Acute medical care of older people- outside hospital

Simon ConroyHead of Service/Senior Lecturer, Geriatric MedicineCardiovascular SciencesUniversity of Leicester

Not an acute medical problem

Inappropriate

admissions

What is intermediate

care?

Ageing population

Lack of primary

care

Poor social services

Patients come out worse than went they went

in

Inappropriate

admissions

Inappropriate investigations

Ageing population

Too many specialists

Black hole

Patients come out worse than went they went

in

Too many specialists

What is the truth?

• Ageing population, increasingly complex care

• More attending emergency care– Despite intermediate care etc

• Lower threshold for admissions

• Coordinated care more challenging as ‘silo mentality’ sets in

Some definitions

• ‘Unscheduled care’, ‘unplanned care’, ‘emergency care’, ‘urgent care’

• Department of Health:– ‘Emergency Care is an immediate response to time critical

health care need. Unscheduled care involves services that are available for the public to access without prior arrangement where there is an urgent actual or perceived need for intervention by a health or social care professional. Urgent care is the response before the next in–hours or routine (primary care) service is available.’

Scope

• Emergency care– 999/ED– Not appropriate for community setting

• Urgent care– ‘In the eye of the beholder’– Most urgent care is sub-acute care

Urgent (sub-acute) care – who?

Urgent (sub-acute) care – who?

Urgent care – what?

• Non-specific presentations– Falls, delirium

• Multiple comorbidities

• Polypharmacy– Also under-prescribing

• Differential challenge– Communication, discharge support

Urgent care - where?

• Where there is ready access to:– Skilled assessment– Diagnostics, if necessary– Safe environment– Rehabilitation– Coordinated care

Figure 3: Fixed-effects meta-analysis of individual patient data: mortality at 6 months.

Shepperd S et al. CMAJ 2009;180:175-182

©2009 by Canadian Medical Association

Urgent care - standards

• The Silver Book– http://www2.le.ac.uk/departments/cardiovascular-sciences/people/conroy/silver-book

• Membership– Age UK– National Ambulance Service Medical Directors– Association of Directors of Adult Social Services– British Geriatrics Society– Chartered Society of Physiotherapists– College of Emergency Medicine– College of Occupational Therapists– Society for Acute Medicine– Royal College of General Practitioners– Royal College of Nursing– Royal College of Physicians– Royal College of Psychiatrists– Community Hospitals Association

Underpinning principles

• All older people have a right to a health and social care assessment and should have access to treatments and care based on need, without an age-defined restriction to services

• A whole systems approach with integrated health and social care services strategically aligned within a joint regulatory and governance framework, delivered by interdisciplinary working with a patient centred approach provides the only means to achieve the best outcomes for frail older people with medical crises

Standards (some)

• All older people accessing urgent care should be routinely assessed for:– Pain– Depression– Skin integrity– Falls and mobility– Continence– Safeguarding issues

– Delirium and dementia– Nutrition and hydration– Sensory loss– Activities of daily living– Vital signs– End of life care issues

Frailty syndromes & urgent care

• The presence of one or more frailty syndrome should trigger a more detailed comprehensive geriatric assessment, to start within 4 hours (14 hours overnight)

• Frailty syndromes– Falls & immobility– Functional decline– UTI & incontinence– Pressure sores

– Delirium and dementia– Polypharmacy (>4 items)– Carer strain

Who needs referring to the MDT?Population:• Younger, single system

problem

• Older, single system problem

• Older, multiple problems, frailty makers

Refer to:Relevant service, e.g. mental health, diabetes

Relevant service, e.g. mental health, diabetes & screen for frailty syndromes

Virtual ward/community MDT

Operationalising good practice• Delivering multidimensional assessment & multiagency

management

• Home based multidisciplinary teams– General practitioners– Community nursing, physiotherapy, occupational

therapy, mental health – Specialist nursing– Advanced nurse practitioners– Interface geriatricians– Social care– Voluntary services

Does it work in practice?

• National Evaluation of the Department of Health’s Integrated Care Pilots; RAND Europe, Ernst & Young; March 2012

Key findings

• Horizontal > vertical integration

• Process improvements – e.g. more care plans

• Professional > patient driven service change– Patients less enthusiastic

• No evidence of reduced emergency care use

• Reductions in elective care use (in and out-patient)– Case management– Reduced costs

Effective urgent community care for older people

• Vertically integrated, using strengths of both sectors

• Comprehensive geriatric assessment, including social care

• Coordinated and communicated

Frail older personin crisis

Intermediate care

Bed-based rehabilitation/reablement

Specialist careIn-patient

CGA

Liaison

SPA – clinical discussion

MDTTriage

TrajectoryTransfer

EFU/AFU

Summary outcomes for EDPercentage change 2010 vs. 2012

Impact on bed days

Despite large increase in older people attending, bed-daysonly modestly increased

Summary

• Urgent care = older people

• It can be in the community, but:– Needs to be vertically integrated– Holistic & interdisciplinary– Underpinned by robust communication and

cooperation