What was the issue you were addressing or working on?
The management of frail Angus patients was reliant on hospital admission and prolonged stay to assess and manage acute or often non-acute de compensation to a frail person’s health. This resulted in high occupancy rates in community hospitals and adverse outcomes for patients such as hospital acquired infection.
What you did?
Numerous Change Fund projects have collectively acted as enablers to improve the Medicine For the Elderly (MFE) model in Angus e.g. Practice based polypharmacy, care home support, ortho geriatric model, Angus community in-reach therapy model, Acute Medicines Unit (AMU) liaison, and practice based multi disciplinary team meetings. Each project was tested in one locality (South Angus) and spread to two other localities. Each project is delivered by locality teams, led by locality geriatrician so there is continuity of care for patients linking all of the pathways and projects culminating in a whole Angus locality approach.
- Angus MFE led AMU liaison (supported by discharge coordinators) reviewed all frail Angus patients admitted within 24 hours. This has resulted in discharge of more than 85% of these patients either to home, with responsive services, or a local community hospital directly from AMU. A surgical model has just commenced.
- Angus Ortho geriatric pathway All Angus patients admitted to Orthopaedic wards are reviewed by Angus MFE within 48 hours and discharge planning is supported by “perfect orthopaedic pathway” to home.
- A Care Home Support service was started where the locality MFE team supported local GP’s to deliver annual medication reviews, support creation of Anticipatory Care Plans, give timely telephone advice at time of crisis and ensure all new admissions to care homes have anticipatory care plans including Do Not Attempt CPR status.
- Practice based Polypharmacy review clinics Every Angus patient on 12 or more medications and over age 75 years has undergone a collaborative medication review with their own GP, practice pharmacist and local MFE Consultant.
- Practice based multidisciplinary team meetings (MDT) with Angus carers, therapists, social work, district nurses, MFE and GP discuss “at risk” patients at weekly meeting aimed at crisis prevention.
- Angus in-reach Therapy project Angus occupational therapists support Ortho geriatric and AMU models with ability to discharge patients home with same day review of function.
What were the outcomes - benefits or otherwise?
- 60% reduction in unscheduled admissions to hospital from care homes.
- Reduction in new care home admissions by 40%.
- Reduction in length of stay in orthopaedics by 8 days and in medicine by 5.5 days per patient.
- New locality based model has led to more efficient and effective service delivery and a significant reduction in bed reliance in South locality – 25 beds are used per night compared to 43 beds 3 years ago.
- Mean patient length of stay in South locality is 6.8 days as opposed to 9.2 days in North locality where spread is 12-48 months behind.