new models of integrated care for frailty...new models of integrated care for frailty prof anne...
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New Models of Integrated Care for Frailty
Prof Anne HendrySenior Associate, International Foundation for Integrated Care
ADVANTAGE JA WP 7 Lead
ADVANTAGE JA“A comprehensive approach to promote a disability-free Advanced age in Europe:
the ADVANTAGE initiative”
The number of people 65+ is predicted to rise from 18% to 28% by 2060
12% of the population will be aged 80+
• Policy Joint Action with 22 Member States and 33 organisations
• Co-funded by the EU and the Member States.
• January 2017 - December 2019 (3 years)
• COORDINATOR: Hospital de Getafe SERMAS, Madrid Spain
• UK Lead – Scottish Government / NHS Lanarkshire
ADVANTAGE JA work packages
(Coordination WP1+ Dissemination WP2+ Evaluation WP3)
Knowing frailty at an individual level
WP4
Knowing frailty at a population level
WP5
Treating/approaching frailty at an individual level WP6
Models of care to prevent, delay or treat frailty WP7
Extending and expanding knowledge on frailty
WP8
Develop ‘Frailty PreventionApproach’ (FPA) and buildconsensus on addressing Frailty in Europe
Implementation
Phase I (2017) - State of the Art - background information collection, analysis, rational discussion and drafting of preliminary documents.
Phase II (2018) – Survey of MS status on frailty,developing and testing draft version of common European model to approach frailty (frailty prevention approach –FPA document).
Phase III (2019) - drafting final documents, debating these with participant MSs, and drafting the final framework (FPA document and policy recommendations).
Robust Pre-Frail or Frail Functional
Limitation
Disability Dependency
Healthy life style advice
Technology enabled support for self management
Reablement support , telecare, ADL advice
and support
Rehabilitation, equipment, housing,
care and support
Care coordination, carer support,
palliative and end of life care
Early identification and intervention can reverse / delay the trajectory and enable adaptation and resilience.
Frailty and Multimorbidity
Lancet Public Health 2018Published Online June 13, 2018http://dx.doi.org/10.1016/S2468-2667(18)30091-4
Preventing Frailty
• Start active ageing recommendations at mid life
• Asses risk for malnutrition using the Mini Nutritional Assessment
• Promote a Mediterranean diet /daily protein >1-1.2 g per kg
• Target BMI < 30
• Low intensity exercise (endurance, flexibility, balance, resistance training) in sessions of 30 to 45 minutes, three times per week.
• Vitamin D supplement if increased risk for falls / fracture
Identifying Frailty
Opportunistic screening in patients over 70 years using tools that are:
Quick to administer (taking no more than 10 minutes to complete).
Do not require special equipment.
Have been validated and are meant for screening
Deficits that make up the electronic Frailty Index
36 Frailty deficits of eFI
20 Disease statese.g., • Hypertension • Arthritis• Chronic Kidney Disease• Ischaemic Heart Disease• Diabetes• Thyroid Disease• Urinary System Disease• Respiratory System Disease
8 Symptoms / signs• Polypharmacy• Dizziness• Dyspnoea• Falls• Sleep Disturbance• Urinary Incontinence• Memory & cognitive problems• Weight loss & anorexia
7 Disabilities• Visual Impairment• Hearing Impairment• Housebound• Social Vulnerability• Requirement for care• Mobility & transfer problems• Activity limitation
1 Abnormal Laboratory Value• Anaemia and haematinic
deficiency
Slides from NHS England
“Fit
” (
50
%)
0 -
0.1
2 o
r 0
–4
def
icit
s
“Mild
Fra
ilty
” (3
5%
)>
0 .1
2 –
0.2
4 o
r 5
–8
def
icit
s
“Mo
de
rate
Fra
ilty
” (1
2%
)>
0.2
4 –
0.3
6
or
9 –
13
def
icit
s
“Sev
ere
Fr
ailt
y”
(3%
)>
0.3
6 o
r m
ore
th
an
13
def
icit
s
Increasing eFI = Increasing Frailty
Source: Development and validation of an electronic frailty index using routine primary care electronic health record data
What do eFIscores mean?
Slide from NHS England
Fit
Mild frailty
Moderate frailty
Severe frailty
5 yrs
Outcomes by stage of frailty
Time (days)
Reducing proportion alive
Source: Development and validation of an electronic frailty index using routine primary care electronic health record data
Slide from NHS England
Validated against outcomes associated with frailty, e.g.
• Emergency admissions
• Emergency bed days
• Nursing home admission
• Mortality811
2,028
4,195
7,844
Fit Mildfrailty Moderatefrailty Severefrailty
Emergencybeddaysper1,000personyear
-
36%
53%
119%
Leastfatigued(Q1) Q2 Q3 Mostfatigued(Q4)
%IncreaseineFIfromleastfatiguedquartile
Validated against fatigue, a phenotypic characteristic of frailty (separate research)
Source: Analysis of supplementary data from Development and validation of an electronic frailty index using routine primary care electronic health record data
Source: Unpublished research by Dr Dawn Moody
Validation of eFI
Managing Frailty Comprehensive Geriatric Assessment Care planning and tailored MDT interventions Telehealth and telecare solutions Falls prevention interventionsTools to reduce inappropriate polypharmacy
Integrated Care for Frailty
a single entry point – generally in Primary Care
simple frailty screening tools in all settings
comprehensive assessment and individualised care plans – including for carers
tailored interventions by interdisciplinary team – both at home and in hospital
case management and coordination of care and support across providers
effective management of transitions between teams and settings
shared electronic information tools and technology enabled care
clear policies and procedures for service eligibility and processes.
Hendry, A, et al. Integrated Care: A Collaborative ADVANTAGE for Frailty. International Journal of Integrated Care, 2018; 18(2): 1, 1–4. DOI: https://doi.org/10.5334/ijic.4156
Context in Scotland
Population 5.5 million
National Health Service
• Universal coverage
• No co-payments
• 14 unified Health Boards
• 38 Hospitals
• 1020 General practices
• 32 Local Authorities
• Free personal care for 65+
Cabinet Secretary for
Health and Wellbeing
Cabinet Secretary for
Finance, Constitution
and Economy
Minister for Local
Government and
Community
Empowerment
Person centred and Integrated care in all policiesCross Government Collaboration
JIT is a strategic improvement partnership between the Scottish Government, NHSScotland, COSLA and the Third, Independent and Housing Sectors 20
Reshaping Care for Older People
• 2011- 2021
• £300 million Change Fund 2011-15
• Change Plans agreed by health, social care, housing, voluntary and independent sector partners
• 20% of funding to be invested in support for carers
Frailty in Primary Care
‘Frailty Five - Must Dos for Me’
Anticipatory Care Plan Polypharmacy Review Falls Risk assessment + TEC solutions Carer support plan and emergency plan Care manager - continuity and coordination
Intermediate Care
• Reablement
• Rapid Response / Early Supported Discharge
• Hospital at Home
• Step Up / Step Down community beds
Telecare
0
5,000
10,000
15,000
20,000
25,000
Cu
mu
lati
ve T
ota
l Nu
mb
er
of N
ew
Use
rs 0 to 17
18 to 64
65 to 74
75 to 84
85+
Unknown
31378 31384 31655 31295 30984 31353 30768 31197 30570
1,073 1,775 2,985 3,915 4,476 5,573 5,951 7,213
2009 2010 2011 2012 2013 2014 2015 2016 2017
Care Home residents aged 65+, ScotlandComparison of actual vs projected (2009 base year)
Actual residents Additional projected
Data: Care Home Census, ISDScotland & NRSChart by Peter Knight ISDScotland Sept 2018
Change Fund
8118 7997 7907 7748 7814 7763 8150 7888 7955
262 523 852 989 12001032 1423 1533
2008/09 2009/10 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 2016/17
Hospital beds used for emergencies: people aged 65+, Scotland Comparison of actual vs projected (2008/09 base year)
Actual ave.beds occupied additional projected
Data: ISDScotland & NRS Chart by Peter Knight ISDScotland Sept 2018
Change Fund
Public Bodies(Joint Working) (Scotland) Act )
Act 2014People are supported to live well at home or in the
community for as much time as they can and have a positive experience of health and social care when they
need it
• All adult care groups +/- children’s services & criminal justice
• Principles for integrated health and social care
• Integrated governance : body corporate or lead agency
• Integrated budgets for health and social care
• Chief accountable officer has integrated oversight of delivery
• Nine national outcomes for health and wellbeing
• Strategic and locality planning based on population needs
Creating the Conditions
• Political will – cross party, whole of government support • Legislative framework for integrated planning and budgets • Strong professional leadership for interdisciplinary practice • Funding as a catalyst for change • Contractual levers - primary care and pharmacy • Disruptive innovation (social and technology)• Investment in voluntary sector and community capacity building • Value and support carers as full partners • Focus on place, home, community and outcomes that matter• Learning and improvement culture
SCIROCCO – Scaling Integrated Care in Context - Maturity Model http://www.scirocco-project.eu/maturitymodel/
A movement for change
Webinar Series and Topic Resources theScotland www.integratedcarefoundation.org/scotland
Special Interest Groups (SIGs) hosted on IFIC website:
o Polypharmacy and Adherence
o Intermediate Care
o Palliative & End of Life Care
o Frailty
o Self Management and Co-production
Sign up at: https://integratedcarefoundation.org/ific-membersnetwork/groups/
Contact
Marie Curran [email protected]
Mandy Andrew [email protected]
Integrated Care Matters
THANK YOU
www.advantageja.eu