Scotland) 13:15 Lunch and networking 14:00 Un-conferencing Graham Ellis (National Clinical Lead, Older People, Healthcare Improvement Scotland) 15:00 Scottish Government Perspective Gregor Smith (Deputy Chief Medical Officer, Scottish Government) 15:30 Next Steps:  Frailty at the Front Door 2  Integrated frailty work with Living Well in Communities (LWIC) Graham Ellis (National Clinical Lead, Older People, Healthcare Improvement Scotland)

What have HIS ever done for us?

https://www.youtube.com/watch?v=uvPbj9NX0zc

What did we do?

Provided direction & change ideas:

• Driver Diagram
• Change Package
• Measurement Plan
• HIS screening tool
• ‘How to’ guidance
• n CGA

Provided on site support & challenge through

• 5 pathway walks
• 6 Value Stream

Maps Networking across 5 sites

• 4 learning sessions to

180 delegates

• 4 project surgeries to

58 delegates

Data reporting and feedback

• 5 teams
• 36 reports
• 100+ run charts

9 new NMAHP

roles to deliver CGA

2 new Frailty

units

1000*CGA

Huddles

20,600*People

screened for frailty Decreased LOS (2 sites)

Increased discharge >75s within 24hrs (1 site)

*Estimated from available data

 Forum - a place to start a conversation or ask a question  Library – a place to upload & share resources with your colleagues and peers  Membership - a place to see who is a member of the group  Notifications – keep up to date

https://www.nssdiscovery.scot.nhs.uk/

Improvement Hub Enabling health and social care improvement

A Chief Executive’s Perspective

Calum Campbell Chief Executive, NHS Lanarkshire

Frailty at the Front Door: A Chief Executive‘s Perspective

Why does it matter to get it right for Older People? What does your chief exec think about frailty at the front door? How do you build sustainable change? How do you make your case for resource?

Older People

Biggest users of inpatient beds Highest mortality rate Highest complication rates after surgery Biggest group in delayed discharges Fastest growing group in population Most likely to consult a GP

Evidence based care

Comprehensive Geriatric Assessment for older adults with frailty works Creating access to what works and evidencing that matters

Chances of breaching

1.7 1.4 1.5 4.3 5 5.5 6.1 6.7 7.3 7.7 8.1 8.9 9.7 11.4 12.4 13.9 15.1 16.5

% 4 HOUR BREACH

Data from A&E departments in Scotland 1/1/17-31/12/17, Courtesy of SCoOP

1/60 1/6

2.6 Beds per 1000

Data courtesy of OECD, 2017

5 10 15 20 25 30 35 40 berdeen Royal Infirmary beth University Hospital y Hospital Hairmyres Dr Gray's Hospital Hospital Crosshouse ity Hospital Wishaw lyde Royal Hospital Median Length of Stay (Geriatric Medicine)

Tackling variation?

Median Geriatric LOS Acute Sites Scotland 2017/18

Data from ISD, 2017/18, Courtesy of SCoOP

How do you build sustainable change/make your case for resources?

Engage a team that share the same vision

Engage

Recruit key people to your case

Recruit

Manage your existing resources to maximise capacity to the best of your ability

Manage

Build your case for development

Build

Aim for the end in mind

Aim

Questions?

Improvement Hub Enabling health and social care improvement

Evaluation Overview

Alison Hunter Improvement Adviser, Acute Care Team

• Key contextual factors
• What was most valued by participants?
• What would have made it better?
• What are the key learning points?

What were we evaluating?

Key contextual factors

What was most valued by participants?

Site Visits for support & challenge Networking to share experiences Time out to think & plan HIS national role as a driver for change Support from the data team Credible clinical leadership Underpinned by open & honest communication

What would have made it better?

Be prescriptive about team make-up Be more pro-active about reporting Facilitate more peer support Provide an

• nline platform

for sharing

What are the key learning points?

Thank you

Improvement Hub Enabling health and social care improvement

NHS Dumfries & Galloway

Board update

Lynne Mann Service Improvement Manager

Who is in your team ?

Original Acute Team

• Consultant geriatrician
• OT/PT
• Pharmacy
• Social Work
• Project/Quality Improvement manager
• Acute physician
• SCN – Combined assessment unit (CAU)
• Nurse manager medicine
• CoE SCN
• Information services
• Health Intelligence
• Project/Quality Improvement manager

New Integrated Team

• Frailty Nurse
• Community nurse manager
• Short Term Assessment

Re-ablement Service (STARS)

• Rapid response/ Nithsdale in partnership

What were your aims at the outset ?

By May 2019, 95% of people aged 75 or over (or 65 years old or over from a care home) presenting for healthcare at DGRI are screened for frailty using a recognised tool and where frailty is identified, a co-ordinated pathway of care is provided. For patients identified as frail;

• Increase in number discharged directly from CAU
• Reduced length of stay in CAU prior to transfer downstream
• Reduced length of stay in downstream ward
• No increase in readmission rates

Data – CGAO2 - % Percentage of people over 75 years old discharged from specified ward/unit within 24 hours

0% 2% 4% 6% 8% 10% 12% 09/09/18 23/09/18 07/10/18 21/10/18 04/11/18 18/11/18 02/12/18 16/12/18 30/12/18 13/01/19 27/01/19 10/02/19 24/02/19 10/03/19 24/03/19 07/04/19 21/04/19 05/05/19 Percentage of patients Week of admission to hospital

Dumfries and Galloway Royal Infirmary

Percentage of people discharged from geriatric beds within 24 hours

Weekly percentage Median

Data – CGAO3 - % or number of people admitted to specialist inpatient geriatric bed, who’s length of stay is longer than 7 days

0% 20% 40% 60% 80% 100% 09/09/18 23/09/18 07/10/18 21/10/18 04/11/18 18/11/18 02/12/18 16/12/18 30/12/18 13/01/19 27/01/19 10/02/19 24/02/19 10/03/19 24/03/19 07/04/19 21/04/19 05/05/19 Percentage of patients with a length of stay of over 7 days Week of admission to hospital

Dumfries and Galloway Royal Infirmary

Percentage of people admitted to a geriatric bed with a hosptial length of stay of over 7 days

Weekly percentage Median

Data – CGA04 - Average length of stay for people admitted to specialist inpatient geriatric bed

5 10 15 20 25 14/10/18 28/10/18 11/11/18 25/11/18 09/12/18 23/12/18 06/01/19 20/01/19 03/02/19 17/02/19 03/03/19 17/03/19 31/03/19 14/04/19 28/04/19 Average length of stay (days) Week of discharge from hospital

Dumfries and Galloway Royal Infirmary

Average length of stay for people admitted to speciality inpatient geriatric bed

Weekly percentage Median

Data – CGAB1 - Number of people over 75, discharged from specified ward/unit, who have re-attended within 7 days

7 11 6 3 3 3 6 4 8 7 3 3

2 4 6 8 10 12 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Number of patients Month of readmission

Dumfries and Galloway Royal Infirmary

Number of people over 75 re-admitted within 7 days following a discharge from geriatric beds

Data – optional extra

10 20 30 40 50 60

14/10/18 28/10/18 11/11/18 25/11/18 09/12/18 23/12/18 06/01/19 20/01/19 03/02/19 17/02/19 03/03/19 17/03/19 31/03/19 14/04/19 28/04/19 Length of stay (in hours) in CAU Admission in week ending

Dumfries and Galloway Royal Infirmary

Average length of stay (hours) in Combined Assessment Unit for patients subsequently transferred to a downstream ward

Avg LOS in CAU (frail) Median LOS in CAU (frail)

Source: Topas

What are you most proud of ?

• Frailty Nurse Appointed
• Frailty Icon & Electronic capture of frailty
• Development of interest group
• Team work and even if the steps were small we

were always moving forward

What is your most important learning you would like to share ?

• Conditions for change
• Perseverance; making small changes when you can, as every small step makes a

difference

• Finding individuals with a interest
• Team resilience - keeping going despite the setbacks and the negativity.
• Publicity, & raising awareness, getting people on side building the guiding collation

What are your next steps ?

• Consolidate and develop role of the frailty nurse
• Complete the daily frailty huddle test, using QI methodology to explore the learning
• Carry out a few site visits to better understand the practical and operational aspects of

a frailty pathway

• Commence the visual development of a frailty pathway
• Explore potential admission avoidance alternatives
• Continue engagement of operational and interest group

Improvement Hub Enabling health and social care improvement

NHS Forth Valley

Board update

Sarah Henderson Consultant

Who is in your team?

Within AMU 3 x Frailty Intervention Team Nurses (1 band 7 team lead and 2 band 6’s) Fastrack therapists (physio & OT) Ageing and Health Consultant of the Day Clinical Development Fellow for Frailty Noon Huddle Above plus Discharge Hub Nurses, Psychiatry Liaison Nurses, Social Work, Closer to Home Team (on the phone) & Older Peoples Nurse Consultant

• Improve identification of Frailty by screening
• Deliver Early Comprehensive Geriatric Assessment
• Ensure the person experiences well coordinated care and support

attuned to their needs, with the focus of support at home or in a homely setting

• Improve the interface and working between health and social care

What were your aims at the outset ?

Screening data

Identification of Frailty

Data – CGAO2 - % Percentage of people over 75 years old discharged from specified ward/unit within 24 hours

• % of patients aged 75 years and over (identified as frail) discharged

directly from CAU/AAU

• % of patients 75 years and over discharged directly from CAU/AAU

Data – CGAO3 - % or number of people admitted to specialist inpatient geriatric bed, who’s length of stay is longer than 7 days

Data – CGA04 - Average length of stay for people admitted to specialist inpatient geriatric bed

Currently awaited – Trakcare launched 2 weeks ago and no information available from information services at present

Data – CGAB1 - Number of people over 75, discharged from specified ward/unit, who have re-attended within 7 days

Going to go back and plot only frail patients with QI.

Review of data showed coding issue Returns for USS (DVT’s) 8 pts were planned returns 4 frail pts 16 GIM pts

What are you most proud of?

• Managed to get 3 full-time nurses
• Managed to change our whole

way of working at the front door.

– Screen – Huddle – Primarily look after Frail patients who now all get CGA initiated by a specialist.

What is your most important learning you would like to share ?

• Data is really important and dedicated QI/Project support is

crucial.

• Don’t give up – it takes time and you can’t change the

whole world in a month.

• Keep going back to your aims to reflect on progress and

plan the next steps

What are your next steps?

Screening

• Look at our processes for this and see if we can refine these. Can Trak help? Could the ED docs/nurses

help?, What can our call handlers pre-screen for us/how reliable are they? Early Comprehensive Geriatric Assessment

• Have the team, build links with therapy colleagues, look at collecting some of this information

electronically with Trak, work with bed managers to push/wards pull the right patients. Coordinate care

• Reflecting on huddles - could members join us in AMU earlier (psychiatry) and feedback at huddle

rather than get referrals, building on links with SW and STA beds to be directly accessable (4 beds new Stirling Care Village)

• Community work streams for unscheduled care

And then…….. Ambulatory unit within AMU for frail patients

Refreshment break

Improvement Hub Enabling health and social care improvement

NHS Greater Glasgow & Clyde

Board update

Dr Lara Mitchell Consultant DME @laramit66043489

Who is in your team?

AHP (Laura Walker) ECAN (Carolanne O’Neill) Health and social care (Fiona Brown/ CRT leads) Consultant DME (me) General Manager (Arwel then Geraldine)

All of the above underpinned by our monthly frailty meetings where:

• Ideas cultivated
• Tests of change planned and executed
• Pathways developed
• Relationships built

20 Consultants DME 5.8 ECAN 2 AHP SW/ Community teams Staff short stay frailty

What were your aims at the outset?

• FRAILTY SCREENING/ CGA
• For all individuals >75 years (and >65 years from a nursing home) presenting at ED or IAU to undergo a frailty

screen and an initiation of a Comprehensive Geriatric Assessment (CGA) at the front door within 24 hours

• CARE COORDINATION
• To ensure coordination of care for frail older patients and the identification of the most appropriate place of care

e.g. home with increased support, short stay frailty ward, acute DME assessment bed, non-acute rehabilitation bed

• r intermediate care bed
• PATIENT CENTRED/ PATHWAY
• To improve the individuals’ experience by providing a person centred, coordinated and dynamic approach to

supporting individuals with a frailty syndrome using a clearly defined pathway

Have we met those aims?

• 1. FRAILTY SCREENING

Monday to Friday all admissions are screened for frailty in unscheduled care and 100% CGA within 24 hours on monthly testing

GROUND FLOOR FRAILTY HUDDLE

10 20 30 40 50 60 70 80 90 100 Apr-16 Aug-16 Dec-16 Apr-17 Aug-17 Dec-17 Apr-18 Aug-18 Dec-18 Apr-19

Number transferred directly to DME bed from ARU 1-3&5

Screening for frailty ground floor

Have we met those aims?

• 2. CARE COORDINATION

Creation of a pathway. From our own data, we know double the amount of patients are getting to our wards earlier and we are taking less from the medical wards

100 200 300 400 500 600 Apr-16 Sep-16 Feb-17 Jul-17 Dec-17 May-18 Oct-18 Mar-19

Number accepted to DME from all sources Short stay ward

• pens. Frailty

team established

20 40 60 80 100 120 Apr-16 Sep-16 Feb-17 Jul-17 Dec-17 May-18 Oct-18 Mar-19

Number transferred directly to DME bed from Medical wards

Short stay ward opens. Frailty team established

Have we met those aims?

• 3. PATIENT CENTRED/ PATHWAY

To improve the individuals’ experience by providing a person centred, coordinated and dynamic approach to supporting individuals with a frailty syndrome using a clearly defined pathway

Data – CGAO2 - % Percentage of people over 75 years old discharged from specified ward/unit within 24 hours

CGA01 CGA02 CGA03 CGA04 CGASL2

% discharged <24 hours % discharged <48 hours LoS > 7 days Av LoS Patient pathway

May- July ‘18 18 % 29% 38% 13.2 days

Short stay 26.6% ARU4 18.6% DME 53.7%

Sept- Oct ‘18 14% 20.6% 51.9% 10.7 days

(HIS frailty)

?

Patients discharged home from ground floor ( non specialty beds)

10 20 30 40 50 60 70 80 90 100 may 16 july 16 sep 16 nov 16 jan 17 mar 17 may 17 july 17 sep 17 nov 17 jan 18 mar 18 may 18 july 18 sep 18 nov 18 jan 19 mar 19

Total Home from IAU / ARU 1-3,5

Data – CGAO3 - % or number of people admitted to specialist inpatient geriatric bed, whose length of stay is longer than 7 days We are going to look at those patients in longer than 30 days On recent data, we know average length of stay is 6 days for acute assessment

Data – CGA04 - Average length of stay for people admitted to specialist inpatient geriatric bed

5 10 15 20 25 30 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18

Short Stay Frailty Unit Opened

29%

reduction in LOS

20%

increased access >1000

>40

extra patients alive at home

£>3M

cost avoided

Short Stay Frailty Unit Moved

3 tests of change – the elevator pitch

AHP weekends Jan- March 2019 a) 159 patients assessed b) 27% discharged home c) 15% discharged

• n the Monday or

tuesday ECAN weekend working ( 2 weekends) a) 28 patients reviewed b) 7 discharged home (saved 42 bed days) c) 10 straight to a speciality bed (off site rehab, dementia/ delirium ward, acute assessment) Communication with short stay ward a) Improved communication b) More rapid discharges

What are you most proud of?

THE TEAM

• They look after each other
• They have great ideas
• They educate others
• They have improved the flow and care

for the older adult at QEUH

• They have changed the culture on the

ground floor

The consultants trust us [ECAN nurses] to make the right decisions – we had a good relationship with them anyway, this work has made it better Metrics agreed across GGC ! Still need to see it in action Change in culture on the ground floor

What is the most important learning you would like to share?

• Invest in your team- they will flourish
• Own your data and work on consistent metrics

at hospital level

• Feedback and debrief regularly
• Be accountable to ‘someone’
• Keep the profile high at a hospital level
• Be brave

What are your next steps?

Business case for weekend

• working. AHP

and ECAN Short stay frailty ward Patient led experience feedback to drive change

Thank you to HIS frailty collaborative for their support and mentorship over the last 18 months. HIS has been a powerful lever for change within our improvement journey

Improvement Hub Enabling health and social care improvement

NHS Lanarkshire

Board update

Yvonne Fielder Service Manager

Who is in your team ?

• Alistair McVean

Clinical Lead Care of the Elderly

• Susan Wilson

SCN Ward 20 and Frailty Unit

• June Delaney

Senior Nurse Care of the Elderly

• Agnes, Frances, Gillian, Ian

ACE Nurses

• Sarah McNally

Occupational Therapist

• Sekhar Santapur

Physiotherapist

• Arlene Brown

Discharge Hub Team Leader

• Jennifer Allan

Service Improvement Manager

• Karen Goudie

Chief Nurse

• Pamela Downey

Information Analyst

• Kerry Paterson/Donna McHenry

Assistant Service Managers

• Yvonne Fielder

Service Manager Care of the Elderly

• Heather Knox

Executive Sponsor

What were your aims at the outset ?

• Deliver a Safe, Effective and Person-Centred Frailty pathway throughout University Hospital Monklands
• Embed a robust Frailty detection process for all patients over 65 years
• Deliver timely CGA for Frailty positive patients identified at initial assessment
• Ensure a ‘Home First’ approach for Frailty positive patients where appropriate, following CGA. i.e. Avoid admission to

hospital if possible

• Work with H&SCP to develop a Discharge to Assess Model

Weekly Average Length of Stay for People Admitted to Specialist Inpatient Geriatric Bed (All CotE Wards)

MAU Nurses Frailty Screening Additonal ACE Resources 2 4 6 8 10 12 14 16 18 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19 Weekly Average LOS in days

Ward 20 Weekly Average LOS (excludes Frailty Unit)

5 10 15 20 25 30 Sep 18 Sep 18 Sep 18 Sep 18 Oct 18 Oct 18 Oct 18 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19 Weekly Average LOS in days

Weekly Average Length of Stay for People Admitted to Frailty Unit

MAU Nurses Frailty Screening Additonal ACE Resources 2 4 6 8 10 12 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19 Weekly Average LOS in days

Ward 20 Discharges Per Week (including Frailty Unit)

Frailty Assess Separate on Trak 5 10 15 20 25 30 Aug 18 Sep 18 Sep 18 Sep 18 Sep 18 Oct 18 Oct 18 Oct 18 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19 Total Patients discharged per week

Frailty Unit (only) Discharges Per Week

MAU Nurses Frailty Screening Additional ACE Nurse Resources 5 10 15 20 25 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19 Total Patients discharged per week

What are you most proud of ?

• Enthusiasm
• Tenacity
• Uncompromising vision (despite the challenges)
• Development of (and commitment to) the 12 bedded Frailty Unit
• Rapid re-energising and ownership of frailty screening in MAU
• Impact on frail patients of a direct move to the Frailty Unit from MAU (avoiding AMRU)

What is your most important learning you would like to share ?

What the team said!

• Have clear and dedicated leadership

‘The project needed dedicated leadership … with no conflicting priorities’

• Establish a clear and focused MDT from the beginning

‘You need the right team together from the beginning – more than doctors and nurses, the full MDT…’

• Start new improvement projects in the summer before the winter challenges

‘Then we would have had more time to understand the issues, establish the pathway and make it business as

• usual. We didn’t have time to fully engage the front door teams, so the frailty project remained a bit
• insular. I think it got a bit lost’
• Understand the data that you need ….. and can access!

What are your next steps ?

• 17 Frailty beds from 27th May 24 bedded Frailty Unit in line with MRRP plans
• Embed Frailty screening in MAU
• Increase number of patients transferring directly from MAU to Frailty Unit (and MAU to CotE)
• Test further changes to the pathway using additional temporary ACE resource
• Testing of Discharge Coordinator role (impact on D2A too!)

Frailty Unit (Only) Weekly Pre Noon Discharge Rate

0% 5% 10% 15% 20% 25% 30% Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19 % Total Discharges Pre Noon

Ward 20 (including Frailty Unit) Weekly Pre Noon Discharge Rate

Frailty Unit Separate on Trak 0% 10% 20% 30% 40% 50% 60% Aug 18 Sep 18 Sep 18 Sep 18 Sep 18 Oct 18 Oct 18 Oct 18 Oct 18 Oct 18 Nov 18 Nov 18 Nov 18 Nov 18 Dec 18 Dec 18 Dec 18 Dec 18 Dec 18 Jan 19 Jan 19 Jan 19 Jan 19 Feb 19 Feb 19 Feb 19 Feb 19 Mar 19 Mar 19 Mar 19 Mar 19 Apr 19 Apr 19 Apr 19 Apr 19 Apr 19 % Total Discharges Pre Noon

What are your next steps (cont.)?

• Support Pharmacy and AHP colleagues to review workforce for Frailty
• Continue to work with H&SCP colleagues to further develop D2A
• Advanced Nursing Practice for CotE – possibilities +++
• Support identification and management of Frailty in the community to optimize quality of life and prevent

unnecessary hospital admission

• Frailty dataset from TRAK
• Patient and staff experience

Falls Data (Ward 20 including Frailty Unit)

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Ward 20 Total Number of Falls

Total Number of falls Median

Ward 20 (including Frailty Unit) Patient Observation Costs By Month 2018-2019

0.00 1,000.00 2,000.00 3,000.00 4,000.00 5,000.00 6,000.00 7,000.00 8,000.00 9,000.00 10,000.00 April May June July August Sept October Nov Dec January February March

Improvement Hub Enabling health and social care improvement

NHS Lothian

Board update

Gillian Cunningham General Manager Medicine Services SJH

Who is in your team?

The Team

Consultant Geriatricians REACH Nurses Discharge Co-

• rdinators

Multi – Disciplinary Ward Teams AHPs Project and Analytical Support Site Management Integrated Discharge Hub

What were your aims at the outset ?

• To improve the process of identification of frailty at the front door and carry out

screening and assessment at earliest opportunity.

• Co-ordinate whole system ‘end to end’ integrated care which improves

experiences and outcomes for people living with frailty who present to unscheduled care.

• Understand the patient population aged 65+/75+ who are discharged from

Medicine and ensure they are put on the right pathway at the earlier point of their acute illness

St John’s Hospital – Setting the Scene

+3% +10% +16% +19% +21% +22% +23% +23% +26% +26% +27%

+27%

+27% +28% +28% +30% +31% +31% +31% +33% +33% +33% +33% +34% +35% +35% +38% +40% +40% +41% +41% +46% +48%

0% +5% +10% +15% +20% +25% +30% +35% +40% +45% +50% Glasgow City Aberdeen City Inverclyde Na h-Eileanan Siar North Lanarkshire East Renfrewshire East Ayrshire Dumfries and Galloway East Dunbartonshire South Ayrshire Falkirk Scottish Borders East Lothian Highland Orkney Islands Midlothian Clackmannanshire

Projected % change in population ≥75 years old, 2016 - 2026

Scotlan d

St John’s Hospital – Setting the Scene

• We do not have a specialist frailty unit on site
• Frailty is managed throughout medicine on the acute site and within the community via community based

teams

• REACH frailty nurse and AHP model in Medical Admissions Unit screening and commence CGA
• Geriatrician within each medical ward
• Integrated multi disciplinary discharge hub
• REACT services inc hospital at home, rehab at home and reablement

Home ED GP

Medical Admission s Downstrea m Medical Ward Downstrea m Rehab Ward

REACT

Discharg e

Discharge Hub Supporte d Discharge Admissio n Avoidanc e

Data – CGAP1: % Patients Screened Following Admission to Medicine

20 40 60 80 100 120 140 160 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019

Number Admissions to MAU % Admissions to MAU Screened % of Admissions Screened Number of Admissions 65+ to MAU

Increase in MAU admissions Reduction in REACH team reducing overall % screened Limitation of REACH being a Monday-Friday service in hours

Data – CGAP2a: % Patients Screened Within 24 Hours of Admission

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019

Percentage Patients Screened in 24 Hours Week Commencing Admission Date

Increase in MAU admissions Reduction in REACH team reducing overall % screened Limitation of REACH being a Monday-Friday service in hours

Data – CGAO1 - % Patients Discharged From Medicine Within 24 Hours

Challenge of MAU capacity Patients move to downstream wards quickly to facilitate flow therefore screening may be missed Identified as an

• pportunity to

identify alternative pathways therefore aim to progress frailty at front door work

0% 5% 10% 15% 20% 25% 30% 35% 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019

% Patients Discharged Within 24 Hours Week Commencing

% Patients aged 65+ and 75+ Discharged home within 24 hours

65+ 75+

Data – CGAO2- % Patients Discharged From Medicine Within 48 Hours

0% 5% 10% 15% 20% 25% 30% 35% 40% 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019

Patients Discharged Within 48 Hours Week Commencing

% Patients aged 65+ and 75+ Discharged home within 48 hours

65+ 75+

Challenge of MAU capacity Patients move to downstream wards quickly to facilitate flow therefore screening may be missed Identified as an

• pportunity to

identify alternative pathways therefore aim to progress frailty at front door work

Data – CGAO3- % Patients With Length of Stay 7+ Days inc. Delayed Discharges

Integrated Hub Launched

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019

Percentage of Patients Discharge Week Commencing

Percentage of Patients 65+ and 75+ with a Length of Stay 7+ Days on Discharge

65+ 75+

Challenges of: Community service capacity Follow through

• f CGA from

admission unit Complexity of discharge requirements

Data – CGAO3- % Patients With Length of Stay 7+ Days exc. Delayed Discharges

Integrated Hub Launched

• 10.0%

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019

Perecentage of Patients Discharge Week Commencing

Percentage of Patients 65+ and 75+ with a Length of Stay 7+ Days on Discharge Excluding DDs

65+ 75+

Need to create

• pportunity to

provide earlier planning and intervention, follow through

• f CGA from

admission, 7 day working

Data – CGAO4- Average Length of Stay inc. Delayed Discharges

Integrated Hub Launched

5 10 15 20 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019

Average Length of Stay (Days) Discharge Week Commencing

Average LoS Patients 65+ and 75+ with a Length of Stay 7+ days on Discharge

65+ 75+

Challenges of: Community service capacity Follow through

• f CGA from

admission unit Complexity of discharge requirements

Integrated Hub Launched

2 4 6 8 10 12 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019

Average Length of Stay (Days) Discharge Week Commencing

Average LoS of Patients 65+ and 75+ with a Length of Stay 7+ days on Discharge Excluding DDs

65+ 75+

Need to create

• pportunity to

provide earlier planning and intervention, follow through

• f CGA from

admission, 7 day working

Data – CGAO4- Average Length of Stay exc. Delayed Discharges

Data – CGAB1- % Patients Readmitted Within 7 Days

0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 01/01/2018 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019

Percentage of Patients Readmitted Within 7 days Discharge Week Commencing

% Patients 65+ and 75+ Readmitted within 7 days of Discharge

65+ 75+

Data – CGAB2- % Patients Readmitted Within 30 Days

0% 5% 10% 15% 20% 25% 30% 01/01/2018 08/01/2018 15/01/2018 22/01/2018 29/01/2018 05/02/2018 12/02/2018 19/02/2018 26/02/2018 05/03/2018 12/03/2018 19/03/2018 26/03/2018 02/04/2018 09/04/2018 16/04/2018 23/04/2018 30/04/2018 07/05/2018 14/05/2018 21/05/2018 28/05/2018 04/06/2018 11/06/2018 18/06/2018 25/06/2018 02/07/2018 09/07/2018 16/07/2018 23/07/2018 30/07/2018 06/08/2018 13/08/2018 20/08/2018 27/08/2018 03/09/2018 10/09/2018 17/09/2018 24/09/2018 01/10/2018 08/10/2018 15/10/2018 22/10/2018 29/10/2018 05/11/2018 12/11/2018 19/11/2018 26/11/2018 03/12/2018 10/12/2018 17/12/2018 24/12/2018 31/12/2018 07/01/2019 14/01/2019 21/01/2019 28/01/2019 04/02/2019 11/02/2019 18/02/2019 25/02/2019 04/03/2019 11/03/2019 18/03/2019 25/03/2019

Percentage of Patients Readmitted Within 7 days Discharge Week Commencing

% Patients 65+ and 75+ Readmitted within 30 days of Discharge

65+ 75+

What are you most proud of?

• Shown that the frailty (in)REACH model works
• It can be nurse led with consultant geriatrician

input when required

• Proactive management and follow through of

CGA plan is essential

• Early family/patient engagement is key
• Increased the proportion of patients supported on

discharge through REACT services.

• Front line staff engagement and willingness to try

different approaches has been fantastic!

What is your most important learning you would like to share ?

• Shown that the frailty (in)REACH model works and achieves many flow markers such as reduced length
• f stay and improved patient experience through various tests of change including:
• REACH presence in front door observation ward
• Daily frailty rapid run down in medical ward
• Continuity and/or robust handover along with communication from screen through CGA and onwards

is key

• Robust staffing model is needed and staff need to feel valued
• It has to be a team/service based approach, not reliant on an individual
• Limited capacity to sustain team has meant we have not been able to test further opportunities

identified by value mapping

What are your next steps?

• Strive for sustainability of REACH model and team
• Review and define the team and consolidate synergies of teams
• Focus internally on ways of working and processes
• Share our learning at Frailty Programme Board
• Aim for more robust CGA
• Take the opportunity to develop frailty at the front door – Redesign

Q&A’s

Lunch & Networking

Improvement Hub Enabling health and social care improvement

Unconferencing

Graham Ellis & Alison Hunter

Unconference Session; Peer to peer discussion

Unconferencing

The Fundamental Law of Unconferencing

“The sum of the expertise of the people in the audience is greater than the sum of expertise of the people on the stage” Dave Winer

Source of image www.citynet.com

Traditional workshop

The agenda is pre-set One way learning style with Q&A People sit in rows or around a table Networking between sessions Hard to leave the session once it starts Absorbing information

Unconference

People set the agenda Based on discussion People sit in a circle Networking the whole time Encouraged to find the right session Connecting to action

@HelenBevan @Kathrynperera @horizonsnhs Source: adapted from @BCPSQC

Traditional Workshop vs Unconference

The Unconference: 4 principles and a law

Principles:

• 1. Whoever comes are the right people
• 2. Whatever happens is the only thing that could have

happened

• 3. When it starts is the right time
• 4. When it’s over, it’s over

The law is known as the Law of Two Feet: “If you find yourself in a situation where you are not contributing or learning, move somewhere you can”

Your chance to ask that question

• Think about a topic you would like to explore further
• It should be a topic or an idea you want to take action on over the

next 12 months to take your agenda forward

• Write your topic down on a piece of paper
• Bring it to the front and pitch your idea
• Themes will be allocated to tables
• Delegates choose which topic to go and hear about

Table Lead

• Once at your table introduce your question
• r topic for discussion
• State what you hope to get from the

discussion

Unconferencing Questions

1) How to get patient/carer involvement in planning pathways 2) ANP led ward round at weekends 3) Making Frailty work in ED 4) Alternatives to admission 5) Integrating frailty into current pathways 6) How do we influence more positive risk taking with colleagues 7) Whole system integration 8) How do we raise the process of CotE and make it more attractive for nurses

Improvement Hub Enabling health and social care improvement

Scottish Government Perspective

Gregor Smith Deputy Chief Medical Officer, Scottish Government

Dr Gregor Smith

Deputy Chief Medical Officer for Scotland

@DrGregorSmith

A story about sore knees….

Projected % change in Scotland’s population by age group: 2010 - 2035

Lancet 2012; 380: 37–43 Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study Karen Barnett, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke, Bruce Guthrie

Multimorbidity in Scotland

What is ‘Realistic Medicine’?

As healthcare professionals we must:

Listen to our patients - find out what matters most to them - and help them make an informed choice; Address over-treatment (not just under-treatment) Challenge variation in clinical practice; and Offer higher value care

“It’s ok not to follow the guideline provided the reasons are well

• documented. So things that for the majority of people wouldn’t be

advised, for some it might be ok.” Professor John Kinsella

‘‘Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.’ William Osler (1849-1919)

Personalising Realistic Medicine

We must do more to live the core principles of “careful and kind care”

Focus on the person - understand their preferences and values Focus on the service we provide - strive to provide ‘Careful and Kind Care’

It’s about: Good communication Asking the right questions

Citizen’s Panel and Jury

“What should shared decision-making look like and what needs to be done for this to happen?”

• 1. A programme to begin to inform and educate patients
• f their right to ask questions of their health

professional and the benefits of doing this in terms of what they want and the best outcome for them.

• 2. There must be training for all health and social care

professionals so that they use shared decision-making.

• 3. There needs to be independent people who can join

conversations between medical professionals and patients.

The Jury’s Recommendations – Top 3

High quality care that isn’t appropriate is still low value care

Population Technical Personal Using Triple Value to tackle Unwarranted Variation

Scottish Atlas of Healthcare Variation

Surgical Procedures

• Hip replacement
• Knee replacement
• Cataracts >65
• Cholecystectomy
• Hernia
• Tonsillectomy

Same Day Surgery

• Inguinal Hernia
• Lap Cholecystectomy
• Tonsillectomy (adult)
• Tonsillectomy (<16)

“Very interesting to explore the reasons that sit behind the variations - good to have the numbers to support

• pening those

discussions.” “Great start - hope it expands to a wider range of indicators.” “This is excellent. I would be happy to help with any future development to look at provision for cardiovascular disease in Scotland.” Prescribing

• Heart Failure
• Statins 45+
• Stroke
• Triple Whammy 65+

Scottish Atlas of Healthcare Variation

• Tonsillectomy – 2.5

fold variation in use across Scotland

• Deliberation within

clinical community about reasons

• Identification of

drivers of unwarranted variation

• Consensus statement

https://www.isdscotland.org/Products-and-Services/Scottish-Atlas-of-Variation/

cmo@gov.scot @DrGregorSmith

Keeping in touch or Questions

www.realisticmedicine.scot

Improvement Hub Enabling health and social care improvement

Next Steps

Graham Ellis National Clinical Lead

Changes to FATFD 2.0

• Reduced travelling – greater use of Webex
• Amended steering group
• Wider peer network
• Simplified Dataset
• Discovery?
• Members portal
• More emphasis on pre-work and readiness for

change

• Reorganised curriculum

You wait all day for a collaborative…

Frailty at the Front Door 2.0

You wait all day for a collaborative…

Living and Dying Well with Frailty Care Homes BTS Frailty at the Front Door 2.0

Focus on Dementia – Specialist Dementia Units

You wait all day for a collaborative…

Focus on Dementia – Stress and Distress in a General Hospital Living and Dying Well with Frailty Focus on Dementia – Care Coordination Care Homes BTS Frailty at the Front Door 2.0

Focus on Dementia – Specialist Dementia Units

You wait all day for a collaborative…

Focus on Dementia – Stress and Distress in a General Hospital Living and Dying Well with Frailty

• Integrated. Frailty System

Focus on Dementia – Care Coordination Care Homes BTS Frailty at the Front Door 2.0

What is an integrated system for frailty?

Living and Dying Well BTS FATFD Care Home BTS Living and Dying Well BTS

Living and Dying Well BTS FATFD Care Home BTS Living and Dying Well BTS Integrated Frailty System

Whole system diagnostics System mapping Co-design with stakeholders Leadership and team working Improvement methodology and skills Evaluation, Resource and Learning for HIS

Research Frailty Tool Evaluation SCoOP Quality Assurance OPAH HEI CAAS SCoOP Growing Older in Scotland Leadership SCiL SPSP Project Lift Etc.

Conditions for change

And finally…

• Well done
• Don’t give up- where next, what next?
• Report in…
• Offer advice
• Steal shamelessly, acknowledge

graciously, share willingly

• Celebrate Success as often as possible

Have a safe journey home