Testing the eFI in Scotland: focus on Midlock GP practice

 

Some members of the Living Well in Communities and Midlock teams at the NHSScotland event

The Living Well in Communities team is working with Health and Social Care Partnerships in Glasgow City, West Dunbartonshire and Midlothian to test the electronic frailty index (eFI) to identify people over 65 who are living with frailty in the community. The Living Well in Communities team have developed an assets-based approach to support evidence-based interventions that are tailored to the individual. This article looks at the work to date with Midlock GP practice in Glasgow.

The testing in Midlock GP practice

The eFI uses GP read codes to calculate an individual’s degree of frailty and stratifies them into fit, mildly frail, moderately frail and severely frail. The tool has been validated in England. The purpose of testing at Midlock GP practice was to determine if the tool was accurate in a Scottish context. We have been working with a GP and other members of Glasgow City HSCP, including housing and the voluntary sector. The testing involved stratification of the GP population for frailty and reviewing case scenarios to determine if the eFI tool fits with a Scottish population.

Following this process, there was broad consensus at Midlock GP practice that the eFI categories were accurate for their population. This prompted them to consider, how do we support people who are living with frailty? What does this mean for the individual? and how can we work collaboratively in the community to support them?

The case scenarios identified anticipatory care, crisis prevention and palliative and end of life care work as areas where the team could make a difference to support people to remain in their own home.

The team identified three stages of frailty to focus on initially:

  • people who are changing from mild to moderate frailty (anticipatory care),
  • people who are moderately frail with the biggest change in eFI score (crisis prevention), and
  • people who are severely frail with the biggest change in eFI score (palliative and end of life care).

Midlock GP practice has developed a virtual way of working within the multidisciplinary team and have used the Living Well in Communities falls and frailty intervention tool to guide the development of a falls and frailty collaborative working in the community. The team have found the tool beneficial to use during frailty case reviews, as it promotes holistic assessment across agencies and is a useful prompt that helps staff by signposting to partner agencies that could assist in care provision. Incorporating the tool in the case reviews highlighted five key interventions which should be implemented for every individual identified as frail (#Frailty5):

  • Frailty identification and coding on the GP system
  • Anticipatory Care Plans uploaded to eKIS
  • Key worker
  • Carer support and assessment
  • Falls & Frailty Conversation

These interventions had previously not been happening for every person, every time.

The impact so far

“The frailty tool is excellent guidance to follow and know where to signpost people.”

“There was a richness of information shared by the MDT and it’s amazing to know how many supports are there for people.”

All of the team at Midlock have made commitments to support the work. Community nurses are engaging more in anticipatory care planning conversations, and the third sector feel that they are an integral part of the work, and that their contribution is valued. The inclusion of housing options in the tool is valued by the team, and the tool has made them aware of all the supports that are available.

Supporting the Midlock team to test the efi and the falls and frailty interventions tool has helped the team to change the way that they work, with benefits for both staff and those who receive care.

Find out more about the Living Well in Communities frailty and falls work on the ihub website.

We also displayed a poster on our work at the NHSScotland event in June, which you can view here.

Using a population screening tool to identify people with frailty in the community: the e-frailty index

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by Laura Dobie, Knowledge and Information Skills Specialist

The Challenge

A person with frailty can experience serious adverse outcomes following even a relatively minor illness. Timely identification of frailty can help to reduce the likelihood of a poor outcome following an intervention (or eliminate the need for an intervention entirely) and support the long-term management of people’s health needs.

If we can identify people with frailty in the community, we can offer preventative support that could improve their quality of life and reduce the risk of unscheduled admissions.

There are a number of tools which professionals can use to screen people for frailty (see the British Geriatric Society’s Fit for Frailty guidance). However, many of these tools are based on questionnaires that require practitioners to have direct contact with individuals and can only be used to assess people who are actively engaged with services.  It would be resource-intensive and challenging for services to screen large population groups for frailty using these individual assessments.

The risk stratification tool, Scottish Patients at Risk of Re-admissions or Admissions (SPARRA) identifies individuals within the whole population at risk of hospital admission based on nationally-collected data on acute admissions and community prescribing.  However, it does not discriminate frailty from other high-risk population groups and can only identify individuals who are known to services, as they have had recent acute admissions or have been prescribed high-risk medications.  Alternative population screening tools are needed to identify people with frailty living in the community. Continue reading “Using a population screening tool to identify people with frailty in the community: the e-frailty index”

How care homes in Argyll and Bute are working to reduce falls

By Laura Dobie, Knowledge and Information Skills Specialist, Healthcare Improvement Scotland

On 5th December I went along to the Argyll and Bute Care Homes Quality Improvement for Falls Prevention event. It was a really interesting day, and it was great to hear about the work that care home staff are doing to reduce falls and improve quality of life for their residents.

PDSAs and data

Dr Christine McArthur, Project Lead, introduced the day and Sheila Morris, Occupational Therapy Care Home Lead, gave an overview of Plan Do Study Act cycles and the role of data in improvement. She emphasised the importance of carrying out small tests of change and having a clear plan.

The project participants then had the opportunity to discuss a case study of a 72-year-old lady who had had a number of falls, considering risk factors such as polypharmacy and multiple complex conditions, and reviewing the data in the falls diary to identify whether there was a pattern to her falls.

The care home staff observed that people are increasingly coming in to care homes with more mobility problems and multiple conditions and co-morbidities. Sheila commented that everyone in the care home sector is at risk of falling and should have a multifactorial falls assessmentContinue reading “How care homes in Argyll and Bute are working to reduce falls”

Scottish Ambulance Service Falls and Frailty Pathways Action Group first meeting

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On 25th November 2016 the Living Well in Communities team from Healthcare Improvement Scotland’s Improvement Hub (ihub) supported the first meeting of the Active and Independent Living Improvement Programme (AILIP) and Scottish Ambulance Service Falls and Frailty Action Group. This Storify summarises the discussions from the day. Presentations and other resources can be accessed on the Falls and Bone Health Community site.

 

Preventing falls in Argyll and Bute: Cowal Befrienders’ exercise classes

Strength and Balance

In this article we look at a service which is aiming to prevent falls by supporting older people who have difficulty attending classes to take part in exercise.

Background

Exercise has an important role to play in reducing the risk of falls among older people in the community. A recent BMJ review has indicated that exercise-based and tailored interventions are the most effective way to reduce falls and associated healthcare costs among older people in the community, while a recently updated Care Inspectorate good practice resource, Managing Falls and Fractures in Care Homes for Older People has stressed the importance of keeping mobile, doing regular exercise and being physically active.

The Cowal Befrienders’ falls prevention exercise classes are working towards the overall aim that “Older people have a reduced risk of falls that may affect their ability to live independently in the community”.

The classes

Cowal Befrienders host two strength and balance exercise classes per week for older people who require some help to get to the Befrienders’ drop-in centre where the classes are held and support to participate in exercise classes.

Classes are co-ordinated and delivered by Otago-qualified staff employed by Cowal Befrienders (the Otago  exercise programme is designed to prevent falls). Referrals and assessments are managed by the NHS Highland physiotherapy team.

Clients are entitled to six free classes, and can continue to attend for a modest fee of £2.50 per session. There is a small charge for clients requesting transport to their classes to help offset the additional costs incurred to provide this service (£3 return for individuals living within Dunoon, and £5 return for those living outside of the town).

In addition to health and wellbeing benefits, such as increased strength, balance and mobility, and helping participants to feel more confident and independent, the classes also have a social aim: to help older people to expand their social networks and foster peer support, and to increase access to health-promoting information that meets their needs.

The social aspect of the classes has been particularly valued by participants, with 97% citing this as one of the things that they enjoyed most about the classes. Clients also particularly appreciated the encouragement that they were given by staff and volunteers, and the pace of the classes. Continue reading “Preventing falls in Argyll and Bute: Cowal Befrienders’ exercise classes”

Improving Care for People with High Levels of Need

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(Source: Information Services Division Integrated Resource Framework. Data from 2012/13)

The High Resource Individuals team within Living Well in Communities is supporting Health and Social Care Partnerships (HSCPs) through a series of data Deep Dives, to understand how those with the highest level of need interact with services.

Thomas Monaghan, Improvement Advisor, from Healthcare Improvement Scotland’s ihub, and Nathan Devereux, Associate Improvement Advisor, have been contributing to the wider work on High Resource Individuals by exploring ways of improving pathways of care, with support from the Local Intelligence Support Team (LIST) and Information Services Division (ISD).

These Deep Dives help partnerships explore their data on these individuals and identify areas for improvement.

Who are High Resource Individuals?

High Resource Individuals (HRIs) are the small number of people who use a high percentage of hospital and community prescribing resources and inpatient bed days.

Continue reading “Improving Care for People with High Levels of Need”

Managing Frailty The Fife Way: Summary and Resources

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Managing Frailty the Fife Way took place on 17th March 2016 at the Carnegie Conference Centre. The event was an interesting and informative day which explored good practice in managing frailty from Fife, highlighting innovative ways of working and successful examples of integration. There was a lot of sharing and learning on Twitter throughout the day, and you can view a selection of tweets from the day on the event Storify. You can also view the agenda for the day.

Dr Graham Ellis, National Clinical Lead for Older People and Frailty, gave a lively introduction to the day and declared an ambition for Scotland to be the best place to grow old.

Professor Scott McLean, Chief Operating Officer (Acute Services) NHS Fife, gave an overview of acute care redesign in Fife. He argued that it is a myth that hospitals are places of safety and explained their decision not to open surge wards, commenting that they are not good for older people or staff.

Dr Seònaid McCallum discussed health and social redesign in Fife. She emphasised the importance of relationships and building bridges, and the continuous nature of the work.

Karen Goudie, Joy Reid and Louise Kellichan presented on Frailty at the Front Door, highlighting NHS Fife’s frailty screening tool, their frailty huddles and the Integrated Assessment Team’s journey to a 7-day service at the front door.

Avenue Care’s Francis Davidson discussed their work on the Short Term Supported Discharge project, which aimed to help people to recover in their own homes, eliminating the need for a stay in hospital or readmission to hospital. She highlighted the success of joint working on the project and argued that the project has demonstrated that integration really works.

Continue reading “Managing Frailty The Fife Way: Summary and Resources”

Managing Frailty The Fife Way

NHS Fife and the Fife Health and Social Care Partnership are hosting Managing Frailty the Fife Way (#fifefrailty), a learning event for managers and practitioners from acute, community and social care.  The event will allow NHS boards and health and social care partnerships to explore the health and social care system in NHS Fife and learn from examples of good practice and local innovation.

Healthcare Improvement Scotland is supporting the event and Graham Ellis (National Clinical Lead for Older People) will be introducing the day.

On the Day

The event, which now has a waiting list, is taking place on Thursday 17 March 2016 at Carnegie Conference Centre, Dunfermline.

There will be four plenary sessions taking place in the morning by a variety of speakers including, Professor Scott McLean (Chief Operating Officer, NHS Fife Acute Services Division) and Seonaid McCallum (Associate Medical Director, Health and Social Care Partnership).

The afternoon session will be made up of four breakout sessions and a further plenary session with Professor Brendan McCormack (Head of Division of Nursing / Head of QMU Graduate School) before closing with a panel discussion.

Continue reading “Managing Frailty The Fife Way”

Living Well With Frailty: Conference Outputs

The Living well with Frailty event, held at Heriot-Watt University in Edinburgh on the 27th of October brought together colleagues from across the health and social care sector to undertake a deep dive into the issues surrounding frailty.

The day comprised morning and afternoon plenaries, as well as eight breakout sessions ranging from ‘A focus on Dementia – personal outcomes in practice?’ to ‘Care Homes: My care, Your care, Our care – Designing a Care Home for the future’. For a full list of the sessions please download a copy of the agenda from the day. A comprehensive overview of each of the sessions is available below.

Breakout sessions
Timely identification and co-ordination of care for older people living with frailty
Presenters: Penny Bond and Karen Goudie

During this workshop, Karen and Penny from Healthcare Improvement Scotland led a discussion with attendees on what it means to be an older person with frailty going through our hospital system. Brief patient stories were shared to highlight opportunities and challenges as a starting point for discussion. Attendees then shared experience of testing and implementing different approaches to identifying and coordinating frailty care within acute care settings. The timely identification and co-ordination of care for older people living with frailty presentation can be viewed via the following link and you can watch a video of Mrs Andrews’ story on YouTube below.

Continue reading “Living Well With Frailty: Conference Outputs”

Living Well In Later Life

What sorts of things come to your mind when you read the phrase ‘Living well in later life’? How can quality improvement help achieve this and why is the QI community across health and social care getting involved?

Surely how one lives, is not something that anyone other than the individual can control? Living well is about making your own decisions, about exercising choice. So why, one might ask are the health and social care organisations developing a programme that seeks to focus attention on this?

In a nutshell, what we are trying to do, through a series of projects is to empower older people and their loved ones to make decisions about how to live well in later life and provide guidance to help them navigate through the maze of choice of care solutions so that informed decisions about how one wishes to live well can be reached.

Continue reading “Living Well In Later Life”