Acute district general hospital + 3 community hospitals and some community health services. Catchment of more than 330,000 people living in and around urban Ipswich. Remainder of the population is rural and quite isolated. 500+ beds + community beds; annual turnover £200+ million; 3,500 whole time equivalent staff; typically older catchment population than the England average with a greater proportion over 55.
Population served is an aging one (one of the fasted growth rates of very elderly people – over 80s – in the country), increasing levels of complexity of care including dementia, learning and other disabilities, co-morbidities; increasing population non-English reading/speaking; alongside older patients there are older family carers.
The service – FAB – Frailty Assessment Base – brings together the whole system to address the frailty needs of older people in once place by a multi-disciplinary team; reducing admissions, increasing confidence, enabling patients to go home. FAB has proved to be successful in its ambitions to make an impact on individuals and the system.
Based on evaluation of evidence, best practice; involving key stakeholders and led by senior clinicians, specialists in their fields, FAB enables the pooling of expertise within a clear framework and objectives to improve the patients experience, reduce admissions and increase the system’s ability to manage frailty.
FAB was piloted and has been so successful it is now (12 months later) being relocated to a specially designed and refurbished area with increased capacity. Recognised at the HSJ Awards, the project has communicated its ethos and success widely which provides evidence and ideas for others to use.
The positive outcomes for patients and across the system has demonstrated its sustainability which will now continue to grow.
The Issue: Research recognises that 60–70% of acute admissions are in people with long term conditions and/or frailty with only a mild to moderate illness – the Trust recognised the growing number of emergency department attendances and increased attendance to admission conversion rates in those over 85 years (75%)
This was not a good patient experience, likely to be an unnecessary admission and could lead to delays in discharge due to changing circumstances.
The Proposal: In the Autumn of 2015, with winter approaching and expectations of growing numbers arriving with no bed capacity to play with, we embarked on an innovative initiative to:
• Provide an alternative assessment pathway for frailer individuals
• Prevent deconditioning and support onward care in the patient’s own home or community setting where possible
• Raise the awareness of frailty in the local healthcare community
• Support a system-wide response
Prior to establishing our service model a survey monkey questionnaire was sent out to the local practices to establish what local GPs looked for in a frailty assessment service. One of the key findings from this was easy accessibility.
Feedback from patients and carers was reviewed and engagement with the Older People’s User Group enabled two way feedback and ideas for the initiative; enabling an understanding of what really matters to older, frail patients and what worried their carers.
The project is multi-disciplinary – led by specialist elderly care doctors with a multi-disciplinary team of senior physiotherapist, occupational therapist, dietitian, pharmacist and a doctor specialising in elderly care.
October 2015 – A pilot Frailty Assessment Base (FAB) was created to provide an assessment locality for individuals with complex co-morbidities who may otherwise have been admitted for assessment and ongoing care
• Located within Ipswich hospital but it is a community orientated service
• Physically consisting of a waiting area and three assessment areas
• Accessed via GP referral, community healthcare professional referral or the emergency department
• FAB can assess up to 6 patients a day and following assessment a shared care plan is provided to the patient and a copy provided to their GP and any involved community healthcare teams
• Assessment is tailored to the needs of the patient with a maximum of 4 hours spent on FAB
The Frailty Assessment Base opened in October 2015, the data below is for the first six months (pilot)
Patient experience was a key outcome for the service:
• 100% of patients or their relatives were asked to complete a patient satisfaction feedback form. 85% response rate and 100% would recommend the service (94% rate extremely likely to recommend the service and 6% rate as likely to recommend).
Patient destination following assessment; whether an admission was successfully avoided; how onward care was supported:
• 88% of patients assessed avoided immediate admission and were discharged to the community with 58% returning home, a further 24% returning home with increased support and 6% transferring to an intermediate care bed.
• 12% required acute admission following assessment but had received a front loaded geriatric assessment and the average length of stay for these individuals was 1.35 days below the average length of stay for age matched individuals admitted through existing pathways.
Staff satisfaction (in recognition of the role it plays in patient experience)
82% of staff involved in the FAB across the system reported being satisfied with the quality of care they were able to give with most also being happy to recommend working in the FAB
System wide improved outcomes (in recognition that frailty and inappropriate admissions is a system wide issue with system wide consequences):
• Support for self-management – Explanation, advice, Shared Care Plans
• Patient empowerment
• Falls assessment waiting time – reduced from 3 months to 3 days
The service also aims to raise the awareness of frailty in the local healthcare community. Each patient is scored on the Rockwood Clinical Frailty Scale and this is communicated to GPs.
System wide efficiencies:
• Best use of GP time – easy access
• Consultant telephone advice and triage
• No waiting lists
• Front loaded CGA for those admitted – saves time
• Reduction in admissions 274
• Reduction in bed days 1,918
• Cost of service £225k
• Net saving to CCG £500k
• Net saving to Trust £300k
Case Study Example 1 – patient via ED
• 88 year old man attending ED with “funny turns”
• 12 months before FAB
– 27 ED attendances
– 8 acute admissions
• Seen in FAB October 2015
• 6 months after FAB
– Attended ED once
Case Study Example 2 – from a GP
• 90 year old female
• Frailty score 4
• Complex medical problems
• Experienced a loss in confidence and abdominal symptoms
• GP was asked to arrange admission by family but instead referred to FAB
• Seen within 48 hours
• Admission avoided
• Patient reassured and provided with advice on self-management
• Onward referral and sharing of care plan with LHCT
• Patient greatly reassured, went home and has been managing well.
• GP felt this to be a very successful outcome
Reflecting on the last 12 months in total (data analysis currently underway/not completed):
931 patients in our first year, 840 of which we were able to get home (with or without a change in care / support) this is 90%. The breakdown is similar to the pilot with 58% home, 32% returning home with increased support.
3% were transferred to another supportive environment eg. rehab hospital or respite care placement whilst 7% were admitted to acute hospital for medical input.
Over 50% of the patients seen were in the mild to moderate frailty groups on the Rockwood clinical frailty scale. 14% were severely frail or above.
The FAB is a one stop shop pulling together a range of people and services with the sole aim of ensuring the needs of frail, elderly patients are addressed without the need to resort to a lengthy stay or repeated visits.
FAB speaks for itself in terms of its results (outlined above) and especially in the feedback from patients and carers:
“All members of the department are very friendly and helpful”
“It was good to have some explanations for a possible cause rather than being discussed just as elderly”
“I have been so impressed with the wonderful treatment I have received. Nothing could possibly improve all the help and advice I have been given.”
Consultant geriatrician Julie Brache said: “The proactive approach of the new Frailty Assessment Base aims to provide a friendly and comprehensive assessment in a day which helps to maximise independence and avoid the risk of harm from an overnight admission if this is not required.“
Key Learning Points
- Collection and review of evidence base to enable formulation of plan and service that genuinely responds to the issues, needs and wishes of patients, carers AND referrers such as GPs, care homes etc.
• Involve key stakeholders in the design and review – patients, carers and referrers
• Ensure the creation of a solid multi-disciplinary team that covers all aspects needed (including carers)
• Clear access points to the service, clearly communicated
• Prompt response to patient need across the system
• Create an appropriate environment – comfortable, welcoming, warm and friendly staff