This Future Hospital Programme case study from University Hospitals of Leicester NHS Trust details how the introduction of a more effective model of care for older frail people in urgent care settings can see an increase in safe discharges, a decrease in readmission and provide a more stable, well-communicated care team during admission and after.
- Use Plan, Do, Study, Act (PDSA) cycles to structure and optimise the service being developed.
- Forge close relationships between physicians and primary care coordinators to produce a streamlined, more effective service for the patient.
- Work in conjunction with staff from other departments as well as specialist staff to create an effective multi-disciplinary care package for patients.
- Having exemplary care in place for patients is not limited to inpatients and should continue indefinitely following discharge to reduce risk of readmission.
Our story - The challengeUniversity Hospitals of Leicester NHS Trust serves a catchment population of 1.1 million with just a single emergency department (ED), based at Leicester Royal Infirmary. This is complimented by cardio-respiratory departments operating at Glenfield Hospital. Of the catchment population 160,000 are aged 65 and over.
Following an appraisal of the evidence for the benefits of comprehensive geriatric assessment (CGA) it became clear that a new, more effective model of care was required for frail older people in urgent care settings.
Our solutionFrom a series of PDSA cycles we initially developed a ‘mini’ acute frailty unit (AFU). These PDSA cycles were necessary as they allowed us to optimise the structure and processes for a service that delivers CGA for frail older people. The new AFU moved us to work closely with staff in the ED, helping to develop and build stronger relationships. It also highlighted the significance of frailty in caring for acute older patients.
The ‘mini’ AFU led on to the development of a more robust liaison service. This involved geriatricians working closely with therapists in support of the acute medical team. The primary aim of this service was to focus on ambulatory care (ie those patients that could be safely discharged) rather than the totality of urgent care for frail older people. The result of this service highlighted that there was a significant pressure for it to take on an even greater role in the care of frail older people.
“The new AFU moved us to work closely with staff in the ED, helping to develop and build stronger relationships. It also highlighted the significance of frailty in caring for acute older patients.”
From this pressure came the next stage of the development, the emergency frailty unit (EFU). The EFU is a larger dedicated service for frail older patients within the ED. Its core components are:
- robust pathways directing the care of frail older people throughout the 24-hour period;
- a dedicated area for assessment not subject to the 4-hour target;
- a dedicated team: geriatricians, nurses, ‘primary care coordinators’, therapists and strong collaborations with emergency physicians;
- liaison service providing direct clinical support for the care of frail older people throughout the emergency department, as well as education and training for colleagues;
- robust pathways out of hospital formed in mutual trust with community providers and social care.
StaffingThe project totals some 16 or 17 geriatricians plus the acute medical team, primary care coordinators (including gerontological specialist nurses), advance nurse practitioners (from the community hospitals), therapy staff and nursing staff.
OutcomesA number of factors have been important in the success of this new service. The multidisciplinary approach and close relationships forged between physicians and primary care coordinators enables direct links to community settings and enhanced handover procedures. This is extremely important to the success of the service.
The EFU is also supported by a wide range of additional service developments which include:
- a larger AFU being formed;
- changes to the community hospital model of care (which involves advance nurse practitioners alongside geriatricians delivering CGA);
- the introduction of an inpatient psychiatric liaison service for older people.
The EFU can be associated with a 10% reduction in admission in the 85-plus age group, as well as a 25% reduction in readmissions. Likewise the AFU can be associated with a 10% increase in discharges with no adverse impacts or readmissions. The changes to the community hospitals allowed for two wards to be restructured for home based intermediate care.
Key learningMost notable is the clear benefit of co-production. The combination of evidence-based medicines (the principles) and service development (the practicalities) result in policy influence and appears to have gained traction.
Important barriers, to the development of this care model, include:
- developing reciprocal trust and confidence between acute and community services;
- recording outcomes reflecting the ‘superspell’ (acute and community care);
- a lack of appreciation of what CGA brings to the care of frail older people from some.
These efforts and others – notably work from Sheffield Hospitals NHS Trust, the British Geriatrics Society and the Acute Frailty Network – have helped to develop and disseminate good practice in urgent care for frail older patients.
What next?We are currently developing a frail-friendly ED as part of a new build, a range of junior and senior fellowships and an integrated ‘joint venture’ that seeks to support clinical service developments through a shared business unit.
Who’s involved?Dr Simon Conroy, geriatrician
Simon’s ambition is to improve outcomes for frail older people by embedding evidence based medicine into clinical practice (‘campus to clinic’ translational research). His research addresses different models of care for frail older people, assessing feasibility as well as clinical and cost-effectiveness.
His educational activities take an interdisciplinary perspective on developing and teaching knowledge locally (frailty services), nationally (BGS) and internationally (EUGMS & IAGG). Implementation of research findings into clinical practice is key, and best exemplified by work on the Silver Book and the Acute Frailty Network.
More information can be found at the University of Leicester website
This project had partnerships with:
Leicestershire Partnership NHS Trust (the community services), adult social care, primary care and voluntary sector.
British Geriatrics Society , Acute Frailty Network
This case study was first featured on the Royal College of Physicians’ Future Hospital Tell us your story web pages, where you can read a full range of case studies.
FHP disclaimer: This case study is not an endorsement of any individual or organisation. The material within is promotional only and we [the Royal College of Physicians] do not necessarily reflect the views of the author and the organisation they represent.