Keeping our frail and elderly patients out of hospital

STOP PRESS. Negotiations on the 2016-17 GP contract have just concluded (19 February), and it has been announced that the current direct enhanced service for avoiding unplanned admissions will survive for at least the next year. However, despite the worthiness of the aim of supporting frail and vulnerable patients in the community, some practices question the scheme's viability

Unplanned admissions to hospital are on the increase. NHS England reports that the number of emergency admissions to hospital increased by 7.1% during 2014/15 with the highest rise in the older age groups (7.3% aged 75-84 years, 9% in the over 85s).¹ These figures suggest that a large percentage of patients admitted to hospital through urgent and unplanned circumstances are elderly, with more complex health and social care needs, and may be more susceptible due to their frailty.² The fact that these are unplanned admissions also infers that such admissions, and indeed re-admissions, could be preventable if life in the community was improved for this group of vulnerable people. Clearly being admitted to hospital in an emergency situation is both distressing and disruptive for patients, families and carers alike. On a wider scale, we cannot ignore the enormous cost to the NHS of such admissions.

AVOIDING UNPLANNED ADMISSIONS: THE FACTS

Proactive case finding and patient review for vulnerable people 2015/16

To try and combat this growing problem, an Enhanced Service (ES) for general practice was commissioned by NHS England in 2014,³ and has just been extended to March 2017.The aim of the Avoiding Unplanned Admissions (AUA) ES is to provide more personalised support to patients who are deemed at greater risk of unplanned admission to hospital, re-admission and attendance at Accident and Emergency through their vulnerability and frailty, and to avert crisis management.

The main elements of the ES cover five specific areas:

• Increasing practice availability via timely telephone access
• Identifying patients who are at high risk of avoidable unplanned admissions
• Reviewing and improving hospital discharge for patients on the register
• Undertaking internal practice reviews of emergency admissions and A&E attendances
• Distributing a patient survey (subject to feasibility study)

Box 1 highlights the current specifications of the five areas of the ES and the requirements for participating GP practices.

Practices have to complete a reporting template twice a year with payments based on a maximum of £2.87 per registered patient on the total practice list. In order to receive payments, practices have to meet the requirements of the ES specifications (as per Box 1). In addition, practices must ensure that the case management register is maintained at a minimum of 2% of the practice’s adult population for each half of the year (with a 0.2% tolerance to account for any temporary dips).³ However, this is not additional income for practices, but funding from retired elements of the Quality and Outcomes Framework.

AVOIDING UNPLANNED ADMISSIONS IN PRACTICE

So who are the most vulnerable patients on our list? Without doubt, patients on our chronic disease and end of life registers, as well as residents in care and nursing homes, will be readily identified, although indeed not all them will be at risk of avoidable unplanned admissions. Equally, evidence shows that patients living in deprived and urban areas are at greater risk of hospitalisation.⁴ But are there patients we are missing? And what are we doing to ensure they are cared for adequately in our communities to reduce their risk of being admitted to hospital in an emergency? What are our responsibilities as practice nurses to meet the needs of the Enhanced Service?

THE IMPORTANCE OF IDENTIFYING FRAILTY

In order to determine which of our patients are likely to be at higher risk of emergency admissions, the guidance in the ES recommends the use of nationally recognised risk stratification tools. However, such tools are not without their problems and can potentially fail to identify up a quarter of older frail and vulnerable patients who literally slip under the radar but are fundamentally susceptible to crises as a result of even minor deterioration in their health and wellbeing.²

Frailty affects 10% of people over the age of 65 years with 25-50% affected over the age of 85 years.² Frailty, in itself, is a ‘clinically recognised state of increased vulnerability’ and can be viewed as a long term condition in the same way as dementia or COPD.⁵ It is neither an inevitable part of the ageing process nor is it necessarily obviously apparent. People with frailty may also have other complex health conditions or they may have no other discernible long-term problems and therefore remain unknown to their GP or social services. Frailty can be a progressive condition, a combination of physical and/or psychological elements, but equally can improve and in some cases be treated or prevented depending on its underlying cause. People with frailty may be living in social isolation although many will be high users of community services. Even a relatively minor event such as a fall, urinary retention or an infection, however, can significantly undermine the physical and mental health of someone with frailty causing a serious deterioration in their wellbeing, increased dependency or even death.⁶

It is vital therefore that patients within the practice who may be at risk of frailty need to be identified. This can include identifying those over 85 years, patients in care and nursing homes, those aged over 75 years who have been admitted in the last 6 months or have attended A&E, those with frailty syndromes (such as having falls, immobility, delirium, incontinence, susceptibility to the side effects of medication) and patients who are housebound or known to Adult Social Care. It could also include patients with specific medical problems such as dementia, neurological and rheumatological conditions and patients receiving end of life care. This clearly requires a multidisciplinary team approach and benefits from all members of the practice team being involved. Read codes can be used to record frailty as a diagnosis and the use of the Electronic frailty index, which has been developed for Primary Care systems, may be a beneficial tool.⁷

The use of simple, rapid and approved screening tools for all encounters with older people for the presence of frailty is deemed to be good practice.⁸ (Box 2) The PRISMA 7 Questionnaire is a simple self-completion tool which could be sent to patients over the age of 75 years annually and those who score 3 or more could be seen for further assessment.² Additional recommended tests for use in general practice, often used in combination, include:

• Rockwood Clinical Frailty Scale
• Gait Speed Test
• Timed up-and-go test (TUGT)

The Comprehensive Geriatric Assessment (CGA) is the gold standard in terms of assessment and management of moderate or severe frailty in older people but it is acknowledged that in general practice a simplified review based on CGA principles is more appropriate.⁵

PERSONALISED CARE PLANNING

The development of a Personalised Care Plan (PCP) is a collaborative process between the patient and their GP together with members of the multi-disciplinary team to help the patient manage their health and social needs, improve their quality of life and prevent unplanned care and potential hospitalisation.⁹ With the patient’s consent it may also include family members and if applicable, their carers. Assessment of the patient should take a holistic approach to identify their individual health and care needs and may involve the district nursing team, occupational therapists, social workers, mental health teams and voluntary organisations. The plan needs to take into account the patient’s wishes in life, for their future and, when appropriate, in death. The goals and actions of the plan should focus on supporting patients with self-management strategies and accessing additional support as and when the need arises, and enabling the patient to recognise that need. It is requirement of the ES that the patient has a copy of their plan. The patient’s named GP is accountable and responsible for the creation of the PCP but they may appoint a care co-ordinator to act as the main point of contact for the patient. In many practices, it is the practice nurse or nurse practitioner who takes on the role of care co-ordinator with the named GP having overall responsibility. The aim of the PCP is to improve the quality of care for the patient, improve the co-ordination of that care and ultimately improve or maintain the health and well-being of the patient. In addition, plans for intervention through self-management and accessing the appropriate support need to be in place should the patient’s health deteriorate with the ultimate aim to avoid admission to hospital or attendance at A&E.

From the ES point of view, each PCP must be reviewed at least once during a 12-month period to meet the payment criteria, although in practice it is more likely that patients will be reviewed more frequently according to need. MDT meetings and palliative care meetings are also arenas in which patients can be discussed and reviewed by the practice and community teams. These meetings also give rise to discussions about patients who have had unplanned admissions and whether such admissions could have been prevented. In each case the PCP can be examined to determine if it had been implemented or whether there were omissions on the plan that need rectifying, as well as making additional support and resources available to the patient to prevent future crises.

INTEGRATED CARE

The aim of integrated care is to reduce hospital admissions through collaboration of health and social providers, as well as voluntary organisations, to improve services and support for our elderly patients who are most at need. Clinical Commissioning Groups (CCGs) are involved in helping GP practices to deliver the AUA ES and many areas have developed Integrated Care Programmes as a priority to improve care for patients at risk of AUA. The Living Well programme in Cornwall is one example of successful integrated care through the partnership of health, social care, voluntary organisations and local people which, as a result, has demonstrated a 34% reduction of emergency admissions in their high-risk patients.¹⁰

Box 3 highlights the types of professional, voluntary and community resources that are being provided as part of admission prevention initiatives. Such services are aimed at providing the ‘right care, in the right place, at the right time’ to keep vulnerable elderly people out of hospital. The evidence certainly suggests that inappropriate admission to hospital can cause more harm than good for people with frailty.¹¹

CONTROVERSIES SURROUNDING THE ENHANCED SERVICE

So the benefit to primary care of undertaking the AUA ES all sounds good. Apparently, not necessarily. Recent news articles have indicated that some practices have been underpaid significantly for the service, in some cases up to £1 per registered patient. The cause of this has been attributed to discrepancies between the guidelines supplied to practices and the ES specifications used in IT services. Most notable have been changes to coding, the need to manually input records of patients’ deaths, and misunderstandings regarding the timing and frequency of the care plan reviews.¹² In addition, there have been technical problems with data extraction by the Health and Social Care Information Centre which has resulted in some practices receiving reduced funding following the first round of reporting.¹³ The concern for practices will be whether or not undertaking such additional work, which aims to benefit the needs of their more vulnerable patients, is viable. Additionally, practices have suggested that there has been inadequate investment into general practice to sustain these programmes amid little evidence so far to suggest that the ES reduces unavoidable unplanned admissions.¹⁴

THE PRACTICE NURSE’S PERSPECTIVE

Surely the concept of proactive case management to enable our most vulnerable patients to keep well for longer in the community – to prevent deterioration of their frailty, to provide them, and their families and carers, with the tools and resources to support their health needs and to recognise how to manage acute episodes and avoid unplanned admissions to hospital – can only be of benefit?⁸ From a practice nurse’s perspective, we have a responsibility to aid this vulnerable group by identifying those at risk from our daily contact with our patients, or indeed their relatives and carers. It is also our responsibility to be aware of the local resources and support services available in health and social care as well as in the voluntary sector and within our own communities. We may also be involved in the care co-ordination of patient’s personalised management plans or in follow-up care after discharge. We should also have opportunities to discuss and review individuals’ ongoing needs through multi-disciplinary meetings, Gold Standards framework meetings or other clinical meetings within the practice.

CONCLUSION

There is some evidence to suggest that when care planning is done well, it can be effective in improving quality of life and reducing unplanned admissions although, without doubt, there is a need for more robust evidence on its financial impact on the NHS and its true value to individuals, care services and society as a whole.⁹

In truth, it is probably too early to see that sort of impact of the current year’s ES. On a positive note, the introduction of pioneering integrated care schemes for the vulnerable people in our community looks promising.¹⁰ However, whether this ES will continue into 2016/17 remains to be seen.

• See also, Social prescribing in practice by Karen Randall, Practice Nurse September 2015.

REFERENCES

1. NHS England. Board paper NHS performance report. Undated. https://www.england.nhs.uk/wp-content/uploads/2015/03/item10-board-260315.pdf

2. Lyndon H, Stevens G. Toolkit for General Practice in Supporting Older People with Frailty and Achieving the requirements of the Unplanned Admissions Enhanced Service, 2014. NHS England. http://www.nhsiq.nhs.uk/media/2630779toolkit_for_general_practice_in_supporting_older_people.pdf

3. NHS England. Enhanced Service Specification. Avoiding unplanned admissions: proactive case finding and care review for vulnerable people 2015/16. https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/03/avoid-unplanned-admissions-03-15.pdf

4. Purdy S. Huntley A. Predicting and preventing avoidable hospital admissions: a review. Journal of the Royal College of Physicians Edinburgh. 2013;43:340-4. https://www.rcpe.ac.uk/sites/default/files/purdy.pdf

5. British Geriatrics Society. Fit for Frailty. June 2014. http://www.bgs.org.uk/campaigns/fff/fff_short.pdf

6. Morley, J E, Vellas B et al. Frailty Consensus: A Call to Action. Journal of the American Medical Directors Association. 2013;14(6):392-398.

7. National Institute for Health and Research Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber. Development of an electronic Frailty Index (eFI). http://clahrc-yh.nihr.ac.uk/our-themes/primary-care-based-management-of-frailty-in-older-people/projects/development-of-an-electronic-frailty-index-efi

8. University of York. Effectiveness Matters. January 2015. http://www.york.ac.uk/media/crd/effectiveness-matters-January-2015-frailty3.pdf

9. Coalition for Collaborative Care. NHS England: Personalised Care & Support Planning Handbook. 07 January 2015. https://www.england.nhs.uk/wp-content/uploads/2015/01/pers-care-guid-core-guid.pdf

10. Lind, S. GP-led scheme reduced emergency admissions by ‘more than a third’. Pulse. August 2015. http://www.pulsetoday.co.uk/clinical/more-clinical-areas/elderly-care/gp-led-scheme-reduced-emergency-admissions-by-more-than-a-third/20010813.fullarticle

11. NHS England. Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders. February 2014. https://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf

12. Lind, S. Practices underpaid by thousands of pounds in DES chaos. Pulse. 7 December 2015. http://www.pulsetoday.co.uk/home/finance-and-practice-life-news/practices-underpaid-by-thousands-of-pounds-in-des-chaos/20030626.article

13. Matthews-King, A. ‘Significant Minority’ of practices missing thousands of pounds for unplanned admissions DES. 19 November 2015. http://www.pulsetoday.co.uk/your-practice/practice-topics/practice-income/significant-minority-of-practices-missing-thousands-of-pounds-for-unplanned-admissions-des/20030481.article

14. Duffin, C. Number of unplanned admissions increases in 2014/15. Pulse. 24 March 2015. http://www.pulsetoday.co.uk/news/commissioning/commissioning-topics/emergency-admissions/number-of-unplanned-admissions -increases-in-2014/15/20009538.fullarticle