Health partners join forces to improve community frailty services 

23/02/2016 00:00 
A partnership between UCLH, The Whittington and primary care providers in Islington is helping to improve integrated frailty services for older people.

Around 40 per cent of older patients attending UCLH come from the Islington area, with a larger proportion of older Islington patients attending The Whittington. Since 2014 UCLH and Whittington Health have been working more closely together after Islington CCG commissioned an integrated care service for older people in the community.

The service is a multidisciplinary, integrated community ageing team (ICAT), whose key goal is to develop a frailty service for Islington residents with the aim of improving patient experience, outcomes and a shift of care from acute settings into the community.

Dr Nadia Raja, UCLH's lead clinician for medicine for the elderly provides consultant input into the team which involves working closely with geriatricians from Whittington Health and a GP with a special interest in frailty.

Dr Raja said: "With older patients in the area attending either UCLH or The Whittington, it makes sense for us to have a shared strategy to provide coordinated patient care which delivers good outcomes.

"We've been able to provide specialist support to nursing homes in Islington - there's evidence nationally that we need to support those services more, with the aim of improving advance care planning in these settings.”

“It’s all about what’s important to the patient,” explains Karina Clapham, lead nurse for the integrated community ageing team, or ICAT for short. “The focus is always on them and what they want.”

The lynchpin of the service, which got off the ground in mid-October, is an initial comprehensive two-hour assessment, which Karina or her nurse colleague  carry out in the patient’s own home. It focuses on physical, mental, and social wellbeing.

The results of the assessment then prompt further support and intervention from other members of the team, such as physiotherapy, occupational therapy services, or pharmacy, depending on need.

And very often, frail patients have mobility or balance problems, which prevent them from getting out and about, and socialising. In these cases, ICAT works with local ‘clinical navigators’ from charity Age UK to try and redress this.

One of the benefits of this lengthy assessment process is that it can uncover longstanding issues that the GP has simply not had the time to pick up and deal with, explains Karina.

“Lots of these patients have complex problems that can be very difficult for GPs to sort out in the time they have, and being able to take that time and come up with an action plan is really helpful for the GP,” she says.

But quite often it can be something relatively simple that makes the difference, she says.
“A patient that has been suffering dizzy spells and had a few falls for some time might not have been taking their medicine properly or taking a combination of medication that is making them dizzy,” she explains.

The other benefit of the service is that quite often the patient has made serial visits to doctors for diagnostic tests, and has reached a point where they just can’t see the point of doing this any longer, so a home visit is much more acceptable.

Dan Windross, Integrated Care Commissioning Manager at the CCG commented: “The collaborative working which is central to the service has meant that staff have built better relationships with patients and gained a greater understanding of the challenges they face. The number of patients being cared for in the community has increased, this means fewer people need to stay in hospital.

Dr Ruth Law, ICAT clinical lead, said: "We now have the resources to actively help and manage care for frail older people in the community, with much greater interaction between hospital and community teams. If patients do need to come in to hospital those links with community colleagues means we're benefiting from greater awareness and knowledge of patients, and assurance around how their care is continued after discharge."

Islington CCG operates regular multi-disciplinary team (MDT) conferences to bring together clinicians from community, mental health and hospital teams, along with social services and the third sector. The MDTs mean local health services can identify which patients need to be prioritised and how the teams will jointly meet patients' needs. This means fewer patients will need to come to hospital, and patients should be able to be transferred back home or to the community quicker. Better for patients, better for families and carers.

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