Frailty as a Long Term Condition?  Monday 10 November 2014 12noon – 12.45pm Professor John Young National Clinical Director for Integration & Frail Elderly, NHS England & Beverley Matthews LTC Programme Lead, NHS Improving Quality

1. WELCOME
Today’s Webinar
Frailty as a long term condition?

2. Frailty as a Long Term Condition?
Monday 10 November 2014
12noon – 12.45pm
Professor John Young
National Clinical Director for Integration & Frail Elderly, NHS England
&
Beverley Matthews
LTC Programme Lead, NHS Improving Quality

3. Meet the Speakers
Bev Matthews
A nurse by background, Beverley has worked extensively throughout the NHS in a variety of
clinical, managerial and strategic roles. Beverley’s current role as Programme Delivery Lead
for Long Term Conditions Improvement Programmes: LTC Year of Care Commissioning
Model and LTC Framework. Prior to joining NHS Improving Quality in April 2013, Beverley
was Director of NHS Kidney Care and NHS Liver Care. Passionate about service
transformation through developing networks and leading complex programmes. Providing
strategic leadership to partners within health communities, managing stakeholders and
working across agencies.
Professor John Young
Trained at the Middlesex Hospital, London; appointed as a consultant geriatrician in
Bradford in 1986 . He has developed numerous new services including an elderly care
assessment unit; a stroke unit; and an ortho-geriatric unit. Appointed as Head of the
Academic Unit of Elderly Care & Rehabilitation, University of Leeds, 2005.
Quality improvement work includes the national audits of intermediate care and of
dementia care. Between 2001 and 2007 John was seconded to the DH to assist with the NSF
for Older People. He is currently seconded to NHS England as National Clinical Director for
Integration and Frail Elderly.

4. Learning Outcomes
Frailty as a Long Term Condition?
of Care foundation.
 Understanding of case finding tools for frailty
• Understanding a graduated long term condition response to people
living with frailty based on supported self-management; care and
support planning, case management; and anticipatory end of life
care

5. Beverley Matthews
LTC Programme Lead
NHS Improving Quality
Beverley.matthews@nhsiq.nhs.uk

6. Bespoke Support

7. The approach:
• Identify sites guided by intelligence from the LTC Dashboard
and local advice
• Support local health economies to understand their baseline
position through the self assessment Diagnostic Tool
• Provide coaching support to start identifying interventions
that will drive change and develop the local action plan.
• Agree bespoke support package with memorandum of
understanding
• Developing a facilitators network of local champions
• Use evidenced based improvement methodologies to
facilitate change
• Embed measurement and evaluation expertise throughout
the delivery
• Development of implementation guide in real time

8. Tools and Resources

9. Links
Long Term Conditions Dashboard
http://ccgtools.england.nhs.uk/ltcdashboard/flash/atlas.html
Long Term Conditions House of Care Toolkit
www.nhsiq.nhs.uk/improvement-programmes/long-term-conditions-and-integrated-care/house-of-care.aspx
SIMUL8: Simulation Model
http://www.simul8.com/viewer/download.htm
#LTCyearofcare #LTCimprovement @NHSIQ

10. Case Studies
http://www.nhsiq.nhs.uk/10486.aspx

11. LTC Learning Forum
“Lunch & Learn” Webinar Series
&
Bite Size Master-classes

12. Virtual Learning Network
“Lunch & Learn”
• 45 minute “real time” Webinar
sessions
• Topics agreed and learning outcomes
identified
• Faculty of Speakers identified
Open invitation
Bite Size Learning Master-Classes
• Pre-recorded 20 minute Master-classes
• Master-class either as stand alone
sessions or pre-requisites for
Wednesday “Lunch & Learn”
Webinars
• Faculty of Speakers identified
Open invitation

13. Frailty as a Long-Term Condition
Professor John Young
Geriatrician, Bradford Hospitals Trust
National Clinical Director for Integration & Frail
Elderly, NHS England
john.young@bthft.nhs.uk

14. Care and Support Planning
You are, or would like to be, a health care professional.
Which of the following statements about care planning
in respect of people with multiple LTCs are TRUE?
When I make a care plan:
1. I pass on lots of information to the patient True / False
2. I do most of the talking True / False
3. I follow a template very closely True / False

15. The Frailty Paradox
National Audit of
Community Rehab 2012
N = 3,150
Mean age 82y
One or more LTC 77%
Two or more LTC 41%
The frailty paradox:
We know it’s out there, but where exactly?

16. Frailty is currently recognised ………………
Mrs Greenaway was found on
the floor (“FLOF”) with new
confusion by the home care
staff and taken to hospital
where is was found to be
poorly mobile.
The hyperacute
frailty
syndromes
 Fall
 Delirium
 Immobility

17. Frailty as a long-term condition ?
A LTC is:
“A condition that cannot, at present, be cured but is controlled by
medication and/or other treatment/therapies” (DH 2012)
Frailty is:
• 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

18. A view of Mrs Greenaway ………
85 years
Lives alone
Recently in hospital following a fall
Broken hip 2011
Chronic heart failure
Diabetes
Chronic Kidney Disease
Taking 10 medications
Review 1
Review 2
Review 3
Review 4
System designed to fragment care into
packages
……. And the frailty??? ……

19. Mrs Greenaway was found on
the floor (“FLOF”) with new
confusion by the home care
staff and taken to hospital
where is was found to be
poorly mobile.
“She was a fall
waiting to happen.”
Home care staff
 Fall
 Delirium
 Immobility
Frailty is ………………

20. Frailty as a LTC
(Global loss of physiological reserve)
Clegg, Young, Iliffe, Olde-Rikkert, Rockwood. Frailty in elderly people. Lancet 2013; 381: 752-762

21. Frailty as a LTC
(Global loss of physiological reserve)
Clegg, Young, Iliffe, Olde-Rikkert, Rockwood. Frailty in elderly people. Lancet 2013; 381: 752-762

22. Frailty as a LTC
(Global loss of physiological reserve)
Resilience
gap
Clegg, Young, Iliffe, Olde-Rikkert, Rockwood. Frailty in elderly people. Lancet 2013; 381: 752-762

23. Earlier (more timely) diagnosis of frailty
Two approaches:
1. The simple way: empowering patients
2. The very simple way: empowering professionals
Which one shall we choose??
“Fit for Frailty” BGS/RCGP 2014
http://www.bgs.org.uk/campaigns/fff/fff_full.pdf

24. The 4m walking speed test detects frailty
Van Kan et al JNHA 2009; 13:881
Systematic Review of 21 cohorts
4M
Taking more than 5
seconds to walk 4m
predicts future:
 Disability
 Long-term care
 Falls
 Mortality

25. Development of an NHS Primary
Care Electronic Frailty Index (eFI)
Existing EHR (“SystmOne”)
Read Codes (>80,000 8,000 2,200)
Read codes map onto 43 Candidate ‘DEFICIT’ Variables
Tested in ResearchOne (n=226,988 >65y)
Validation Process (n=227,063 >65y)

26. Deficits constructed for the eFI

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

28. Candidate Preventable Components for “Frailty”
• Alcohol excess
• Cognitive impairment
• Falls
• Functional impairment
• Hearing problems
• Mood problems
• Nutritional compromise
• Physical inactivity
• Polypharmacy
• Smoking
• Social isolation and loneliness
• Vision problems
Stuck et al. Soc Sci Med. 1999
(Systematic review of 78 studies)
Additional topics:
• Look after you feet
• Make your home safe
• Vaccinations
• Keep warm
• Get ready for winter
• Continence
………others…….??
Supported-Self Management Plan for Healthy Living
in Later Life

31. “It’s Care Planning
Jim, but not as we
know it!”

32. Care & Support Planning:
Evidenced-based medicine or Evidenced-informed practice?
Guideline medicine
Care & Support Planning
Single LTC Multiple
LTCs/Frailty
Standardised
care
Individualised
care

33. Care and Support Planning
(?2% ES 10% LES?)
Information
gathering
Agreed & shared
‘care plan’
Professional
Story
Information
Sharing
Person’s Story
Goal Setting and
Action Planning
 Year of Care
Consultation 1
Consultation 2

34. Mrs Greenaway and Care & Support
Planning……..
What are the most
important things you’d like
to discuss today?
1. The pain in my feet
2. Difficulty sleeping
3. Getting out for a chat
4. I don’t like all these
tablets; do I really need
them all?

35. Care and Support Planning
You are, or would like to be, a health care professional.
Which of the following statements about care planning
in respect of people with multiple LTCs are TRUE?
When I make a care plan:
1. I pass on lots of information to the patient True / False
2. I do most of the talking True / False
3. I follow a template very closely True / False

36. Understanding frailty as a LTC
Supported self-management
for frailty
Care & support planning
Advanced care planning

37. Open Discussion

38. LTC Lunch & Learn Series
….coming soon…
Date Webinar Hosted by Bev Matthews &
19 November 2014
Self Management for Life Renata Drinkwater
1 – 2pm
Chief Executive & Trustee
Self Management UK
To register email LTC@nhsiq.nhs.uk
3 December 2014
1 – 2pm
"Population level commissioning
for the future"
Dr Abraham George
Kent County Council
7 January 2015
1 – 2pm
Self Management Support
Return on Investment
Renata Drinkwater
Chief Executive & Trustee Self
Management UK
21 January 2015 Commissioning for Outcomes Bob Ricketts CBE
Director of Commissioning Support
Services & Market Development,
NHS England