commissioning with frailty - clinical senateemsenate.nhs.uk/downloads/documents/clinical...

$: Commissioning with frailty - Clinical Senateemsenate.nhs.uk/downloads/documents/clinical senate/proactive... · Falls and hip fractures ... and related that to existing outcomes Maps$
East Midlands Clinical Senate Advisory ReportCommissioning services for an ageing population and those living with frailty

Report byDr Ben PearsonConsultant Physician

East Midlands Clinical Senate Council member

Suzanne HorobinEast Midlands Strategic Clinical Networks and Senate

3East Midlands Clinical Senate Advisory Report Commissioning services for an ageing population and those living with frailty

1. Executive summary � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4

2. Introduction and purpose of the report � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 6

2.1. East Midlands Clinical Senate � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 6

2.2. Supporting commissioning � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 6

2.3. Understanding the demographics � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7

3. What is frailty? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 9

4. Demographic imperative for change � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11

4.1. Variation in outcomes � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 12

4.2. Falls and hip fractures - forward projection � � � � � � � � � � � � � � � � � � � � � � � � � � � 13

5. What does the literature tell us and what are we doing about it?

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 16

5.1. Access all ages - Royal College of Surgeons of England � � � � � � � � � � � � � � � 16

5.2. Cochrane Review of Physical Activity in Older People � � � � � � � � � � � � � � � � � 18

5.3. National Audit of Intermediate Care � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 18

5.4. Making our health and care systems fit for an ageing population � � � � � 20

5.5. Previously published commissioning guidance � � � � � � � � � � � � � � � � � � � � � � � � 23

5.6. Workforce development � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 26

5.7. East Midlands Academic Health Science Network response � � � � � � � � � � � 28

6. Comprehensive Geriatric Assessment � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 29

7. Principles and standards underpinning good practice � � � � � � � � � � � � � � 33

8. Referenced evidence base � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 34

8.1. Literature review � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 34

8.2. Collation and summary of existing professional and national guidelines

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 35

9. Acknowledgements � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 36

Content


1. Executive summary

Commissioning services for an ageing population and those

living with frailty needs to change� The emerging evidence

around frailty, the existing evidence for comprehensive

geriatric assessment and the absolute need to provide

holistic person centered care for everyone, particularly older

people, mandates that change�

There is a demographic imperative to change the way we

commission services� As an example: older people living

with frailty are at increased risk of falls and hip fracture�

Across the East Midlands in 2012 - 13 there were 4805 falls

with hip fracture in people aged over 65 (HES data)� There

was significant variation in spend by CCG in relation to hip

fractures over the same period from under £500,000 to

£3,500,000� The population aged over 65 living across the

East Midlands is going to increase by 43% by 2030�

If we continue to commission for illness-based condition-

specific pathways we will continue to frustrate and fragment

the experience of healthcare for our most vulnerable

population� Patients with dementia are particularly at risk if

we fail to balance the complexities of co-morbidities or to

understand our patient’s views�

“The NHS must change to meet the needs of a population that lives longer, for the

millions of people with long-term conditions, and for all patients who want person

centred care. It means breaking down the boundaries between family doctors and

hospitals, between physical and mental health and between health and social care.”

- Simon Stevens


1. Executive summary

We reference the extensive evidence base and summarise

recent national publications with valuable guidance on

delivering services for older people and those living with

frailty� Comprehensive geriatric assessment is described

along with evidence for benefits realisation� Important

principles and standards underpinning good practice are

stated�

We have included a number of examples of good practice

in the form of case studies from around the region

demonstrating the application of best practice� Models

include the use of comprehensive geriatric assessment,

service redesign and innovative approaches to workforce

and training�

The report concludes with important messages from the

recent literature� Our aim has been to bring together our

regional expertise in good clinical practice to endorse a

commissioning strategy for our ageing population and those

living with frailty�

Commissioners who understand frailty and who ensure their

services are “Fit for Frailty” will achieve better outcomes

for their older population, for those with dementia and for

those who live with frailty�


2. Introduction and purpose of the report

2.1. East Midlands Clinical Senate

The East Midlands Clinical Senate is the clinical conscience

and guiding intelligence for strategic service change in the

new NHS� Combining expert clinical leaders with patient

involvement, the Clinical Senate provides proactive and

reactive advice across the health care system for the benefit

of improved patient outcomes and population health�

The Clinical Senate supports healthcare commissioners

across the East Midlands to make improvements in the

quality, safety and experience of patient care by providing

clinically lead, expert, strategic advice in areas of major

healthcare challenge�

The Senate Council made an early decision to produce two

proactive reports; one covering physical activity and exercise

medicine and this report, on commissioning services for an

ageing population and those living with frailty�

2.2. Supporting commissioning

We intend this report to be a useful, practical resource

for commissioners� And while we recognise that different

detailed solutions work in different areas, we feel that

concepts like “frailty” and interventions like “comprehensive

geriatric assessment” are incredibly important� This report is

an opportunity to explain the language, help understanding

and ensure that value adding principles and standards drive

commissioning�



There is also a strong feeling that we do not reinvent the

wheel� Many sensible conclusions exist in the literature and

evidence base� Our feeling is that these are either not well

understood or that current commissioning strategies are

based on unhelpful condition specific pathways, silo working

or are constrained by existing provider organisational

structures�

2.3. Understanding the demographics

Demographic data support an imperative case for change�

The Office for National Statistics estimates that the number

of people in Britain over the age of 65 will increase by

65% over the next 25 years� The Institute of Public Care’s

Projecting Older People Population Information (POPPI)

programme predicts a 43% increase in the over 65

population in the East Midlands by 2030, with greater

increases of 78%, 72% and 116% in the 80-84, 85-89 and

90 and over populations respectively�

We recognise the significant needs of people living with

dementia, both patients and those who care for them�

This report is not intended to specifically focus on any one

diagnosis that may contribute to the clinical syndrome of

having frailty� However if services are well designed for frail

older people we would expect to see benefit for patients

with dementia�



In explaining the concept of frailty we also have to

acknowledge that there is no single symptom or sign, or

diagnostic disease label that can reliably identify frailty�

Surrogate markers from population health outcome data

however help to illustrate relevant points� In the report

we have used falls and hip fracture data in the over 65

population to serve this purpose�

We have set out detailed public health comparative

information for the East Midlands population aged over 65

and related that to existing outcomes� Maps of variation will

draw commissioners’ attention to inequalities�


3. What is frailty?

A 2014 NHS England, South report states that the clinical

condition of ‘frailty’ is one of the most challenging

consequences of population ageing�

• Anageingpopulationisatriskofanincreasing

number of individuals having frailty

• Havingfrailtycanbethoughtofasastateof

vulnerability due to accumulated impairments in

physical, mental or environmental wellbeing

• Adiagnosisofdementiacanindicatefrailtyevenwhen

the patient’s physical state does not

• Peoplelivingwithfrailtyareatriskoffunctional

decline and crises following small changes in their

physical, mental or environmental state

• Managingfrailtyrequiresongoingcomprehensive

multidisciplinary, multidimensional, multi-agency

assessment, diagnoses and care planning

• Olderpeoplewithfrailtycanbereadilyidentifiedand

may already be known to local professionals� They

often have weak muscles and conditions like arthritis,

poor eyesight, deafness and memory problems�

They typically walk slowly, get exhausted quickly and

struggle to get out of a chair or climb stairs

Between a quarter and half of people older than 85 are

estimated to be frail, with an overall prevalence in people

aged 75 and over of approximately 9%� People with frailty

have a substantially increased risk of falls, disability, long-

term care and death�

On the background of ongoing research to define frailty,

there are some simple approaches described� At present we

do not formally ‘diagnose’ frailty or identify it with a specific

Healthcare Resource Group code� This makes systematic


3. What is frailty?

case-finding and proactive care difficult� Slow walking

speed is a simple test that could help; taking more than five

seconds to walk four metres is highly indicative of frailty�

Although there is no evidence around primary intervention

at present, there is for secondary prevention of some aspects

of the frailty syndrome e�g� falls� However the 2014 British

Geriatrics Society publication “Fit for Frailty” advises against

a systematic case-finding approach at this stage�

Frailty has a significant impact on those living with it, their

families and carers and the care system� Frailty impacts

on the ability to live independently and to maintain social

interactions and is often related to a decline in mental

health� Frailty is closely linked to an increased risk of falls

and consequent fractures� It can also lead to social isolation,

a need for social care and ultimately transition from home

into a residential or nursing care setting�

CASE STUDY SUPPORTING FRAILTY THROUGH HOME IMPROVEMENTS AND MODIFICATIONS�

The Kings Fund have recently suggested that for every £1 spent on improving homes the NHS saves £70

over 10 years (Making the Case for Public Health Interventions, 2014)�

Derby’s Healthy Housing Service (HHS) partnership recognises that people have the potential to enjoy a

better home environment and improved health and well-being when they feel comfortable, confident,

safe, and secure at home� The aim of the service is to help those most vulnerable to poor health outcomes

as a consequence of poor housing and fuel poverty� Interventions include home improvements and

modifications to reduce the risk of poor health and home accidents�

By way of newly established referral routes, many individuals who might ordinarily miss out on or fail to

engage with initiatives offered by Derby City Council and its partners are now directly referred for support

from an expansive pool of professionals and community volunteers; contributing to the reduction in health

inequalities in the city�

In a sample (n=150) of falls clients who had been referred into the service over the period July 2012 to

June 2013 there was a reduction of 37% in A&E activity and 54% in emergency admissions to hospital in

the six months post intervention in contrast with the six months pre intervention�

Andrew Muirhead, Senior Public Health Analyst


4. Demographic imperative for change

The East Midlands data show us that demographic

imperatives for change are stark:

• Theover65populationwillincreaseby43%between

now and 2030

• Thepredictedriseintheover85spopulationiseven

greater with a 167% increase predicted by 2035 on

the 2013 baseline from 102,866 to 274,600

• Thepredictedriseinfallsrelatedadmissionsandhip

fractures cannot be met with current resources or

service design

• Wewillseeasignificantriseinthenumberofolder

people living with frailty in the population



4.1. Variation in outcomes

Maps of variation show marked differences in

life expectancy, long term health outcomes,

injuries due to falls, hip fractures and excess

winter deaths across the region�

For the purposes of illustration of this variation

we have selected the following three maps

which show the extent of variation in disability

free life expectancy across the region�

The maps provide one marker of the

commissioning landscape for an ageing

population and those living with frailty� Disability Free Life Expectancy in males aged 65,

2010-2012

Disability Free Life Expectancy in females aged 65,

2010-2012

Standardised admissions ratio for hip fractures in

persons aged 65+



Although improvements in disability free life expectancy

are predicted to reduce the overall prevalence of frailty

in this group, the rise in the number of over 65s (and the

expectation that a far greater proportion of this group

will be in the 85+ age group) indicates that we will see a

significant rise in the number of older people living with

frailty in the population�

This is likely to result in increased healthcare need to prevent

and manage the higher levels of frailty related morbidity

that can be expected�

The delivery of a sustainable care system for this population

group will require a paradigm shift, with a greater focus

on primary and secondary prevention to reduce the

prevalence and consequences of frailty, through coordinated

approaches across the health and social care system�

4.2. Falls and hip fractures - forward

projection

Hospital Episode Statistics (HES) data for the East Midlands

show 15,957 falls related hospital admissions amongst the

over 65s occurred in the 2012/13 financial year, with 5,255

of these being coded as ‘with complications’� The cost of

this activity was £47,442,307� The data also show 4,805

hip fractures amongst the over 65s in the East Midlands

over the same period with 1,698 of these coded as ‘with

complications’ costing £27,670,203�

The following graphs highlight the roughly 2:1 gender ratio

for falls admissions and 4:1 gender ratio for hip fractures

with females experiencing the higher incidence of both�



The graphs also project forward to 2030 showing the

expected numbers of falls admissions and hip fractures

in the East Midlands if current incidence rates are applied

based on the growing older population� The projection

predicts a 66% increase in falls admissions to 27,200 by

2030, and a 62% rise in hip fractures to 11,333 in the same

time period�

Based on the current tariff costs the predicted rises in falls

admissions and hip fractures would lead to overall costs of

£78,754,230 and £44,881,069 respectively by 2030�

0

5000

10000

15000

20000

25000

30000

2014 2015 2020 2025 2030

Num

ber

Year

Number of fall admissions in the East Midlands projected from 2014 to 2030 by

age and gender

Females 80+

Females 65-79

Males 80+

Males 65-79



0

2000

4000

6000

8000

10000

12000

2014 2015 2020 2025 2030

Num

ber

Year

Number of hip fracture admissions in the East Midlands projected from 2014 to 2030

by age and gender

Females 80+

Females 65-79

Males 80+

Males 65-79

There is already considerable variation across the east

Midlands region in the CCG spend on falls and hip fractures:

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

Tota

l Cos

t

Costs for Finished Admission Episodes for Hip Fractures (2012-13) by CCG and HRG CC'sCosted at PBR tariff year where possible with Market Forces Factor | Aged 50 and OverSource: PBR Tariff (Costs) , HES (Episodes), Public Health Outcomes Indicators

CC not indicated

Without CC

With CC



This report has considered the advice of a number of

publications, including:

• Access all ages - Royal College of Surgeons of England

• Cochrane review of physical activity in older people

(2012)

• National audit of intermediate care (2013)

• Kings Fund report - Making our health and care

systems fit for an ageing population (2014)

• Safe, compassionate care for frail older people using

an integrated care pathway

We highlight here content from each of these reports

considered to be particularly relevant to commissioners of

health and social care in the East Midlands�

5.1. Access all ages - Royal College of

Surgeons of England

This report states that a patient’s relative need for a range of

health interventions, including surgical treatment, increases

with age� Despite this the report shows that across a range

of common conditions, elective surgical treatment rates

decline steadily for the over-65s�

There are a number of explanations for these trends:

Clinical factors

For example the impact of existing conditions or health

needs, which could mean that the risks of treatment

outweigh the benefits�

http://www.rcseng.ac.uk/publications/docs/access-all-ages

http://summaries.cochrane.org/CD004294/STROKE_physical-rehabilitation-for-older-people-in-long-term-care

http://summaries.cochrane.org/CD004294/STROKE_physical-rehabilitation-for-older-people-in-long-term-care

http://www.nhsbenchmarking.nhs.uk/partnership-projects/National-Audit-of-Intermediate-Care/year-two.php

http://www.kingsfund.org.uk/publications/making-our-health-and-care-systems-fit-ageing-population

http://www.kingsfund.org.uk/publications/making-our-health-and-care-systems-fit-ageing-population

http://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf

http://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf



Clinical approaches

The way in which individual clinicians approach the

treatment of older people based on their own experience,

attitudes and evidence:

• Apatient’schronologicalageandhisorherbiological

age may be conflated - this means decisions may not

always be made on the basis of a comprehensive and

objective assessment but on a series of assumptions

about fitness in older age

• Theclinicalbenefitofprovidingtreatmentmaybe

questioned when relative life expectancy is shorter�

• Communicationwithpatientstodiscussrisksand

benefits, and to inform and to reflect on issues and

anxieties, may be limited or ineffective

• Theremaybeashortageofevidence,tools,strategies

and specialist clinical input to support surgical

treatment in older age

Patient awareness and preference

Patients may lack the information they need to make an

informed decision about whether surgery is right for them�

Even with the right information and support, patients may

opt out of treatment for a range of personal reasons�

The 25 recommendations of this report focus on 6 key areas:

1. Informing and communicating with patients to

encourage them to seek help and take part in

decisions about their treatment and care

2. Improving the evidence base to further our

understanding of the impact of age on surgical

decision making

3. Developing guidance to promote age equality in

surgical care

CASE STUDY REDUCING LENGTH OF STAY

SCOPES (Systematic Care

of Older People in Elective

Surgery) is a clinical

intervention designed to apply

the tenets of Comprehensive

Geriatric Assessment (CGA)

in older people presenting

for elective hip and knee

replacement to Nottingham

University Hospitals NHS Trust�

All over 75 year olds

presenting for elective hip

or knee replacement, with

an Edmonton Frailty Score

≥ 5, are seen 16-18 weeks

pre-op by a geriatrician

led multidisciplinary team

comprising physiotherapist,

occupational therapist and

nurse with access to other

services including social work

as required�

Assessment follows a 5

domain CGA model (medical,

psychological, environmental,

social and functional) with

comprehensive history taking

and examination accompanied

by baseline indices including

mental state evaluation, lying

and standing blood pressure,

3 minute timed up and go,

peak expiratory flow rate,

body mass index, an ECG and

routine bloods�

(continued...)



5.2. Cochrane Review of Physical

Activity in Older People

This report has shown a wide range of benefits to balance,

wellbeing, mobility, cognition and bone fragility from

evidence-based tailored exercise interventions� There is

particularly clear evidence regarding the benefits of exercise

for older people�

The East Midlands Clinical Senate has produced a report

for commissioners entitled Physical Activity and Exercise

Medicine�

5.3. National Audit of Intermediate Care

In drawing attention to the importance of multi-agency

working across whole systems this report offers alternatives

to the current system response of hospital care; step

up care for hospital avoidance and step down care for

early hospital discharges� Intermediate care services were

benchmarked using Patient Reported Experience Measures

using the “I” statements recommended by National Voices�

This 2013 audit demonstrated that the current provision of

intermediate care is around half of that required to avoid

inappropriate admissions and provide adequate post-acute

care for older people�

4. Delivering the most appropriate care by improving

models of working and developing guidance for

clinicians

5. Measuring progress and tackling underperformance

6. Delivering high quality commissioning for older

people

(...continued)

Interventions focus on

management of long-term

conditions, identifying and

treating occult diagnoses,

environmental risk assessment

and provision of aids and

appliances as required and

a bespoke programme of

physiotherapy, ranging from

a written exercise programme

to day-case attendance at the

NUH rehabilitation unit�

The intervention also includes

a robust anaemia diagnosis

and treatment algorithm,

developed in conjunction with

the blood transfusion service�

During the first six months

the approach resulted in

a reduction in average

length of stay of 2�1 days

for hip surgery and 2�35

for knee surgery� On the

day cancellations of elective

hip and knee surgery was

reduced to zero� This delivered

a cost saving of £166,000

based upon bed savings and

repatriation of patients from

the private sector back to

NUH�

Dr Adam Gordon

Consultant and Honorary

Associate Professor in

Medicine of Older People



Weak local strategic planning processes were identified as a

reason for lack of improvement in intermediate care capacity

since 2012� Truly integrated services across health and social

care are fundamental to delivering “person centred and co-

ordinated” care�

CASE STUDY SUPPORTING ADMISSION AVOIDANCE THROUGH EARLY INTERVENTION

NHS Nene & NHS Corby Clinical Commissioning

Groups commission independent care homes to

provide health funded placements for patients� To

ensure the clinical quality and safety of placements

a team of quality improvement managers

undertake review visits to care homes� The visits

are rated and reports, with recommendations, are

issued to each provider�

Analysis of the clinical review visit outcomes

highlighted a need to drive forward improvement

across the care home sector; to shift focus to early

intervention, treatment and prevention, develop

service provision and drive clinical quality�

A Frail and Older People work stream was

developed to:

• improveoutcomesforpatients

• educatestaffwiththeskillsandconfidence

to deliver appropriate care

• improvestandardsandpromotegood

practice

• preventavoidableadmissions

• reducedistrictnurseinput

• reduceGPcallouts

A training toolkit consists of:

• FacilitationSkillstraining

• FallsandFractureManagement

• UrinaryCatheterManagement

• DeliriumAssessment

• Anti-Psychoticstraining

• Diabetesmanagement

• Tissueviability

• Venepuncture

• SubcutaneousFluidsandNutrition

As a result falls have reduced by 13%, prescription

of antipsychotics has reduced by 25% and referrals

to emergency departments were down by 47�9%�

Overall the improvements delivered savings of

£159,000�

Waseem Shahzad - Health Education East Midlands



CASE STUDY EMPOWERING FRONT LINE STAFF

Through a series of engagement workshops with care home

managers and health and social care professionals from across

Nottinghamshire, a Clinical Quality Framework was created� This

has been trialled at a basic level, forming the foundation of a new

bespoke ‘tiered training’ approach�

The Clinical Quality Framework is a toolkit consisting of a training

programme, training resource (workbook) and a Competency

Assessment Framework� This toolkit was successfully used to deliver

training to 187 members of staff from 5 care homes (residential and

nursing) in 6 half day training sessions�

The Clinical Quality Framework proved effective in empowering

frontline staff in care homes to deliver sustainable, evidence based

care� 93% of participants stated the training would have a positive

change on their daily working practice and 95% of the attendees

stated their knowledge around the subject had increased�

This method of a tiered training approach has been successful in

delivering training on a large scale within a short period of time,

focusing on the key essential messages� This training supported

with relevant resources ensures care homes can keep building on

the learning and the consistency of the same trainers� Training

programme delivery to all five homes shows the ability to reduce

unwarranted variation across the City�

Sandra Hynes , Community Programme - Nottinghamshire County

council, Nottingham City Council, Nottingham CityCare, County

Health Partnerships, Clinical Commissioning Groups in South

Nottinghamshire, Nottingham University Hospitals and the Carers

Federation

5.4. Making our

health and care

systems fit for an

ageing population

In their report the Kings

Fund identifies the key

components of service

delivery for older people,

recommending improvement

efforts consider them all

since many older people use

multiple services:

• agewellandstaywell

• livewellwithone

or more long term

conditions

• livewellwithcomplex

co-morbidities,

dementia and frailty

• rapidsupportcloseto

home in times of crisis

• goodacutehospital

care when needed

• gooddischarge

planning and post-discharge support

• goodrehabilitationandre-ablementafteracuteillness

or injury

• highqualitynursingandresidentialcareforthosewho

need it

• choice,controlandsupporttowardstheendoflife

• integrationtoprovidepersoncentredco-ordinated

care



The report quotes the dissatisfaction of older people and

their carers with out-of-hours provision and rapid general

practice responses� It recommends that service leaders

should review the effectiveness and consistency of local

provision for urgent primary care and carry out regular

reviews of admissions for, and accident and emergency

attendances by, frail older people so that lessons from

preventable admissions can inform service redesign�

Many older people experience needs that tend to be

characterised as ‘minor’ but which can significantly affect

their independence, wellbeing and social engagement�

These include:

• mobilityproblems

• foothealth

• chronicpain

• visualandhearingimpairment

• incontinence

• malnutrition

• oralhealth.

These conditions are also characterised by highly variable

access and quality in terms of treatment� Local service

leaders must not underestimate the importance of providing

services to address these ‘minor’ needs, and should re-

examine local provision, addressing any gaps�



A key aspect of good

management of long term

conditions is ensuring that

the services and support

provided reflect the persons'

own circumstances and

preferences� People with

long term conditions

should be enabled to

engage in collaborative

care planning through pre-

arranged appointments,

co-producing a single

holistic care plan with their

care coordinator� This is

particularly important for

older people with multiple

long term conditions, since

interventions and care

planning approaches that

focus on single chronic

conditions can lead to

chaotic overall care for these

patients�

The crucial role of carers in maintaining older peoples’

independence and wellbeing is recognised in the Dilnot

Review on Care and Support, and the National Strategy

for Carers� The World Health Organisation, in its strategy

for healthy ageing in Europe, identified ‘public support

for informal caregiving’ as a key strategic priority� Local

leaders in health and social care, mental health, local

government and their voluntary sector partners should

CASE STUDY USING INTEGRATED TEAMS TO SUPPORT PATIENTS WITH FRAILTY

Lincolnshire West CCG commissioned ‘integrated teams’ in 2012/3�

The teams are made up of professional staff from local health and

social care providers� The aim of the team is to proactively manage

the care needs of frail people through early identification of frailty

and proactive management�

Since this work commenced, the Lincolnshire Health and Care

(LHAC) review is leading to the development of neighbourhood

teams� The initial focus of the neighbourhood teams is in managing

those with frailty�

Where integrated teams already exist, it is envisaged that they will

swiftly develop into neighbourhood teams�

An example of how the team is working with and for patients:

A patient with mental health issues living in rented accommodation

was about to be made homeless and have his benefits stopped� With

the patients consent, these concerns were taken to the Neighbourhood

Team where staff from the mental health, housing, safeguarding

and well-being teams were present, along with the patient’s General

Practitioner, to discuss how these issues could be addressed�

The NT were able to prevent this gentleman from being evicted,

and later got him rehomed into council accommodation� They were

also able to sort out direct payment for his rent in order to prevent

him getting into arrears again� A patients’ advocate was arranged

to help this gentleman with future care and ensure he is seen on

a regular basis by the mental health team to prevent him reaching

crisis in the future�

Tracy Means - Lincolnshire Community Health Services



review the needs of carers for older people in terms of peer

support, education, information and training, and respite,

incorporating these into all health and wellbeing plans and

mapping their own service provision against any national

strategies to support carers�

Key issues highlighted in the King’s Fund report were the

use of comprehensive geriatric assessment at the right time

and an understanding of frailty� Many health and social care

economies are describing a “left shift” towards prevention,

pro-active care and self-management and services provided

away from hospitals, closer to home� Achieving this will

require much more integrated working to ensure that the

right mix of services is available in the right place at the right

time� Incremental, marginal change is not sufficient; change

is needed at scale and at pace�

5.5. Previously published commissioning

guidance

The 2014 report “Safe, compassionate care for frail older

people using an integrated care pathway: Practical guidance

for commissioners, providers and nursing, medical and allied

health professional leaders” states that

• Iffrailolderpeoplearesupportedtoliveindependently

and understand their long term conditions, and

educated to manage them effectively, they are less

likely to reach crisis, require urgent care support and

experience harm

• Commissionerandproviderorganisationsneedto

decide which case finding and identification tools

they will use, but it is important to have a consistent

approach across all organisations involved in the care

pathway



• NHSEnglandrecommendssettingarangeofCQUINs

with providers at critical points of the frailty pathway

to help resource and embed service redesign� They

suggest that CQUINs should be developed that

encompass

o Establishment of case-finding in primary care and

a register of frail older people

o Systematic screening for frailty in people over the

age of 75 when they present in primary care, at

hospital admission and in the community setting

o Comprehensive geriatric assessment using shared

templates across all providers

o Personalised care planning, shared across all

organisations

o Development of seven-day services to support

frail older people closer to home

o The training of the voluntary sector in simple

frailty screening, and the establishment of referral

pathways, by community services

o Same-day discharge of frail older people using

discharge to assess methodology

CQUINs relating to frailty should be based on

recognised evidence� NICE Quality Standards for

dementia, hip fracture, mental wellbeing of older

people in care homes and stroke can be found at

http://www�nice�org�uk/guidance/qualitystandards/

QualityStandardsLibrary�jsp

• Outcomemeasuresareofkeyimportance,butprocess

and balancing measures should not be excluded� These

can be very useful in determining effective change

and action in the short term especially where an

intervention is particularly complex or where outcome

measures can take a long time to determine

http://www.nice.org.uk/guidance/qualitystandards/QualityStandardsLibrary.jsp

http://www.nice.org.uk/guidance/qualitystandards/QualityStandardsLibrary.jsp



CASE STUDY INTEGRATED HEALTH AND SOCIAL CARE MODEL IMPROVING CARE

The PRISM (Profiling Risk, Integrating Care,

Systematising Self Care) programme is predicated

on a requirement to shift the approach from the

current disease specific and reactive model of care

to one where patients are proactively managed

in a holistic way by multidisciplinary integrated

health and social teams supporting all of a patient’s

needs�

The PRISM model is based on systematic and

concurrent implementation of 6 key elements:

• Riskstratificationofthepopulationusinga

sophisticated computer based algorithm (the

Devon tool) to identify those at high risk of

admission to hospital

• Developmentofmultidisciplinaryhealthand

social care teams, working with named GP

practices to deliver complex and proactive

case management of patients at high risk of

admission to hospital

• Systematisationofself-caretosupport

people to live more independently and be

involved in decisions about their care

• Integratedhospitaldischargepathways

which bring together acute and community

teams to facilitate timely discharge from

hospital and support to live independently at

home

• DevelopmentofanenhancedIntermediate

care model which delivers Intermediate

care and rehabilitation in the patient’s own

home�

• CoordinatedandIntegratedapproachto

end of life care planning and care delivery

• Supportfororganisationsandstaffto

understand and address cultural and

behavioural barriers which may reduce their

ability to work seamlessly across the system�

The model was piloted in Newark and Sherwood

CCG during 2012/13 with 3 locality based multi-

disciplinary health and social care teams covering

100% of the CCG adult population� It has now

been scaled up and rolled out across the whole of

Mid Nottinghamshire with all the adult population

now covered by one of 8 locality based health

and social care multi-disciplinary teams working in

partnership with named GP practices�

Whilst an independent evaluation of the pilot is

near completion, initial qualitative data confirms a

consensus from all stakeholders that PRISM is more

effective than the previous approach in terms of

patient satisfaction, staff satisfaction, and patient

outcomes including hospital admissions�

During the 6 months following the launch of

the first multi-disciplinary team non- elective

admissions for patients with Long Term Conditions

reduced by 16%� This reduction was seen within

every GP practice involved in that locality, a trend

which has continued across the CCG as the

additional teams have become operational� Overall

across Nottinghamshire County (5 CCG’s) the

numbers of non-elective admissions have increased

by 0�4% in the last year, however within Newark

and Sherwood CCG we have seen a decrease of

1�9% - the largest decrease of all of the CCGs�

Mansfield and Ashfield CCG, Newark and

Sherwood CCG, Sherwood Forest NHS Foundation

Trust, Nottinghamshire Healthcare NHS Trust,

Nottinghamshire County Council, East Midlands

Ambulanced Services and Central Nottinghamshire

Clinical Services.



5.6. Workforce development

Health Education East Midlands’ Mandate states “The

priority is to train and retain a healthcare workforce

equipped with the skills to deliver much more proactive

care and support for patients in the community, and with

the right skills to support people with long-term medical

conditions to live with dignity in their own homes� Increasing

the number of General Practitioners and community

nurses will be crucial in delivering more proactive and

community based care to all and in providing and leading on

personalised care for frail older people�”

Its governing body has endorsed the move to focus its

educational investment on the workforce caring for the Frail

Elderly�

An agreement to develop a national career framework is

being developed for nurses caring for older people� The

Framework is comprised of three tiers of education and

training based on delivering the core knowledge and skills

required at foundation, specialist and higher specialist level�

The aim in splitting the education and training into three

tiers is to ensure that nurses caring for older people receive

education and training specifically focussed to support the

role they perform�

The three tiers are:

• Foundationleveleducationwhichissuitableforall

registered nurses

• Specialistleveleducationwhichissuitablefornurses

who work predominately with older people

• Higherspecialisteducationwhichissuitablefornurses

in a specialist care of older people role



More locally, Health Education East Midlands is:

• Commissioningtrainingandeducationforarangeof

health and social care staff who are caring for older

people with complex needs (including Allied Health

Professionals, Social Workers and the wider support

workforce)

• Workingcloselywiththenationalprogramme

supporting a post-registration education framework

for nurses working with older people with complex

needs

• Increasingtherateofrolloutofdementiatrainingfor

all NHS staff working with patients with dementia

• Supportingincreasednumbersofstaffundertaking

training alongside other professions (multi-professional

development)

The Nursing and Midwifery Council provides guidance on

the care of older people in its report of the same name�

The report suggests that whilst older people do not have

a particular need for the care outlined compared with any

other age group, inherent ageism in society can mean

that they are less likely to receive it� The guidance aims to

encourage nurses to develop a positive attitude towards

older people, and embrace positive feelings of respect and

an understanding that older people are important members

of society, the majority of who have the potential to

participate actively and be in control of their own lives�

http://www.nmc-uk.org/documents/guidance/guidance-for-the-care-of-older-people.pdf

http://www.nmc-uk.org/documents/guidance/guidance-for-the-care-of-older-people.pdf



5.7. East Midlands Academic Health

Science Network response

The East Midlands Academic Health Science Network Frail

Older People programme aims to advance the delivery of

Comprehensive Geriatric Assessment (CGA) to frail older

people across the region, focussing on certain areas where

it is felt that currently it is not adequately or uniformly

delivered, and in the community whenever possible� These

areas are:

• urgentcare

• dementia

• falls

• healthcareincarehomes

• healthpromotionforolderpeoplewithfrailty

They seek to achieve their aims by supporting patients,

carers, professionals and organisations around the region to

share innovation and best practice� They are encouraging

leaders in each part of the region to use this to drive up

standards against these benchmarks of quality� This process

has been started through the creation of a knowledge hub

which is an online community for knowledge transfer and

exchange� http://emfop�org�uk/


6. Comprehensive Geriatric Assessment

Comprehensive geriatric assessment (CGA) is the most

thoroughly researched model for healthcare delivery to frail older

patients� CGA delivers measurable health improvements for frail

older people� Although well understood by specialists to improve

outcomes for older people it is not routinely commissioned�

CGA is the gold standard for the care of people with frailty�

Because it is a multifaceted complex intervention it may

be misunderstood by those unfamiliar with it� CGA is a

multidimensional assessment, treatment plan and regular review

delivered by a multidisciplinary team usually including doctors,

nurses, physiotherapists, occupational therapists and social

workers�

A core component of CGA is the provision of a holistic medical

review that will diagnose medical illnesses, optimise treatment

and formulate a care plan; apply an evidence based medication

review (e�g� STOPP/START criteria) and include discussion with the

person and their carers to agree an individualised comprehensive

care and support plan�

Key elements of CGA include:

• Itisforthosewithfrailty(notnecessarilyeveryone)

• Clinicaljudgementandexperienceshoulddrivethe

recognition and identification of frailty

• Theassessmentmustbecomprehensive;thatismedical,

psychiatric, functional, social and environmental (not single

issue or single agency or discipline)

• Acareplanmustbemadebasedontheassessmentwhich

should form the basis of case management

• AdvancedCarePlanningisoftenanessentialpartoffrailty

management

• Careplandeliveryrequiresco-ordination,integration,

iteration and leadership

CASE STUDY IMPROVING PATHWAYS

A Frail Elderly Assessment

Team (FEAT) at the Royal Derby

Hospital has developed an

improved pathway for all older

people with frailty admitted to

the acute trust�

All acute admissions are

screened for frailty on arrival

in the Emergency Department

or Medical Assessment Unit�

Acute medical care takes

priority and unwell patients

have aspects of the assessment

deferred�

Once identified as at

risk of frailty a parallel

multidisciplinary assessment

begins� This allows the

therapists to conduct their

assessment alongside and

in some cases before a full

medical review has taken place,

expediting Comprehensive

Geriatric Assessment and timely

discharge where possible�

The team have access to

speech and language therapy,

dieticians, discharge facilitators

and the psychiatry liaison team�

Dedicated FEAT pharmacists

undertake medication reviews

and reconciliation�

Of 2598 patients seen by the

team, 71% went home the

same day� Initial monitoring

shows no increase in

readmission rates�

(continued...)



CGA done half-heartedly does not work� Sufficient intensity

and duration of therapy is required to produce meaningful

benefit e�g� in preventing falls� Consistent and appropriate

physical environments are important for people with

dementia, including in care homes�

CGA needs to take account of individual variation - that is,

physical and mental health, personality, biography, ethnicity,

preferences and beliefs�

CGA may conclude that the best care plan for an individual does

not follow what is recommended in disease-specific guidelines�

CGA has to interface with social care and end of life care -

especially given the different funding and service models for

social care�

CGA needs to include provision for dealing with crises,

acute illness and acute deteriorations in function that give

equitable access to proper assessment and investigation,

including inpatient and intermediate care services� Flu and

pneumococcal vaccination, vascular disease and bone

health management and falls prevention, day care and carer

support are all important interventions� Anticipatory care and

proactive support to care homes is also needed�

A framework for providing the core principles of CGA in

community and outpatient settings is presented in the British

Geriatrics Society publication “Fit for Frailty”�

The delivery of CGA will have substantial workforce

and training implications that need to be understood by

commissioners� A 5 to 10 year planning timetable is needed -

those who will be dependent then are alive now and we have

the population and dependency projections� Research and

training should be accommodated within those plans�

(...continued)

The recognition and coding

of frailty has increased

by 700%� Frailty and its

assessment are now at the

forefront of everyone’s mind

and it is central to the trusts

future thinking and planning�

Quotes from the Emergency

Care Intensive Support Team

report;

“The simplicity of the four

frailty markers make it

simple for ED to use and

flag patients� The electronic

system means that patients

can be easily identified by

the FEAT once they have left

ED�”

“FEAT work in partnership

with acute physicians

and there is no separate

frailty unit which keeps

it integrated into core

assessment function and

everyone’s business�”

“We felt that the FEAT model

was an example of good

practice for the assessment

and management of frail

patients� It encompasses

recognised good practice

(See Silver Book or recent

Kings Fund publication

by David Oliver on frailty

pathways)� We particularly

liked the working relationship

with acute medicine�”

Derby Hospitals NHS

Foundation Trust



CASE STUDY USING COMPREHENSIVE GERIATRIC ASSESSMENT WITH PATIENTS AT HOME

With timely intervention covering the 5 domains

of Comprehensive Geriatric Assessment (CGA),

some frail older people could continue to live at

home with additional support - thus preventing

unnecessary admission into hospital and/or care

homes�

Two trials were conducted in Nottingham City and

Nottingham West areas to evidence social worker

initiated CGA� Admissions were reduced as were

problems associated with polypharmacy�

Referrals were made by social workers to a

Community Geriatrician who responded within 48

to 72 hours� A letter was sent from the Geriatrician

to the Social Worker, Care Home Manager, GP and

any other relevant community based therapists� A

package of support was then co-ordinated by the

Social Worker to reflect assessment and all follow

up actions are assigned to the GP�

The project was successful in delivering social

worker initiated CGA� It was recognised that social

worker intervention may possibly be too late in

the process of effectively enacting a CGA� During

the trial, referrals identified people at high risk

of deterioration, so intervention was reactive for

patients already identified as in crisis� To be proactive

and to prevent a patient deteriorating, an earlier

‘trigger’ point needs to be identified in the process�

It was also established that the medical component

of CGA may be appropriately delivered by a

community matron or supervised geriatric medicine

speciality trainee registrar�

Sandra Hynes, Community Programme -

Nottinghamshire County council, Nottingham

City Council, Nottingham CityCare, County Health

Partnerships, Clinical Commissioning Groups in

South Nottinghamshire, Nottingham University

Hospitals and the Carers Federation



CASE STUDY

USING COMPREHENSIVE CGA AND COLLABORATIVE WORKING

A trial delivering Comprehensive Geriatric Assessment (CGA) to frail older people on the acute medical

assessment ward at Nottingham University Hospitals delivered positive outcomes�

Staff from the Acute Trust, City and County councils, Nottingham City Care Partnership, County Health

Partnerships and the four local CCGs collaborated to provide assessment and care�

The CGA team was made up of:

• AcuteMedicalGeriatricians(10sessions)

• SeniorNurseCGACoordinator

• RegisteredGeneralNurse

• Physiotherapist

• Physiotherapyassistant

• Supportworker

• Rapidresponseliaisonpsychiatricnurse

• SocialworkCommunityCareOfficer(1city/1countysocialservices)

• CommunityMatrons(dailyrotasystemCityCare/CountyHealthPartnerships)

A clinical presentation model was used to identify patients requiring referral to the team:

A single CGA document has been implemented and is used across care settings facilitated by local

electronic care record systems�

The team ensures that frail older people either go home on the day of admission or are appropriately

moved to health care of older people wards with a plan in place�

Transfer of care within and from hospital is supported by a multi-disciplinary CGA plan of care�

Sandra Hynes, Community Programme - Nottinghamshire County council, Nottingham City

Council, Nottingham CityCare, County Health Partnerships, Clinical Commissioning Groups in South

Nottinghamshire, Nottingham University Hospitals and the Carers Federation

Over 70 years and presenting with:

1 Falls / ‘collapse’ / syncope

2 Delirium and acute confusion

3 Previous admission in the last month

4 Known Parkinson’s Disease

5 Decision made to admit to Health Care of Older People team, but Acute Physician judgement that

CGA team and Geriatrician review would be useful

6 Acute physician request for review by CGA team (with specific question i�e� complex discharge

planning / medication review / ongoing or complex delirium)


7. Principles and standards underpinning good practice

In this report we have emphasised to commissioners that

there is a very strong clinical consensus, a strengthening

evidence base and a stark demographic imperative to

change the way services for frail older people are provided�

We have to move away from the current focus on disease-

based systems of care to a more holistic and goal-orientated

approach� Achieving this will require commissioners to

think beyond organisational boundaries and to involve

experienced health and social care professionals in their

plans� Measuring what matters to patients and their carers

will help inform commissioning strategies�

The East Midlands Clinical Senate recommends the following:

• Commissionedservicesforolderpeople

should include an assessment that helps

to identify individuals who have frailty

• Interventionsforolderpeoplewhohave

frailty should be evidence based

• Themanagementofolderpeoplewith

frailty should include the process of

care known as Comprehensive Geriatric

Assessment

• Whenpeoplelivingwithfrailtyshow

functional decline or suffer crises

the health and social care response

must be quick, comprehensive, and

multidisciplinary and delivered as close

to home as judged safe and effective by

a senior responsible decision maker

• Thecareandmanagementofpeople

living with frailty should promote

autonomy, be least restrictive, allow

choice and provide rehabilitation and re-

ablement wherever possible

• Thevision,strategyanddetailedplans

of commissioners should be enhanced

by the involvement of patients, carers

and experienced health and social care

professionals


8. Referenced evidence base

8.1. Literature review

Frailty in Elderly People - Clegg A, Young J, Iliife S, Rikkert MO,

Rockwood K�- Lancet, 2013

Prevalence of frailty in community dwelling older persons: a

systematic review - Collard et al - Am Geriatr Soc, Vol� 60

Physical rehabilitation for older people in long-term care - Crocker

T, Forster A, Young J, Brown L, Ozer S, Smith J, Green J, Hardy J,

Burns E, Glidewell E, Greenwood DC - Cochrane, 2012

Effective exercise for the prevention of falls: A systematic review

and meta-analysis - Sherrington C, Whitney JC, Lord SR, Herbert

RD, Cumming RG, Close JCT - Journal of the American Geriatrics

Society, 2008, Vol� 56

Effects of physical exercise therapy on mobility, physical

functioning, physcial activity and quality of life in community-

dwelling older adults with impaired mobility, physical disability

and/or multi-morbidity: a meta analysis - de Vries N, Ravensberg C,

Hobbelen J, Olde Rikkert M, Staal J, Nijhuis-van der Sanden M� 1,

s�l� : Ageing Research Reviews, 2012, Vol� 11�

Do home based exercise interventions improve outcomes for frail

older people? Clegg A, Barber S, Young J, Forster A, Iliffe S� 1, s�l� :

Reviews in Clinical Gerontology, 2012, Vol� 22

Better management of patients with multimorbidity� M, Roland�

s�l� : British Medical Journal, 2013, Vol� 346�

Ordering the chaos for patients with multimorbidity� J, Haggerty�

s�l� : British Medical Journal, 2012, Vol� 345�

Community care of vulnerable older people: cause for concern�

Beales D, Tulloch A� 615, s�l� : British Journal of General Practice: the

Journal of the Royal College of General Practitioners, 2013, Vol� 63�


8. Referenced evidence base

Epidemiology of multimorbidity and implications for health care,

research, and medical education: a cross sectional study� Barnett K,

Mercer S, Norbury M, Watt G, Wyke S, Guthrie B� 9836, s�l� : The

Lancet, 2012, Vol� 380�

The Identification of Frailty: A Systemative Literature Review�

Shelley A� Sternberg, Andrea Wershof Schwartz, Sathya

Karunananthan, Howard Bergman and A� Mark Clarfield� s�l� : The

American Geriatrics Society, 2001�

The Frailty Syndrome: Definition and Natural History� Xue, Qian-Li�

Baltimore : s�n�, 2010�

8.2. Collation and summary of existing

professional and national guidelines

Safe, compassionate care of frail older people using an integrated

care pathway: Practical guidance for commissioners, providers and

nursing, medical and allied health professionals - NHS England,

South (2014)

Fit for Frailty - British Geriatric Society (2014)

Access all Ages - Royal College of Surgeons (2012)

Physical activity and exercise medicine - Prof Mark E Batt, East

Midlands Clinical Senate (2014)

National Audit of Intermediate Care - Benchmarking Network

(2013)

Making our health and care systems fit for an ageing population -

The Kings Fund, (2014)

Delivering better services for people with long-term conditions:

building the house of care - Kings Fund, 2014�


9. Acknowledgements

The author of this report, Dr Ben Pearson is a consultant

physician with interests in acute and general medicine

and geriatrics� He is the Divisional Medical Director for

the Division of Integrated Care for Derby Hospitals NHS

Foundation Trust, the secondary care doctor for Mansfield &

Ashfield Clinical Commissioning Group governing body and

a member of the East Midlands Clinical Senate Council�

The Clinical Senate would like to thank the following Senate

Council and Assembly members for their contribution to the

preparation of this advisory report:

Anne Marlow - Director of Innovation, Health Education

East Midlands

Cath Chisholm - Transformation Programme Facilitator -

Kettering General Hospital

Clare Credland - Interim Matron for unplanned care,

Lincolnshire Community Health Services

Darren Aw - Consultant Geriatrician, Nottingham University

Hospitals

Hazel Firmin - Clinical Team Lead, Lincoln South Locality,

Lincolnshire Community Health Services

Pui-Shan Tang - Advanced Analyst, East Midlands

Academic Health Science Network

Tasso Gazis - Consultant Physician, Endocrinology, Diabetes

and General Medicine, Nottingham University Hospitals

Brian J Rowlands - Professor of Surgery (Emeritus),

Nottingham University Hospitals


9. Acknowledgements

Ben Anderson - Consultant in Public Health (Healthcare),

Public Health England Centre East Midlands

Fiona Moor - Head of Dietetic Services, Derby Hospitals

Tracy Means - Clinical Team Leader / Complex Case

Manager, Lincolnshire Community Health Services

Further thanks to:

Professor John Gladman

Professor Rowan Harwood

Dr Adam Gordon

Dr Adrian Blundell

Dr David Stokoe

Dr Simon Conroy

Dr Jane Youde

Dr Judy Underwood

Dr Amanda Sullivan

Kathleen Sartain - Patient representative

Maureen Godfrey - Patient representative

SKYLINE. GRAPHIC DESIGN www�skylinedesign�org�uk

skyline@mail�org

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