Improving acute care for people living with frailty
There are approximately 560,000 people living with frailty in Scotland, which is over 10% of the population. We know that the population is ageing and with that, the prevalence of frailty is increasing. This increase is having an effect on hospital care with more than 60% of Scottish hospital beds used by the over 65s.
We need to ensure that older people with frailty have access to the appropriate specialist care at the right time and in the right place. That requires identification of frailty at the earliest opportunity to address their needs as early as possible in their hospital admission.
The ihub’s Frailty at the Front Door collaborative launched in December 2017. Over the next 18 months, we worked with five NHS boards to test approaches to improving care coordination for people living with frailty who present to unscheduled acute care services. The boards and hospitals involved were:
- NHS Forth Valley – Forth Valley Royal Hospital
- NHS Lothian – St John’s Hospital
- NHS Lanarkshire – University Hospital Monklands
- NHS Greater Glasgow and Clyde – Queen Elizabeth University Hospital
- NHS Dumfries and Galloway – Dumfries and Galloway Royal Infirmary
Introducing comprehensive geriatric assessment (CGA)
CGA is a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older person in order to develop a coordinated plan to maximise overall health with aging.
There is compelling evidence to support the benefits of early and effective CGA, re-enablement and intermediate care for people living with frailty, which include:
- improved care experience
- shorter periods of time spent in hospital care
- more support to care for people in their own home.
Improvements to processes and systems
The aims of the Frailty at the Front Door collaborative were to:
- identify frailty on presentation to hospital
- deliver rapid assessment of frailty using CGA, and
- coordinate the needs of people living with frailty using structured, focused frailty huddles to determine the most appropriate pathway of care.
To achieve their aims, the teams within the collaborative made changes to both their processes of care and systems of working. Using quality improvement (QI) methods, the collaborative provided:
- clear direction and change ideas through a driver diagram, screening tool, change package and measurement plan and CGA guidance
- onsite support
- networking across the five sites to share learning
- data reporting and feedback.
Evaluating the impact of these changes
Each of the five test sites worked in different contexts and were at different stages in developing improvements to the way in which frailty was recognised and coordinated at the front door of acute care. Through the collaborative, each site established the foundation for improvements in their own contexts, and all sites better understood the factors involved in supporting frail patients who presented to acute hospitals. Notably, this included an improved understanding of how to offer alternatives to hospital admission.
We used a dual approach to evaluate the impact of this collaborative, including a review of the data submitted from each site and case studies to explore key contextual factors affecting implementation and identify key learning points to inform the next phase of this work.
Our evaluation showed that the length of stay in the frailty unit at University Hospital Monklands reduced, and that the initial improvement was sustained over the following months.
And, there was a decrease in the length of stay for patients in geriatric medicine (excluding stroke) at Queen Elizabeth University Hospital (QEUH). On average, patients admitted to geriatric specialist beds are now in hospital for 1.8 fewer days than before.
Collaborative participants described the following achievements at team level:
- Raising awareness of the needs of people living with frailty within and beyond the initial project team.
- Using QI methods, including data, to identify opportunities for improvement, test and implement changes.
- Achieving culture change at the front door of the hospital with impacts across the hospital and community.
- Establishing effective multi-disciplinary working that includes medicine, nursing and allied health professionals.
The biggest achievement across all sites was raising awareness of the needs of people living with frailty who present to acute hospitals, and beginning to raise that awareness of need across the whole health and care system.
Several sites were confident that they had achieved significant culture change at the front door of their hospital, which would effect change downstream in wards and in the community.
“The culture change has happened over time. It’s been about seeing the difference that we could make, Immediate Assessment Unit (IAU) seeing what a frailty team could do, the way that the ECANs skills base has developed – they’re more confident.”
Nurse, Queen Elizabeth University Hospital
Sharing the learning
Our case studies highlighted the importance of number of factors that underpinned the achievements of the teams who participated in this collaborative, including:
- leadership at both an operational and strategic level
- an effective multi-disciplinary team to plan and undertake tests of change
- support from experienced quality improvement practitioners and project managers
- a clear reporting structure within organisations that tracks progress
- consensus on how frailty is defined
- a communications strategy within organisations, and
- support to access and use data.
“We very much appreciate your mentorship, wisdom and practical help as we have progressed along our frailty journey over the last three years.
“Healthcare Improvement Scotland’s ihub has been instrumental in us being able to have a bird’s eye view at what has been going on and how to make those changes in our behemoth of an institution.”
The next phase of this work, the Frailty at the Front Door collaborative 2, started in September 2019. We’ll build on the learning from the first phase to spread improvements in three key areas:
- Identifying frailty
- Timely multi-disciplinary CGA
- Coordinating care for people living with frailty.
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