Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event. Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development. This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being. More information is available online: www.expo.nhs.uk

1. Integrated Care for Older People with
Frailty and Multimorbidity
Helen Lyndon, Nurse Consultant, Clinical Lead Frailty, NHS
England
Lucy Watson, Director of Quality, Safety and Governance,
Somerset Clinical Commissioning Group
Dr Mike Pearce, General Practitioner, Somerset Clinical
Commissioning Group

2. Our session today
• Introduce the concept of frailty and multimorbidity in older people.
• To update the on the work NHS England is undertaking to promote
the concept of frailty as a long term condition including products
that can support service development within a community and
primary care setting.
• Implementation in practice - information from Somerset CCG to
embed the frailty pathway in Symphony data and collaborative
working pilots and Unplanned Admissions Direct Enhanced
Service.

3. Where is frailty?
“ I know it when I see it but what I see may not be the same as what everyone else sees”
Community dwelling adults aged 65+ = 7% - 12%
Community dwelling adults aged 85+ = 25% - 50%
The Frailty Paradox
Not recognised
Not diagnosed
Not recorded
Chen, X, Genxiang, M, Sean X (2014) Frailty Syndrome: an overview . Clinical Interventions in Aging
2014:9 433–441

4. Frailty – a complex syndrome
of increased vulnerability
4
Life course
determinants:
Biological
Genetic
Psychological
Social
Environmental
Decline in
physiologic
reserves
+
Multiple long
term
conditions
Candidate markers:
Nutrition
Mobility
Activity
Strength
Endurance
Cognition
Mood
Adverse Outcomes:
Disability
Morbidity
Hospitalisation
Institutionalisation
Death
Prevent/delayfrailty
Primary prevention
Health promotion Delay onset FRAILTY
Delay/prevent adverse outcomesRodriguez-MañasL, Fried LP. Frailty in the clinical
scenario. Lancet. 2014 Nov6
Reversibility

5. A definition of frailty
• Frailty is not a disease but a combination
of the natural ageing process and a variety
of medical problems
• It focuses on the loss of reserve, energy and
wellbeing
• A useful definition is: “Multidimensional loss of
reserves - energy, physical ability, cognition and
health”
Rockwood et al (2005)
Ageing Fitness
Disease

6. Frailty is a loss of physiological reserve
Clegg, Young, Rockwood Lancet 2013

7. Frailty as a Long Term
Condition
A Long Term Condition is:
“A condition that cannot, at present, be cured but is controlled by medication
and/or other treatment/therapies”(DH 2012)
Frailtyis:
• Common (25-50% of people over 80 years)
• Progressive (5 to 15 years)
• Episodic deteriorations (delirium; falls; immobility)
• Preventable components
• Potential to impact on quality of life
• Expensive

8. Proactive interventions in
frailty
Ten years ago
Two years ago
One month ago ‘He is a fall
waiting to
happen
“Dad is
slowing
down”
“I’mnot
as steady
on my feet
as I was”

9. Proportion
alive
Time
Primary care electronic Frailty Index
(eFI): survival plots (n=227,648; >65y)
Fit
Mild frailty
Moderatefrailty
Severe frailty
5 yrs

10. Implementation of a pathway of care for older
people living with frailty – NHS England Guidance
If frail older people are supportedin
living independently and
understanding their long-term
conditions,andeducatedto manage
them effectively,they are less likely to
reachcrisis,require urgent care
support andexperience harm.
This document summarises the
evidence of the effects ofan
integratedpathway of care forolder
people and suggests how a pathway
canbe commissionedeffectively using
levers and incentives across providers.
http://www.england.nhs.uk/ourwork/pe/safe-care/

11. 11
Healthy active
ageing and
supporting
independence
Living well with
long term
conditions
Living well with
complex
comorbidities
and frailty
Rapid support
close to home in
crisis
Good acute
hospital care
when needed
Good discharge
planning and
post-discharge
support
Good
rehabilitation
and reablement
High quality
nursing and
residential care
home care
Choice, control
and support
towards the end
of life
Cross-organisationalstandards
Commissioning intentions CQUINNS Frailty toolkit

12. Frailty Toolkit for Primary Care
Includes:
• Case finding tools and advice
• How to populate frailty registersand
read coding
• Comprehensive geriatricassessment
• Care coordination
• Care planning
• Medicationreview in frail older
people
http://www.nhsiq.nhs.uk/improvement-programmes/long-
term-conditions-and-integrated-care/long-term-conditions-
improvement-programme/house-of-care-
toolkit/national/commissioning/tools-and-
levers/enhanced-services-resources.aspx

13. Integrated Care for Older People with
Frailty and Multimorbidity
Lucy Watson, Director of Quality, Safety and Governance,
Somerset Clinical Commissioning Group
Dr Mike Pearce, GP Somerset Clinical Commissioning Group

14. Somerset Approach
• Somerset Frail Older People’s Programme Board with
representationfrom health, social care, independent sector, and
patient and user groups
• Reference to evidence base from the British Geriatric Society and
best practice
• Somerset Pathway for Older People with frailty published in April
2014
• Workshopheld in December 2014 to lead implementation of the
pathway with NHS England national lead
• Good engagement from all providers and voluntary sector

15. Costs and Benefits
Improved quality of care and experience for older people;
• Older people are admitted to hospital more frequently, have longer length of stay and occupy more bed
days
Sustainable system against rising demand;
• Older people are some of the highest cost users of services
Overall pathway to be delivered within existing resources;
• Current resource can deliver ‘better to more’
Significant opportunity to move support out from hospital centric care to community care and
supporting neighbourhoods;
• Frailty does not respond to the current single condition medical model
Efficiency savings through collaborative teams / models of working across providers, including
third sector;
• Better use of the staffing resources across the whole system

16. Vision & Purpose
• Maintaining health and independence for Older People
• Improve the quality of services for our patients and provide value for
money through transformationof the health and care system
• Engagement with local communities and local voluntary
organisations
• Care in the right place at the right time by the right staff.

17. Vision of Older People
“ I can plan my care with people who work together to
understand me and my carer(s), allow me control, and bring
together services to achieve the outcomes important to me.”
National Voices

18. Framework for Older People

19. South Somerset – Vanguard programme
• Symphony Project in South Somerset to implement House of
Care to improve care and outcomes for people with long term
conditions
• Development of a Symphony dataset across all health services
and socialcare identified increasingnumber of co morbidities that
people have drives up the cost and use of care services
• A Symphony care model was developed
• Led to the Vanguard programme and three Local Implementation
Groups to test and learn based on the Symphony care model

20. Somerset Frailty Programme
• Accept frailty as a long term condition and gained support for
frailty to be included in the Symphony data set
• Strong clinical leadership and support and agreement on pathway
and frailty tools
• CQUIN for frailty developed for all NHS Trust contracts for 2015 –
16 to include use of Rockwood clinical frailty scale and
comprehensive geriatric assessment
• Development of personalisedcare planning and case
management through LIGs and Test and Learn Pilots

21. Common Principles
• Frail older people should have access to comprehensive geriatric
assessment in order to develop a co-ordinated and integrated plan for
treatment and long term follow up
• A shared definition of the target population
• Agreement on risk stratification to target the right service at the right level to
the right people to deliver the best possible outcome
• An integrated multi-disciplinary and system wide approach to include
information sharing across organisations and voluntary sector
• Care co-ordinator role with appropriate clinical skills, authority and expertise
to negotiate care across pathways and organisations.

22. Engage primary care
• Agreement on use of screening tools and Comprehensive Geriatric
Assessment, case finding to identify frail older people and develop care
plans
• Engaged with GP champions to support development of frailty registers
using the Unplanned Admissions DES
• Using Joint Commissioning as the route with NHS E and LMC support
• Recruiting a frailty lead to support workforce development across public
and independent sector
• Provision of Master classes to support implementation in primary care
and with the voluntary sector and peer support projects through LIGs

23. Successes
• Taunton and Somerset NHS Foundation Trust recruiting two frailty
practitioners to support implementation of the acute pathway
• Engagement with the Consultant workforce to support the pathway
and improved care for older people in hospital
• Yeovil have frail older people’s assessment unit
• Agreed one clinical management plan to follow the patient
• Benefits of using contract levers with clinical engagement

24. Outcomes
• Older people want the ability to remain at home in clean, warm,
affordable accommodation
• To remain socially engaged; to continue with activities that give
their life meaning
• To contribute to their family or community; to feel safe and to
maintain independence, choice, control, personal appearance and
dignity
• To be free from discrimination; and to feel they are not a ‘burden’ to
their own families and that they can continue their own role as
caregivers

25. Next Steps
• Transfer of responsibility for delivery to Local Implementation
Groups and Test and LearnPilots and integrating relevant work
programmes.
• Using our Patient Participation Groups to start socialdiscussions
about planning for frailty and choices at end of life- starting the
conversation
• Development of electronic frailty registers in primary care
• Demonstrating we have improved care and outcomes for older
people

26. Thank you for listening