Jon Tose Developing a strategy for frailty in South Tyneside Whats - PowerPoint PPT Presentation

Developing a strategy for frailty in South Tyneside Jon Tose

Developing a strategy for frailty in South Tyneside • What’s the problem? • What’s the plan?

By 2030, the number of people over 80 will have doubled… Emergency hospital admissions by age band 700,000 Over the last decade, some 40% 85+ Number of admissions 600,000 80-84 of the increase in emergency 500,000 75-79 70-74 admissions is from over 65s 400,000 65-69 300,000 200,000 100,000 - The rate of emergency readmissions has also grown faster for older people In 2008, there were 1.9 million Population estimates for frailty: people with more than one long 65-69 = 4% term condition. By 2026, 3 million 70-74 = 7% people will have three long term 75-79 = 9% conditions 80-84 = 16% Over 85 = 26%

Multimorbidity in Scotland ( Scottish School of Primary Care Barnett et al Lancet May 2012) The majority of over-65s have 2 or more conditions, and the majority of over-75s have 3 or more conditions

Frailty is loss of physiological reserve Frailty syndromes present in crisis FUNCTIONAL ABILITIES Hyper-acute “Minor illness” eg Frailty syndromes: UTI • Immobility Independent • Falls • Delirium Dependent • Fluctuating disability • Incontinence (Clegg, Young, Rockwood Lancet 2013)

STRUCTURAL, RELATIONAL & CULTURAL FRAGMENTATION (SILOS OF PROVISION) HOSPITALS PRIMARY CARE SOCIAL CARE COMMUNITY COMMUNITY HEALTH AMBULANCE NURSING SERVICES SERVICES MENTAL NURSING & HEALTH VOLUNTARY CARE HOMES PHARMACY SECTOR SERVICES HOSPITAL-AT- HOME; “VIRTUAL WARDS; COMMUNITY HOSPITALS; HOME THERAPY TEAMS; COMMUNITY MATRONS; SPECIALIST NURSES; CARE HOME REHAB; PALLIATIVE CARE; “ENABLEMENT” SERVICES, etc , etc…

Does anybody want my patient?

WHOLE SYSTEMS THINKING

Remember this? https://www.kingsfund.org.uk/audio- video/joined-care-sams-story

Outcomes to Focus On TOP 3 AREAS For BEST PRACTICE HIGH OUTLIER IMPROVEMENT medication emergency hospital activity reviews [4] admission within within last year of 30 days [16] life [19] polypharmacy [5] unplanned admissions [15]

Developing a strategy for frailty in South Tyneside • What’s the problem? • What’s the plan(s)?