Frailty Delivering the New GMS Contract Next Steps

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Frailty: Delivering the New GMS Contract & Next Steps Andy Clegg Senior Lecturer &

Frailty: Delivering the New GMS Contract & Next Steps Andy Clegg Senior Lecturer & Consultant Geriatrician University of Leeds & Bradford Royal Infirmary andrew. [email protected] nhs. uk @drandyclegg

Evidence for community-based interventions Intervention Outcome Comprehensive geriatric assessment of older people 14% reduction

Evidence for community-based interventions Intervention Outcome Comprehensive geriatric assessment of older people 14% reduction in nursing home admission Comprehensive geriatric assessment of ‘frail’ older people 10% reduction in hospital admissions Community-based post discharge care 13% reduction in nursing home admission 10% reduction in hospital admission Group-based education (supported selfmanagement) 40% more likely to be living at home Falls prevention 8% reduction in falls Exercise interventions s t a e v a C Reducing inappropriate polypharmacy Improved function Reduced falls/hospitalisations Beswick Lancet 2008, Clegg RCG 2012, Theou J Aging Research 2011

Considering the caveats • Clinical and public health decisions are almost always made with

Considering the caveats • Clinical and public health decisions are almost always made with imperfect data • There will always be an argument for more research and for better data, but waiting for more data is often an implicit decision not to act or to act on the basis of past practice rather than best available evidence • The goal must be actionable data that are sufficient for clinical and public health action that have been derived openly and objectively and that enable us to say, “Here’s what we recommend and why. ” Frieden NEJM 2017

How should we take action?

How should we take action?

Apply established models of LTC management Organisational, system-level approach to caring for people with

Apply established models of LTC management Organisational, system-level approach to caring for people with LTCs in a primary care/community setting Components of the approach are highly relevant for frailty

Applying the chronic care model in frailty 1. Identify relevant subpopulations of people with

Applying the chronic care model in frailty 1. Identify relevant subpopulations of people with frailty for proactive care 2. Mobilise community resources to meet needs of people with frailty 3. Empower and prepare people with frailty to self-manage their condition(s) 4. Embed proactive planned interactions which incorporate individual goals 5. Embed evidence-based guidelines into practice & integrate specialist expertise

e. FI development and validation Development cohort 250, 000 Internal validation cohort 250, 000

e. FI development and validation Development cohort 250, 000 Internal validation cohort 250, 000 External validation cohort 500, 000 Clegg Ageing 2016 (open access)

Outcomes Outcome Mild frailty (HR, 95% CI) Moderate frailty (HR, 95% CI) Severe frailty

Outcomes Outcome Mild frailty (HR, 95% CI) Moderate frailty (HR, 95% CI) Severe frailty (HR, 95% CI) 1 yr care home admission 2. 00 (1. 68 to 2. 39) 2. 70 (2. 41 to 3. 04) 5. 94 (4. 61 to 7. 64) 3 yr care home admission 1. 52 (1. 37 to 1. 69) 2. 70 (2. 41 to 3. 04) 3. 42 (2. 84 to 4. 12) 5 yr care home admission 1. 56 (1. 43 to 1. 70) 2. 34 (2. 10 to 2. 61) 3. 00 (2. 42 to 3. 70) 1 yr hospitalisation 1. 85 (1. 81 to 1. 88) 2. 96 (2. 90 to 3. 02) 4. 62 (4. 50 to 4. 74) 3 yr hospitalisation 1. 71 (1. 69 to 1. 73) 2. 54 (2. 51 to 2. 58) 3. 64 (3. 57 to 3. 70) 5 yr hospitalisation 1. 63 (1. 61 to 1. 64) 2. 43 (2. 40 to 2. 46) 3. 59 (3. 54 to 3. 65) 1 yr mortality 1. 91 (1. 78 to 2. 04) 3. 39 (3. 15 to 3. 65) 5. 23 (4. 73 to 5. 79) 3 yr mortality 1. 74 (1. 68 to 1. 81) 3. 02 (2. 90 to 3. 14) 4. 56 (4. 29 to 4. 84) 5 yr mortality 1. 66 (1. 62 to 1. 71) 2. 73 (2. 64 to 2. 81) 3. 88 (3. 68 to 4. 09) Clegg Ageing 2016 (open access)

Frailty trajectories and care pathways Sup Co m Proportion alive Ca re pr eh

Frailty trajectories and care pathways Sup Co m Proportion alive Ca re pr eh port e &S d se en siv e up po rt P Ge r iat Fit (50%) lf-m ric anag eme nt lan As nin g se ss Mild frailty (35%) Moderate frailty (12%) m en t Severe frailty (3%) Time 5 yrs

National implementation & dissemination

National implementation & dissemination

2017/18 GMS Contract

2017/18 GMS Contract

NHSE Six Step Guidance 1. Identification e. g. using e. FI 2. Clinical confirmation

NHSE Six Step Guidance 1. Identification e. g. using e. FI 2. Clinical confirmation (e. g. CSHA Clinical Frailty Scale) 3. Coding of frailty diagnosis 4. Consent for summary care record 5. Falls assessment & medication review 6. Clinical judgment for other relevant interventions https: //www. england. nhs. uk/wpcontent/uploads/2017/04/updated-supporting-guidance-frailtyidentification-may-17. pdf

Falls assessment in primary care: BGS/AGS guidance

Falls assessment in primary care: BGS/AGS guidance

Full evaluation • Falls history • Gait, balance, mobility, muscle weakness • Visual impairment

Full evaluation • Falls history • Gait, balance, mobility, muscle weakness • Visual impairment • Cognitive impairment • Urinary incontinence • Home hazards • Cardiovascular examination (e. g. dysrhythmia/AS) & medication review

Evidence base: individualised, multifactorial intervention • Strength & balance training • Home hazard assessment

Evidence base: individualised, multifactorial intervention • Strength & balance training • Home hazard assessment & intervention • Vision assessment & referral • Medication review with modification/withdrawal

Commissioning falls prevention services

Commissioning falls prevention services

Options for designing falls prevention services 1. Specialist falls service, involving a single point

Options for designing falls prevention services 1. Specialist falls service, involving a single point of access for referrals, multifactorial interventions, and strength & balance exercises 2. Services that include a component of falls prevention e. g. frailty services/pathways 3. Embedding prevention in ‘non-specialist’ services, either contractually or via locally agreed ways of working • Case finding • Developing workforce competencies • Incorporating strength & balance training into physical activity services

GMS contract: other interventions

GMS contract: other interventions

Six essential characteristics of a service for frailty 1. Effective recognition, diagnosis and referral

Six essential characteristics of a service for frailty 1. Effective recognition, diagnosis and referral for frailty 2. Use of tools to assist case finding 3. Trained staff with appropriate expertise 4. A person-centred approach, moving away from diseasefocused to holistic, goal orientated care 5. Practice underpinned by comprehensive geriatric assessment & personalised care planning 6. Integration across services/settings

Next steps: Personalised Care Planning Personalised care planning to improve quality of life for

Next steps: Personalised Care Planning Personalised care planning to improve quality of life for older people with frailty Clegg A, Young J, Bower P, Cundill B, Farrin A, Foster M, Foy R, Hartley S, Hawkins R, Holmes J, Hulme C, Humphrey S, Lawton R, Pendleton N, West R, Bates C, Nazroo J NIHR PGf. AR £ 2. 7 M (October 2017 to February 2023)

Personalised Care Planning for Older People with Frailty Aim To establish whether PCP for

Personalised Care Planning for Older People with Frailty Aim To establish whether PCP for older people with frailty improves quality of life (SF 36) and reduces health and social care resource use at 12 months Work Package 1 Refining the target population by exploring Qo. L & health/social care resource use in frailty, using the e. FI (Research. One; CARE 75+; ELSA) Work Package 2 Optimising the Age UK integrated care service to deliver PCP for older people with frailty Work Package 3 Feasibility study (cluster RCT, 8 general practices, 400 participants) Yorkshire Work Package 4 Definitive cluster RCT, 40 general practices, 2, 000 participants – Yorkshire & Greater Manchester

Research Outputs • Identification of the target population for PCP in frailty, using the

Research Outputs • Identification of the target population for PCP in frailty, using the e. FI as a well-validated and widely available tool • A suitably optimised PCP intervention, including a common framework for routine NHS delivery • Definitive evidence on the effectiveness and costeffectiveness of PCP for older people with frailty • Information for policy-makers and commissioners on wider NHS implementation

Summary • There is an existing evidence base for community interventions to improve outcomes

Summary • There is an existing evidence base for community interventions to improve outcomes for older people with frailty • Considering frailty as a long-term condition enables development of a community-based model of care, based on the existing evidence base • The e. FI identifies subpopulations of older people at increased risk of adverse outcomes • The e. FI, supported by clinical judgment, can help in the identification of older people with frailty as part of the 2017/18 GMS contract • National guidance on designing & commissioning falls prevention pathways and frailty services • Next steps include optimising and evaluating personalised care planning for older people with frailty in a major research programme

Thank you

Thank you