CHIN Two Update Frailty & Palliative Care MDT

1. CHIN Two Update Frailty & Palliative Care MDT Dr Claire Hassan, The Clinic - Oakleigh Road North Wednesday, 21st November 2018 Working together with the Barnet population to improve health and wellbeing

2. CHIN 2 Membership CHIN 2 Practices • Brunswick Park Medical Centre • Colney Hatch Lane Surgery • East Barnet Health Centre (Dr Monkman) • East Barnet Health Centre (Dr Helbitz) • East Barnet Health Centre (Dr Peskin and Dr Hussain) • Friern Barnet Medical Centre • St Andrews Medical Centre • The Clinic – Oakleigh Road North *Combined list size – 53,450 Working together with the Barnet population to improve health and wellbeing

3. Area of Focus As of 2011, 13.3% of the borough's population is over 65 - the sixth-highest of London's boroughs. The number of people aged 65 and over is predicted to increase by 33% between 2018 and 2030, compared with a 2% decrease in young people (Barnet Joint Strategic Needs Assessment) We know that elderly people are dying in A&E or soon after admission - would they have been better served by caring for them in the community? QI project carried out for patients from Oakleigh Road HC looking at over 65s admitted with a code of pneumonia or UTI. Working together with the Barnet population to improve health and wellbeing

4. MDT Rationale QI Data (April 2017-February 2018) Pneumonia • 12 patients admitted (2 patients had multiple admissions) • Average age 87.5 years • 5 died during admission • 1 died shortly after (death linked to starting NOAC during pneumonia admission) UTIs • 10 patients admitted (4 patients had multiple admissions) • Average age 80.4 years • 1 died during admission • 2 died at home of unrelated causes Working together with the Barnet population to improve health and wellbeing

5. MDT Membership MDT Extended Team • Palliative care consultant • Consultant Geriatrician • Consultant Old Age Psychiatrist • Patients and their carers • Case Manager (LAS) MDT Core Team • GPs • CHIN Specialist Practice Nurse • MDT Administrator • Social care • CLCH Community Nurse • CCG practice-based pharmacist • Age UK (Barnet) Working together with the Barnet population to improve health and wellbeing

6. Coordinate My Care (CMC) What is CMC? Together with their clinicians, patients may record their preferences and wishes within an electronic personalised urgent care plan that also includes clinical information and relevant medical history. What’s in it? The urgent care plan contains clinical information about the patient’s diagnosis, allergies, medications and resuscitation status as well as their wishes and preferences on where they would prefer to be cared for and, if appropriate, where they would wish to die. Who can see it? The care plan can be seen by all health and social care providers who have a legitimate relationship with the patient – this including patients; doctors; nurses; social care providers; emergency services including the ambulance service, NHS 111 and the out of hours GP service Working together with the Barnet population to improve health and wellbeing

7. MDT Evaluation Will be conducted by Dr Ray Sacks (innovative GP for Barnet) with input from Public Health and CCG. Evaluation Metrics will include: • Reviewing number of care plans developed and the uptake of CMC • Reviewing non-elective admissions and A&E attendances • Deprescribing / Appropriate prescribing Working together with the Barnet population to improve health and wellbeing