It's "special", expanding and delivering outstanding care for our older patients. Meet the Frailty Team

 

Here, in our latest Meet the Team, our Consultant Nurse for Older People, Renee Comerford, explains all about the work of the  Frailty Team (which only started last year).

By way of general introduction, she says:  " The role of the Frailty Team is incredibly rewarding and we are in a very privileged position of helping and promoting independence to our patients who often present in a very vulnerable state. Working closely with patients' families and carers, who are often at crisis point, our team has produced some fabulous results."

Background

The NHS is faced with the demands of an ageing population and increasing number of people with multiple long term conditions. Whilst much can be done to keep people as independent as possible at some point many people living with frailty will present to hospital.

Our Frailty Team is special. We are so lucky to be able to make a difference to people’s lives when they need us most. Hospital is not the best environment for our frail patients increasing  the risks of falls, infection and acute delirium. The Acute Frailty Team aim to provide the best care for our patients in the right place at the right time. Our aim is always to aide our frail patients to live well at home. Home First is our overall aim, because this is where our frail patients want to be as they want to remain as independent as possible.  Our fantastic team work hard to  achieve this with  many successful  patient stories daily

Our Team

The Frailty Team at HRI was formed in 2017 in collaboration with the Acute Frailty Network with a small team consisting of Consultant Geriatrician, two nurses and  the support of the therapy team.

The Acute Frailty Team  has evolved very quickly and now consists of a Nurse Consultant for Older People who is Head of the Frailty Service, a team of  specialist nurses in  care for older people and frailty with well over 150 years of experience, two geriatricians, specialist Occupational Therapists, specialist physiotherapists,  two Physician Associates,  two Advance Clinical Practioners and one training post, one Pharmacist and a  Frailty co-ordinator who have just joined our ever-expanding team

MDTs twice a day

The team holds an MDT twice a day to discuss the care and discharge planning of all the frail patients on our case load with  both community services, social services and also part of our wider MDT.  The MDT discuss and review patients focusing on what actions are required in order to provide best practice care in the hospital and once home.  For example, what care or support or signposting do they require to help them live well at home with their frailty? Patients do not want to spend their precious time  being readmitted to hospital so we need to look at what we need to do to prevent this happening. We constantly challenge ourselves and our colleagues as sometimes we need to step outside of the box  and do things differently to maintain someone’s wishes.

Our partners

The Acute Frailty Team also works closely with our partner organisations, the Locala START team, CHFT CRISIS team, social services Calderdale and Kirklees HAT team. We are all one team delivering an Acute Frailty Service. Our frail patients travel through all services so we must work together to deliver  a good patient experience

 

Our hours 

The Frailty Team work over 7  days 8am-8pm, assessing patients as they present to ED, MAU,or CDU and soon to be SAU (front end). Frailty patients most commonly  present with falls, increased or new confusion (delirium), collapse cause,’ off legs’, urine infection, or ‘acopia’. The patients are assessed using the  nationally recognised frailty  Rockwood Clinical Score and referred to the team via the referral phone.

How we assess

Patients are then assessed using the gold standard approach to improving the outcomes for the frail older people, a comprehensive Geriatric assessment (CGA), this is a multi-disciplinary assessment which identifies the medical, social, functional  and physical needs of a frail person so a coordinated plan of care can be implemented. The team currently use a CGA  found under the title CHFT comprehensive assessment, which we encourage the ward staff to read in order to see the assessment,and  recommendations in order to assist with ongoing care planning.  The team are currently working with Cerner/EPR to develop a robust electronic CGA which can be used throughout the Trust and potentially community systems so they are no gaps in the patient's story.

 

In order to complete the CGA the team spend time data gathering from a variety of sources, discussions with relatives, carers, and friends, We access system one, liaise with community matrons, district nurses, care homes, Quest matrons, care home support teams, other specialist nurse teams and mental health liaison teams. Most importantly we ask the patient what they want and where they would like to be.

 

Once a holistic  assessment is obtained of the patients support and care system we can focus on where to provide the treatment required . We always aim to discharge back to their home in order to complete treatments with follow up as required from other health or social services. For those patients we are unable to discharge immediately we will continue to oversee the treatment plans and elevate, reassess throughout the day for up to 72 hours from admission. We strive to coordinate care for our patients in our 6 beds on MAU,we have daily ward rounds with our Consultants and work closely with the MAU team to provide patient centred care to patients and their families and carers. We also in reach into other beds to provide expert advice and complete the gold standard CGA.

Well done Claire!

Claire Brewster joined the team in  June and one of her first experiences was a man ( only in his 60s) who was brought into ED after being found wandering the streets at night with a head injury. He was unable to tell us his name and  it was initially thought he was ‘drunk’ . However, after assessment, and copious amounts of detective work we found out that this patient had advanced early-onset dementia and was unable to speak/tell us his name. We were able to trace his family who had realised he had gone missing and were anxiously looking for him . His family had been caring for him at home but it had reached crisis point and his safety could no longer be maintained at home. By the end of the day, with the help of the team, we had secured him a place in a safe environment.

Other work above and beyond

A lot of our work also involves education and helping to influence the teams we work with. We want our patients to be as independent as possible in their last years, not siting in a hospital ward waiting. We encourage patients to sit out, get dressed and to be as mobile as possible in order to prevent a lengthy hospital stay and al the risks  which that may bring.

In summary

The Frailty Team has a fantastic team spirit.  We enjoy the challenge of the role and the diversity of each day. No two days are ever the same. One of the most interesting aspects of the role is listening to the patients. They always have a story, and if you spend the time to listen it will help you understand what they want to achieve.