Primary and Community Care

Same Day Emergency Care (SDEC) at St James’ Hospital, Leeds provides urgent care at the interface between primary and secondary care, offering comprehensive geriatric assessment (CGA) to those living with frailty, aiming to prevent hospitalisation and delay frailty progression. Advance care planning (ACP) is a vital component of prioritising care preferences including at end-of-life, but timing often falls short in practice. This quality improvement (QI) initiative aims to proactively open ACP discussions, allowing patients to consider their care goals, ensuring our care is aligned with their priorities.

Between July 2022 and April 2023, the project involved 1039 patients. Led by Advanced Clinical Practitioners with support from consultant geriatricians and a palliative care specialist nurse, ACP discussions were encouraged through prompts in daily staff huddles and drop-in teaching sessions. ACP uptake increased from 7.8 % to 19.3%. Insights from a perception survey involving 83 healthcare professionals revealed key barriers including clinical workload, limited space, lack of experience and confidence as well as prognostic uncertainty and patient factors. Education and training, clinical supervision, patient information leaflets and a conducive environment were positively associated with ACP.

There has been a cultural shift in the department as the practitioners now routinely prompt staff to undertake ACP in safety huddles. Key catalysts for ACP initiation were found to be progression of frailty, terminal diagnoses, dementia, and recurrent hospital admissions. As a new SDEC unit is scheduled to open in the coming months, with provision of space and privacy, our aim is to improve the quality and quantity of ACP discussions with the patient at the centre of all decision-making. In line with these endeavours, parallel support within the community through our home (virtual) ward will further enhance proactive care planning in older people living with frailty.

Background

The East Kent Frailty Home Treatment Service (Frailty HTS) provides person-centred, hospital-level care for people living with frailty. The Frailty HTS can diagnose and treat acute medical illness at home or in care homes. The team philosophy is “we identify what you want and strive to make it happen”. This project was underpinned by advance care planning for people living in care homes, which the frailty team supports through proactive work with the primary care network care homes teams.

Frailty is associated with increased healthcare costs and poor outcomes associated with hospitalisation. The acute hospitals were under extreme pressure. The Frailty HTS serves 360 care homes.

Methods

Carers and the ambulance service discuss all acutely unwell care home residents with the Frailty HTS prior to conveyance except in the case of a long bone fracture or acute cardiac/cardiovascular event (unless care plan is not for escalation).

There were communications initiatives to care homes and Ambulance Trust explaining referral process and eligibility. A dedicated frailty HTS clinician was available to respond to calls.

Results

The pilot has seen an increase in referrals of people living in care homes from SECAMB to Frailty HTS (monthly average up from 49 up to 64) an increase in direct referral from care homes (monthly average up from 15 to 21.5). We also saw a reduction in attendance of care home residents at ED (monthly average down from 276 to 209) and reduced admissions to hospital from care homes (monthly average down from 203 to 191).

Conclusion

This project raised awareness of an alternative to acute hospital care for people living in care homes. Referrals to the Frailty HTS were increased and attendance at ED and admissions to hospital reduced.  Due to system pressures it continued to run and became business as usual.

Introduction

The UK is expanding provision of acute medical care in peoples’ own homes through Hospital at Home (H@H) and virtual wards. Our H@H service is training junior doctors to meet the growing clinical need in this environment. We describe the use of simulation training to improve the H@H induction process.

Methods

From their experiences in H@H, junior doctors identified specific training needs to build relevant competencies. From this feedback, PDSA cycle one involved junior doctors designing a dedicated simulation training (H@H-SIM). Stations addressed clinical, practical and advanced communication skills required in H@H using high- and low-fidelity simulation. PDSA cycle two used post-course evaluation to refine H@H-SIM through introduction of FP10 prescribing stations, point-of-care testing (POCT) and greater emphasis on practical skills. Revisions were evaluated via participant questionnaire before and after the H@H-SIM.

Results

Cycle two of H@H-SIM involved twenty doctors. The clinical scenarios, prescribing and practical skills stations, including POCT and IV administration, were perceived as the most useful parts of training. Overall self-rated confidence in knowledge and skills to work in H@H improved from a mean of 6.9 to 7.7/10. Before H@H-SIM, 60% were ‘not confident’ with recognising end of life (EOL), IV administration or decision-making around remaining at home; 10% with advance care planning (ACP). After H@H-SIM, 10% felt ‘not confident’ with recognising EOL or ACP and 5% with IV administration. Concerns persisted with using equipment, prescribing and availability of senior support. An additional station on recording ECGs was suggested. 

Conclusions

Working in a H@H context and seeing patients in their homes can be daunting for junior doctors. H@H-SIM embedded into induction is one way to prepare doctors for this role, improve their confidence and has potential for wider replication.

Background: Older adults are the fastest-growing and most sedentary group in society. With sedentary behaviour associated with deleterious health outcomes, reducing sedentary time may improve overall well-being. Adults aged ≥75 years are underrepresented in sedentary behaviour research, and tailored strategies to reduce sedentary time may be warranted for this subset of older adults. The development of an intervention to reduce sedentary behaviour in adults aged ≥75 years using co-production and behaviour change theory is reported.

Methods: Four co-production workshops with community-dwelling older adults aged ≥75 years were held between October-December 2022. The intervention development process was informed by the Behaviour Change Wheel (BCW) and Theoretical Domains Framework (TDF). Audio recordings and workshop notes were iteratively analysed, with findings used to inform subsequent workshops.

Results: The co-production group consisted of six community-dwelling older adults aged ≥75 years and two researchers. The developed intervention consists of four components (activity monitoring, educational material, group sessions and researcher follow-up), maps to 24 behaviour change techniques and targets barriers to reducing sedentary time. Participants were receptive of the co-production process.

Conclusions: Integrating co-production with the BCW can provide several benefits, with the BCW providing structure to the intervention development process, and co-production increasing the likelihood of the developed intervention being viewed as feasible by older adults. Furthermore, coding intervention components to the BCW may further our understanding of what approaches are successful or unsuccessful at influencing behavioural change. Transparent reporting of the intervention development process may benefit researchers developing interventions with older adults. Future research will pilot the co-produced intervention.

Introduction:

Frailty is a condition that makes it increasingly difficult for individuals to recover from adverse health events and gradually erodes independence. NHS interventions in England have focused on those with more severe frailty. We tested HomeHealth, a home-based, tailored, multi-domain (six-session) behaviour change intervention to promote independence in the over-65s living with mild frailty, in a RCT recruiting 388 people (intervention 195; control 193). HomeHealth was delivered by the voluntary sector in three diverse areas and addressed mobility, nutrition, socialising, and psychological goals, among other domains. We aimed to explore acceptability, participant engagement, and experiences of delivering and receiving the service.

Methods:

Following a mixed-methods approach, we extracted quantitative data on types of goals and progress towards goals from Health and Wellbeing plans and appointment checklists. Between July 2022 and May 2023, we interviewed 49 older participants, 7 HomeHealth workers and 8 stakeholders. Older people were purposively sampled for diversity in socio-demographic characteristics, cognitive and physical functioning, intervention adherence and allocated HomeHealth worker. Interviews explored their motivations to engage; experience of participation, delivery and study support followed by their suggestions for improvement. We analysed qualitative data thematically and quantitative data descriptively.

Results:

Most participants set mobility goals (49%), followed by a combination of goals (31%), and made moderate progress towards these. The intervention (completed by 93.3% participants) was positively received, boosted participants’ confidence, and provided emotional support. Participants reported that sometimes behaviour was maintained post-intervention, but further appointments would have been welcomed to fill the gap in other services. However, some people found it difficult to identify goals to work on, particularly when they already felt independent and well supported.

Conclusions:

Services to support older people with mild frailty are acceptable, have good engagement, and can lead to behaviour change, particularly among those who self-identify a need for change.

Introduction: The Community Geriatrician team based at the Countess of Chester Hospital is a multidisciplinary team offering comprehensive assessments at home to older patients with frailty. The team review frail patients identified as being at risk of hospital admission. Cognitive impairment and dementia are increasingly common concerns in our patient group and significant risk factors for admission. Frail patients often struggle to access traditional memory clinics for a variety of reasons and can therefore remain undiagnosed. They often require a more holistic approach in their home environment. We therefore identified a need to offer a dedicated frailty memory pathway within our community geriatrician team enabling better access to dementia assessment and diagnosis in complex frail patients.

Method: A frailty memory assessment pathway was proposed and commenced in 2022. Following identification of a cognitive concern during the initial comprehensive geriatric assessment a further home visit is arranged to assess memory in more depth. Patients are then discussed, and a diagnosis reached via a monthly Frailty memory MDT attended by Consultant psychiatrist, Consultant geriatrician, and Specialist Occupational therapist. Following delivery of a diagnosis our AGE UK well-being coordinator within the team provides post diagnostic support and sign posting to patient and family. A retrospective audit was undertaken reviewing the 44 patients diagnosed since pathway commenced. The number of hospital admissions and number of inpatient bed days was compared in the 3 months pre and post initial assessment.

Results: In the 3 months following assessment 82% of patients had a reduction or unchanged number of admissions, there was a total reduction of 71 inpatient bed days.

Conclusion: We believe our pathway offers a unique multidisciplinary approach to dementia diagnosis in the frail population, improving frail patients access to dementia assessment with a reduction in hospital admissions.

Introduction: The Frailty Intervention Team (FIT) is a multidisciplinary team that provides a service to community based frail adults. This particular service is novel in the sense that it is a hospital based out-patient service as opposed to frailty at the front door or a community based service and has access to rapid diagnostic and intervention services.

Aims: The aim of this research is to share and describe the model of this relatively new and novel service for the benefit of other service providers.

Method: A prospective database review was performed to provide descriptive data on the service between 2021 & 2022. Variables examined included referral source, MDT members involved on initial assessment and follow up, patient’s objective outcome measures and a history of falls.

Result: Between the years 2021 and 2022, 350 new patients and 912 review patients were seen by the team with an additional 139 Medical Assessment Unit consultations carried out also. Of these service users 37.38% were male and 62.61% female. The average Clinical Frailty Score was 4.98 (4.91 men, 5.05 women). This indicates the mean service users is ‘Living with Mild Frailty’ - a cohort that may be otherwise missed by other services.

Conclusion: This research highlights the demand for access to out-patient frailty interventions in line with the National Clinical Programme for Older Persons which promotes access to ‘the right person, in the right place, at the right time’.

Objective: To evaluate the environmental impact from home visits the ESD team carry out and the implementation of electric vehicles to reduce the carbon footprint.

Methods: Travel expense data of the ESD team across the last 2 weeks of April was collected and CO2 emissions from each team member was derived. A focus group was conducted to gather the team’s stance on electric vehicles for home visits.

Results: A significant amount of CO2 is produced daily, with the total across the two weeks being close to that of a small-to-medium enterprise. Introducing an electric vehicle would help reduce the CO2 emissions, with a 62% reduction seen in week 1 if the person with the greatest emissions were to have the vehicle.

Conclusion: Although there are disadvantages, implementing an electric car into a department where multiple home visits are carried out in a day would help significantly in reducing the carbon footprint and help NHS Wales reach their environmental targets.

Introduction

Sustaining independence is important for older people, but there is insufficient guidance about which community services to implement.

Methods

Systematic review and network meta-analysis (NMA; PROSPERO CRD42019162195) to synthesise effectiveness evidence from randomised or cluster-randomised controlled trials of community-based complex interventions to sustain independence for older people (mean age 65+) living at home, grouped according to their intervention components. Main outcomes: Living at home, activities of daily living (ADL), care-home placement, and service/economic outcomes at one year. We searched five databases and two registries, and scanned reference lists. A random-effects NMA was used. We assessed risk of bias, inconsistency, and certainty of evidence.

Results

We included 129 studies (74,946 participants). Nineteen intervention components, including ‘multifactorial-action’ (individualised care planning), were identified in 63 combinations. Few studies contributed to each comparison. High risk of bias and imprecision meant results were very low certainty (not reported) or low certainty (unless otherwise stated). Findings may not apply to all contexts. For living at home, evidence favoured ‘multifactorial-action and review with medication-review’ (odds ratio (OR) 1.22, 95% CI 0.93 to 1.59; moderate certainty), and three other interventions: ‘multifactorial-action with medication-review’; ‘cognitive training, medication-review, nutrition and exercise’; and, ‘ADL, nutrition and exercise’. Four interventions may reduce odds of remaining at home. For instrumental ADL (IADL), evidence favoured ‘multifactorial-action and review with medication-review’ (standardised mean difference (SMD) 0.11, 95% CI 0.00 to 0.21; moderate certainty). Two interventions may reduce IADL. For personal ADL, evidence favoured ‘exercise, multifactorial-action and review with medication-review and self-management’ (SMD 0.16, 95% CI -0.51 to 0.82). Among homecare recipients, evidence favoured addition of multifactorial-action and review with medication-review (SMD 0.60, 95% CI 0.32 to 0.88). Other findings were inconclusive.

Conclusions

The intervention combinations most likely to sustain independence include multifactorial-action, medication-review and ongoing review of patients. Unexpectedly, some combinations may reduce independence.

Introduction: Scotland's National Dementia strategy (2017) highlights the need to improve identification and management of dementia. Hospital at Home (H@H) teams often identify undiagnosed cognitive decline as part of comprehensive geriatric assessment. A trainee ANP in dementia services was appointed in 2019 in West Lothian; before this, the average waiting time to memory clinic assessment was 6 months for a home visit, and 12 months for outpatient clinic review. Affiliated with REACT H@H, the ANP identified a significant unmet need for assessment of cognitive decline in a patient cohort referred to H@H.

Method: Baseline data from patients reviewed by the dementia ANP was collected between Sept 2021 – Feb 2022, including referrals from H@H. A new pathway was then introduced to streamline referrals including education and upskilling of the H@H team. Further data was collected between Sept 2022 – February 2023.

Results: In the first cohort, 161 patients were assessed by the Dementia ANP, of which 39 (24%) had been referred from H@H. 60 patients (37%) were seen as a home visit, and 101 (63%) in clinic. 2 (1%) of referrals were managed with advice only. 125 patients (78%) were given a diagnosis of dementia; other diagnoses included delirium, low mood and anxiety. In the second cohort, 168 patients were assessed by the Dementia ANP, 39 (23%) being referred from H@H. 94 (56%) were seen in clinic and 74 (44%) as home visits. 10 (6%) of referrals were managed with advice only. 138 (82%) were given a diagnosis of dementia. Time to diagnosis assessment of dementia was reduced to 1 month for home assessment, and to 4 months for outpatient clinic assessment.

Conclusion Appointment of a Dementia ANP and integration with H@H  services improves time to assessment and diagnosis of dementia.