21 The Jean Bishop Team, Hull: A New Model of Care for Comprehensive Geriatric Assessment of the Frail Population

• Published in: Age and ageing Vol. 49; no. Supplement_1; pp. i1 - i8
• Main Authors: Athorn, K, Folwell, A, Harman, D, Kar, S, Windass, L
• Format: Journal Article
• Language: English
• Published: Oxford Oxford University Press 06-02-2020; Oxford Publishing Limited (England)
• Subjects: Advanced nurse practitioners; Basal ganglia; Care coordinators; Care plans; Caregivers; Central nervous system diseases; Chronic obstructive pulmonary disease; Community services; Coordinators; Cost analysis; Diabetes; Diabetes mellitus; Emergency admissions; Evaluation; Frail; Frailty; Future; Geriatric assessment; Geriatricians; Geriatrics; Health problems; Hospitalization; Interdisciplinary aspects; Intervention; Movement disorders; Older people; Patient admissions; Patients; Pharmacy; Physicians; Planning; Primary care; Residential care; Residents; Satisfaction; Social services; Teams; Workforce
• ISSN: 0002-0729; 1468-2834
• DOI: 10.1093/ageing/afz183.21

Abstract
Introduction
Hull CCG recognised system’s over-reliance on reactive, hospital care and workforce deficits, requiring a modernised service model for frail older people that moved from individual provider focus to system-wide perspective, with emphasis on proactive care.
Methods
Electronic Frailty Index (eFI) in primary care system identified 3,200 out of 300,000 Hull residents Hull with severe frailty. Recruited 9 GPs with extended role in older people’s care and Advanced Nurse Practitioners to support 4 Community Geriatricians. Redesigned roles for pharmacy, social services and non-clinical care coordinator teams. New therapy roles created, multiple third sector organisations involved, including carer support, and purpose-built location with older people in mind.
Interventions
Structured and anticipatory comprehensive geriatric assessment of all 3200 residents (either at home or in care homes) by the multidisciplinary multiagency team. Pre-assessment home visit by support worker to complete patient concern’s questionnaire. Dedicated patient transport and one-stop multi-disciplinary team assessment in one building. Proactive discussion of RESPECT and advance care planning, electronic personalised care plan delivered with system-wide record sharing across providers, Same day basic diagnostics available. Complex care coordinators ongoing support in community. Multi-disciplinary outreach to care homes and truly housebound.
Results
99.7% patients and carers extremely likely/likely to recommend the service
21,000 interventions for 2,500 patients seen since June 2018
Majority of patients moderately frail by Clinical Frailty Score
Average saving on drug costs - £110.17 /patient/year
15% reduction in ED attendances, 29% reduction in emergency admissions
Patients’ survey: adequate time and opportunity to discuss health problems/concerns, felt informed and empowered during consultation and in future planning
Very high levels of staff satisfaction
Conclusions and future
Innovative high quality, cost-effective new model of care delivering improved patient care and experience with emphasis on proactive care and future planning
High levels of patient and staff satisfaction
Future expansion with disease specific teams including COPD, parkinsonism and diabetes and targeting moderately frail by eFI.
Redesign of community services with improved integration across teams and providers can be a blue-print for other services.