The Liverpool Frailty Service was set up in 2014; it was recognized that frail older people requiring admission to hospital were often not seen by the most appropriate health professionals and care tended to be fragmented, with duplication of assessments between primary and secondary care.
The service included the acute hospital, Liverpool Community Health, Merseycare and Liverpool City Council. In Liverpool the frail elderly population is increasing and make up the fastest growing proportion of unplanned attendances and admissions to the RLBUHT.
A significant proportion of frail older patients with complex needs in the past were triaged to short stay units or specialty based wards and did not receive a specialist comprehensive geriatric assessment.
In the first 11 months of 2013, 2893 patients over 65 presented to the Royal Liverpool ED with falls or confusion or who resided in care homes; when compared resources at that time, would indicate a significant proportion of patients who would be likely to benefit from a Comprehensive Geriatric Assessment (CGA) were not seen by the most appropriate specialist.
Emerging evidence now points to a significant reduction in these risks where a model of care involving real time acute CGA and bespoke multidisciplinary care by a consultant led frailty team is used.
This enables patients to return home as soon as possible, delivers better outcomes, reduces very long lengths of stay and reduces the risk of in hospital decompensation.
At a local level, the care of frail patients presenting acutely is currently often fragmented and inefficient and increases risk from duplication of assessments between primary and secondary care. It is increasingly recognised that, for elderly patients presenting acutely, a lack of specialist geriatrician led care and a disjointed hospital – community service interface, markedly increases the risk of poor clinical outcomes, adverse inpatient events and prolonged length of stay, readmission and mortality within the acute setting.
There is robust evidence that the delivery of a Comprehensive Geriatric Assessment (CGA) in a specialist unit results in improved patient outcomes, a reduction in medical complications associated with prolonged hospital stay, a reduction in delirium, reduced dependence and lower rates of institutionalisation and reduced length of stay.
There is also emerging evidence that such models of care can reduce mortality rates. The service consists of an in-reach team of 4 Frailty Specialist Nurses (FSNs), 8 til 8, 7 days a week, supported by a consultant geriatrician ward round on the emergency floor 5 days a week, an 18 bedded frailty unit base on one of the Clinical Gerontology wards, and a community frailty team, including therapists, mental health practitioners, social workers and community nurses.
The aim was to case find frail patients attending the Emergency Department and the Acute Medical Admissions Unit, using the Bournemouth Frailty criteria. Once patients were identified the Comprehensive Geriatric assessment is started by the FSNs and a consultant geriatrician then reviews the patients, making a decision to discharge, admit to the frailty unit (if discharge likely to be within 72 hours), or to another bedbase either within the acute hospital or community setting.
On transfer to the frailty unit patients undergo a full comprehensive geriatric assessment, with twice daily consultant led multi-disciplinary meetings and a daily consultant ward round. Once patients are medically optimised the team takes the patient to their own home to complete a Discharge to Assess visit, which enables us to assess patients in their usual environment and plan their on-going care.
The community arm of the team provide a five day on-going period of treatment and monitoring and transfer on-going care needs to the most appropriate community team when necessary. In some cases patients may require a more prolonged spell of reablement.