Lucy Jackson, Consultant in Public Health, Leeds City Council

1. People living with frailty- what is frailty?- the Leeds approachHealth Leaders Network, 30th April 2019 Lucy Jackson, Consultant in Public Health, Leeds City Council Becky Barwick, System Integration, Leeds CCG Alison Raycraft, Lead Nurse for Older People, Leeds Teaching Hospitals Trust

2. What is Frailty “Frailty is a distinctive state related to the ageing process, as multiple body systems gradually lose their in-built reserves” (NHS England 2014) It is progressive Typically erodes functional, cognitive and/or emotional reserves Increases vulnerability to sudden loss of independence and adverse health outcomes following a comparatively minor stressor event such as an acute infection or injury

3. Concept of the Frailty Fulcrumbalancing resilience and vulnerability https://vimeo.com/weareingenious/review/140588708/19f348eec7

7. What is FrailtyA state of vulnerability to poor resolution of homeostasis following a stressor event, which increases the risk of adverse outcomes. Clegg, Young, Iliffe, Olde-Rikkert, Rockwood. Frailty in elderly people. Lancet 2013; 381: 752-762

8. Understanding ….. • the concept of frailty as a long term condition and recognise all stages from emergence to end of life care • -the five conditions often associated with frailty (known as the frailty syndromes) and how they commonly present, i.e. delirium/ recurrent falls/ sudden deterioration in mobility/ new or worsening incontinence/ medication side-effects • - that frailty syndromes may be a first presentation of frailty • - the importance of early recognition and timely management of frailty syndromes

10. eFI Frailty Categories The eFI has been used to define frailty categories: Fit (eFI score 0 - 0.12): People who have no or few long-term conditions that are usually well controlled. This group would mainly be independent in day to day living activities. Mild frailty (eFI score 0.13 – 0.24): People who are slowing up in older age and may need help with personal activities of daily living such as finances, shopping, transportation. Moderate Frailty (eFI score 0.25 – 0.36): People who have difficulties with outdoor activities and may have mobility problems or require help with activities such as washing and dressing. Severe Frailty (eFI score > 0.36): People who are often dependent for personal cares and have a range of long-term conditions/multi-morbidity. Some of this group may be medically stable but others can be unstable and at risk of dying within 6 - 12 months

11. List of deficits assessed in EFI

12. Rockwood scale

14. Malnutrition and Dehydration • Supporting the wider workforce to identify risks, seek support and signpost/refer • effectively • Improving Nutritional Care in Older People – Training • Malnutrition helpline • Co-produced campaign work to prompt conversations in communities • Funding 86 lunch clubs/37 NNs • Wider Determinants – Winter and Adverse Weather • Ensuring people get the support they may need to increase their winter resilience; • Winter friends • Fuel poverty • Flu Vaccinations • Medicines Reviews • Physical Activity • Social connections

15. Risk of Falls or Fear of Falling

16. Living well with frailty, promoting independence and community skills • Proactive identification, care and prevention – MDT/Case manager/Care co-ordinator building on INTs • LCP – wider community including other care providers; third sector; Leeds Directory • Medicines review • Community Geriatrician • Social care wider offer – Talking points ;Reablement – SkiLs; Telecare

17. LTHT and Third Sector Partnerships • Carers Leeds • Leeds Age UK- Hospital at home • British Red Cross • Leeds Directory • RVS- Activity Co-ordinator and activity • Hospices

19. Leeds Population Segmentation Framework

20. Why frailty?

21. What happened next? A Population Health Management Approach

23. Proactive Frailty Model – Draft 4 Working with & Better Conversations Proactive Identification through clinical systems (EFI) How do we ensure that in-patients receive person centred, proactive care? This is largely a single team or works as a single team SERVERE • MDT • GP • Geriatrician • Case-Manager • Care Coordinator • Neighbourhood Team (including ASC, Neighbourhood Networks, Memory Support workers) • Community MH Team/Primary Care MH workers • ASSESSMENT AND CARE PLANNING Virtual / Community Frailty Ward Community Beds MH Older People Home Treatment Service Primary care CCSP annual review as minimum for severe and moderate Unplanned hospital admission or access to crisis services See SRAB action plan / Recovery Plan / Newton Europe work and Home First Strategy MODERATE MILD Enhanced support to care homes Identification of those missed by EFI and those in impending crisis Care plan and risk plan travels with person ACUTE EPISODE / CRISIS Co-Producing Local Solutions Seamless proactive approach Specialist services ; e.g. palliative care, tissue viability, dietetics etc Frailty independence services ; e.g. home care package etc Frailty optimisation services including planned care; e.g. strength and balance, medications review, memory clinic etc • SW Contact Centre Pharmacy • Neighbourhood Networks / Third sector Carers, friends and family • Self Social Prescribing • Fire and Rescue Healthy living services • Libraries / One Stop Centre Overall principle is to rebalance people’s assets as per the Frailty Fulcrum

24. Geographic distribution of Frailty

26. Local Care Partnership Footprints

28. Population Health Management– From System to Person and From Person to System Population Insight Actions Economic Modelling; Actuarial Projections System Resource allocation between providers Segmentation; Benchmarking Resource allocation within providers Design System Based Savings Place Focus on segments; Target unwarranted variation; Risk Stratification Impactability Clinical audits Priority Lists Local Priorities Neighbourhood Analyse Individual Care Pathways Priority People Priority People Person

29. Leeds – Moderate Frailty Dashboard • Within Each Decile, Are there Different Characteristics of Demographics/Activity/Health to Drive Focus?

30. Theographs: Telling a Person’s Story with Real Data • Real Person in Leeds: Mild Frailty

31. Seacroft LCP, Lead: Dr George Winder • Focus: cohort of people living with moderate frailty—with a special focus on those individuals aged 60-75 and a secondary focus on those 75+. • How the LCP could more proactively ensure that individuals have an individualised personal care plan that really homes in on ‘What matters most’ to the individual • Garforth LCP, Lead: Dr Lesley Freeman • Focus: advance care planning, working with the severe frailty cohort with dementia, who are living in care homes. LCP Design & Implementation Action Planning • Following Design to Action Workshops supported Optum and BI Leads, LCP are crystallising their plans for testing PHM interventions : • Woodsley LCP, Lead: Dr Philip Dyer • Focus: people within the moderate frailty cohort, aged 60-74, with 5+ LTC’s including COPD, depression and anxiety. • Pudsey LCP, Lead: Dr John Keene • Focus: people aged 60+ in the moderate frailty cohort who are socially isolated and with mobility and weight loss issues

32. Example - Creating Person-Centred Care Plans to Motivate Change Example: Personalised Planning • Counties Manukau DHB in New Zealand Tying Health and Care Goals to Personal Ambitions