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.

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Update From The High Resource Individuals Roundtable

HRI 1 PNG

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

Representatives from the Scottish Government, National Services Scotland, Health Boards, Care Inspectorate, Healthcare Improvement Scotland and Health Scotland got together on 11th May to discuss the work taking place around High Resource Individuals (HRIs) across the country.

Background

In Scotland, a small number of people use a high percentage of hospital and community prescribing resources and inpatient bed days. By focussing on people with a high level of need there is potential to better understand and align the resources used, manage service capacity and demand, and ultimately improve care pathways for those that require the most support.

2020 Vision

Starting with the principles of the Scottish Governments 2020 Vision – that everyone is able to live longer healthier lives at home, or in a homely setting – the group aimed to set out clear objectives and actions for these HRI projects, such as:

  • supporting practical, independent living
  • ensuring care is person-centred
  • fostering a culture of improvement
  • effective and efficient use of resources
Presentations & Workshop

A number of short presentations highlighted some of the work currently taking place, sparking discussion on potential values and challenges so far. Continue reading “Update From The High Resource Individuals Roundtable”