No more in and out of hospital. How Frailty's delivering better care for elderly patients.

The work of our Frailty Team starts a new series for 2019 called Patient Stories at CHFT.

We want to showcase how our patients are really benefitting from how we are changing and evolving how we deliver  our care to make their experience a better one.

If you've an inspirational story about how you've transformed a pathway improving care for patients - and we know there are many examples -  then let us know.

Email: jacqui.booth@cht.nhs.uk and your work will feature in this new Patient Story showcasing how CHFT is constantly changing and never standing still when it comes to putting our patients first.

So, let's hear it for Frailty Team and their story based on one Calderdale elderly man's experience.

-------------------------------------------------------------------------

Our patient had been admitted into our hospitals nine times in two years yet he is now benefitting from the care and supervision from our Frailty Team and their partners.

His care is very much home-based which prevents delirium and he also has an Advanced Care Plan in place linking all the partners involved in his care.

After his last discharge his delirium had resolved within 30 mins of him being back in his own home and he has not yet had to be readmitted. (Delirium is a new confusion by a combination of factors and can even affect children.  Medication, environment, age and infections are other factors which can trigger delirium).

Matron Renee Comerford, said a long stay in hospital can mean a delirium develops into something more severe and takes longer to recover from and detecting them early is key to a successful outcome.

She said: "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."

This patient’s story is just one of the many successes and better outcomes as a result of our Frailty Team working together with partners. It was presented at the last Trust Board  meeting as an example of good practice and working together.

Once back home, our patient and his relative were supported by physios and occupational health therapists who carried out further assessments  on his needs and community visits of up to four times a day were put in place.

Renee added: “ The Frailty Team isn’t just a silo. We aren’t just one service. Our patients have to go through so many pathways, it’s not just us. There are so many teams involved.”

She also said there is an extra emphasis on a patient’s back story – as well as how they are currently presenting – to help better understand what may be needed.

Renee,  Clinical Service Superstar at Celebrating Success 2018, adds: "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 to setting up our new Frailty Team 

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 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.