Specialist Interagency Teams
Approach
Access to specialist interagency teams for a comprehensive geriatric assessment [CGA] and case management including the development of an emergency health care plan to coordinate care and optimise nutrition and hydration, incontinence, vision and hearing, cognition, end of life and dementia care.
Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary (usually) process to understand a person’s needs to be able to develop a holistic plan for treatment, rehabilitation, support and long term follow up.
Case management is a way of coordinating care around a person with long-term conditions and complex needs, normally used for those at risk of adverse outcome such as hospital admissions. It should be targeted, community-based and pro-active.
The following are examples of what to consider when thinking about supporting people with multimorbidity and increasing complex care needs (implementation and delivery will vary depending on local circumstances and care pathways. It is likely that with increasingly needs a person will be referred to a specialist interagency team for a CGA and onwards case management):
- Proactive comprehensive geriatric assessment (CGA) [general practice/community-based] and follow-up for people identified as moderately or severely frail, with a specific focus as part of CGA on medication review and falls assessment – see below.
- An identified keyworker who acts as a case manager and coordinator of care across the system – community, primary and inpatient hospital care.
- Case management delivered through integrated locality-based teams.
- A multi-disciplinary care team led by clinician, usually a GP, wraps around the patient and is responsible for the patient from pre-admission, during admission and post admission.
- The case manager or MDT designs the care plan with the patient and carer (informed decisions), if appropriate. The care plan is shared with providers across the system and implemented by MDTs and updated appropriately (e.g. in response to a crisis).
- Carers are offered an independent assessment of their needs and signposted to interventions to support them in their caring role.
- A comprehensive service for those people with dementia and mental health problems must be available and accessible.
- A comprehensive service for those with palliative care needs must be available and accessible
- Identification through GP lists
- Tools are used systematically to identify frail older people at the end of their life
- IT systems support coordination
- Advance care planning is not seen as a one-off event
- Equitable access to specialist palliative care services
- Services are available to reduce polypharmacy in frail older people.
- For those people living in care homes, implementation of the Enhanced Health in Care Homes (EHCH) framework should be considered.
Resources
- To understand a person’s needs and inform care and support consider the need for a Comprehensive Geriatric Assessment (CGA) – http://www.bgs.org.uk/cga-toolkit/cga-toolkit-category/what-is-cga/cga-what
- Case Management. Kings Fund. What is it and how it is best implemented. 2011. https://www.kingsfund.org.uk/sites/default/files/Case-Management-paper-The-Kings-Fund-Paper-November-2011_0.pdf
- NICE clinical guideline on multi-morbidity: Assessment, prioritisation and management of care for people with commonly occurring multimorbidities.
- Older people with social care needs and multiple long-term conditions [ng22], Guideline, NICE (2015) – https://www.nice.org.uk/guidance/ng22
- Frail older people – Safe, compassionate care summarises the evidence of the effects of an integrated pathway of care for older people and suggests how a pathway can be commissioned effectively using levers and incentives across providers.
- British Geriatrics Society (2014). Fit for Frailty: Consensus best practice guidance for the care of older people living with frailty in community and outpatient settings www.bgs.org.uk/index.php/fit-for-frailty
- Integrated care for older people with frailty: Innovative approaches in practice, BGS/RCGP (2016) http://www.rcgp.org.uk/about-us/news/2016/november/joining-up-care-for-older-people-with-frailty.aspx
- MDT Development – working toward an effective multidisciplinary/multiagency team, NHS England (2015) – https://www.england.nhs.uk/wp-content/uploads/2015/01/mdt-dev-guid-flat-fin.pdf
- Characteristics of an effective MDT. National Cancer Action Team. 2010 http://www.ncin.org.uk/view?rid=136
- Personalised Care Planning templates and guidance, including templates for advance care plans, emergency care and treatment plans, NHS England – https://www.nhs.uk/conditions/social-care-and-support/care-plans/
- Age UK report. Supporting older people – Improving later life. Services for older people what works https://www.ageuk.org.uk/Documents/EN-GB/For-professionals/Research/Services-what_works_spreads.pdf?dtrk=true
- Hidden in Plain Sight by Age UK https://www.ageuk.org.uk/Documents/EN-GB/For-professionals/Policy/health-and-wellbeing/Hidden_in_plain_sight_older_peoples_mental_health.pdf?dtrk=true
- Quest for Quality – a call for leadership, partnership and quality improvement, British Geriatrics Society (2011) – http://www.bgs.org.uk/campaigns/carehomes/quest_quality_care_homes.pdf
- NHS England: Enhanced Health in Care Homes site. Useful tools for implementation and building new care model. https://future.nhs.uk/connect.ti/carehomes/grouphome
- Effective Healthcare for Older People Living in Care Homes, British Geriatrics Society (2016) – http://www.bgs.org.uk/pdfs/2016_bgs_commissioning_guidance.pdf
- GP services for older people: a guide for care home managers, Social Care Institute for Excellence [SCIE] (2013) – https://www.scie.org.uk/publications/guides/guide52/gp-roles/relationships.asp
- Clinical input to care homes, NHS England Quick Guide (2016) – https://www.nhs.uk/NHSEngland/keogh-review/Documents/quick-guides/Quick-Guide-clinical-input-to-care-homes.pdf
- NICE quality standard on nutrition support in adults – https://www.nice.org.uk/guidance/qs24
- Malnutrition Universal Screening Tool (MUST), British Association of Parenteral and Enteral Nutrition [BAPEN] (2003) – http://www.bapen.org.uk/pdfs/must/must_full.pdf
- Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition, NICE guideline [CG32] – https://www.nice.org.uk/guidance/cg32
- Health toolkit to support the development of a hospital food and drink – https://www.england.nhs.uk/commissioning/nut-hyd/10-key-characteristics/
- Commissioning excellent nutrition and hydration, Guidance, NHS England (2015) – https://www.england.nhs.uk/commissioning/nut-hyd/
- Oral health for adults in care homes, NICE guideline [NG48] – https://www.nice.org.uk/guidance/ng48
- Malnutrition Matters: A commitment to act – A three-step guide to improving nutritional care in England, British Association of Parenteral and Enteral Nutrition [BAPEN] (2004) – http://www.bapen.org.uk/pdfs/malnutrition-matters-a-commitment-to-act.pdf
- Hydr8 app case study, November 2016 – https://future.nhs.uk/connect.ti/carehomes/view?objectId=26525637
- Faecal incontinence in adults: management. Clinical guideline [CG49] June 2007 https://www.nice.org.uk/guidance/cg49
- Self-reported hearing impairment and the incidence of frailty in English Community‐Dwelling Older Adults: A 4‐Year Follow‐Up Study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5484326/
- Naomi Feil, founder of Validation Therapy, shares a breakthrough moment of communication with Gladys Wilson, a woman who was diagnosed with Alzheimer’s in 2000 and is virtually non-verbal. Learn more at www.memorybridge.org. https://www.youtube.com/watch?v=CrZXz10FcVM
- Delirium: prevention, diagnosis and management. Clinical guideline [CG103] July 2010 https://www.nice.org.uk/guidance/cg103
- NICE quality standard on delirium – https://www.nice.org.uk/guidance/qs63
- NICE quality standard on dementia: support in health and social care – https://www.nice.org.uk/guidance/qs1
- NICE quality standard on dementia: independence and wellbeing – https://www.nice.org.uk/guidance/qs30
- Joint declaration on post-diagnostic dementia care and support, Department of Health and partners (2016) – https://www.gov.uk/government/publications/dementia-post-diagnostic-care-and-support/dementia-post-diagnostic-care-and-support
- Making a Difference in Dementia – Nursing Vision and Strategy, Department of Health (2016) – https://www.gov.uk/government/publications/dementia-nursing-vision-and-strategy
- Prime Minister’s Challenge on Dementia 2020: Implementation Plan, Department of Health (2016) – https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/507981/PM_Dementia-main_acc.pdf
- Fix Dementia Care: NHS and care homes report, Alzheimer’s society (2016) – https://www.alzheimers.org.uk/our-campaigns/fix-dementia-care
- Dementia: supporting people with dementia and their carers in health and social care, NICE Clinical guideline [CG42] – https://www.nice.org.uk/guidance/cg42
- Dementia Core Skills Education and Training Framework, Skills for health, HEE (2015) – http://www.skillsforhealth.org.uk/services/item/176-dementia-core-skills-education-and-training-framework
- Shared Lives Plus scheme – supporting older people (including those with dementia) with day support and short breaks to aid living independently longer – https://sharedlivesplus.org.uk/
- Deciding Right, a north east solution for making care decisions in advance http://www.necn.nhs.uk/common-themes/deciding-right/
- EPACCs – electronic systems that improve end of life care, Marie Curie – https://www.mariecurie.org.uk/globalassets/media/documents/commissioning-our-services/strategic-partnerships/rcgps/epaccs-electronic-systems-that-help-improve-care.pdf
- Commissioning toolkit for person centred end of life care
- Specialist Palliative Level Care information for commissioners sets out what good SPC looks like from a system perspective – https://www.england.nhs.uk/wp-content/uploads/2016/04/speclst-palliatv-care-comms-guid.pdf
- Information and links for professionals who support people and their families at the end of life, SCIE – https://www.scie.org.uk/adults/endoflifecare/
- NICE quality standard on EOL care in adults – https://www.nice.org.uk/guidance/qs13
- Hospice services: provider handbook, Care Quality Commission (2015) – http://www.cqc.org.uk/sites/default/files/20160422_ASC_hospice_provider_handbook_April%202016_update.pdf
- NICE quality standard on pressure ulcers – https://www.nice.org.uk/guidance/qs89
Evidence
- The gold standard for assessment and management of frailty is the comprehensive geriatric assessment (CGA).
- Advantage – management of frailty at an individual level: Systematic review – http://advantageja.eu/images/WP6-Managing-frailty-at-individual-level-a-Systematic-Review.pdf
- Geriatrician-led CGA delivered on specialist elderly care wards provided significant improvements in the chances of a patient being alive and in their own home at up to a year after an emergency hospital admission.
- Effectiveness Matters: Recognising and managing frailty in primary care – Centre for Reviews and Dissemination, The University of York – https://www.york.ac.uk/crd/publications/effectiveness-matters/frailty-primary-care/
- A review of community-based complex interventions that included CGA demonstrated a reduction in both hospital and nursing home admissions in an older population with frailty.
- Overall, national evidence suggests that case management had no impact on unplanned admissions. However, local intelligence and a review of specific approaches to care delivery in people with frailty such as nurse home visiting concluded that multiple visits, geriatric training and experience, interdisciplinary collaboration, multidimensional assessment, and use of theoretical frameworks could benefit older adults with frailty.
- Hospital-initiated case management may reduce hospital stay and possibly increase the time to first readmission. One study found that community-initiated case management reduced emergency department visits. What is not clear from the evidence is the optimal use of case management tools for the selection of patients for case management, or where case management could be best targeted.
- A meta-analysis suggested that complex interventions for older people living at home can help them live safely and independently reducing their risks of hospital admission and falls), and could be tailored to meet personal needs.
- Advanced care planning – the majority of older individuals would like the opportunity to discuss their end-of-life care but currently only a few have this opportunity, especially important for those with dementia and cognitive impairment.
- Effectiveness Matters: Recognising and managing frailty in primary care – Centre for Reviews and Dissemination, The University of York – https://www.york.ac.uk/crd/publications/effectiveness-matters/frailty-primary-care/
Nutrition and Hydration
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Bowel and bladder care
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Sight and hearing
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Cognition and Dementia Care
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End of Life Care
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