Transcript Service Models - Prof. Peter Crome`s Conference

Beyond the geriatric giants: moving from elderly care
to evidence-based medicine for the older person.
Conference to honour the career of
Professor Peter Crome
Keele, March 21st 2013
Service Models
Finbarr Martin, Geriatrician
Guys & St Thomas’ Hospital and King’s College London
Medicine - No Country for Old Men !
“We realize that for all practical purposes the
lives of the aged are useless, that they are often
a burden to themselves, their family and the
community at large. Their appearance is
generally unesthetic, their actions
objectionable, their very existence often an
incubus to those who in their humanity or duty
take upon themselves the care of the aged.”
Nascher IL. Geriatrics: the disease of old age and their treatment. Philadelphia: P
Blakiston's Son & Co, 1914.
A surgeon rides to the rescue
• Marjory Warren (1897 – 1960) at Isleworth Infirmary
• 1935 took over an adjacent workhouse to form the
West Middlesex County Hospital.
• Systematically reviewed several hundred inmates
• Classified into 5 groups
Adapted from Barton A and Mulley GP, 2003
Her achievements
Warren MW A case for treating chronic sick in blocks in a general hospital. BMJ 1943.
Warren MW . Care of the chronic aged sick. Lancet 1946
• discharged many patients by providing
rehabilitation and appropriate equipment.
• Upgraded wards, improved patient and staff morale
• Advocated
– creating a medical specialty of geriatrics
– providing special geriatric units in general
hospitals
– teaching medical students about the care of
elderly people, by senior doctors with specialist
interest in geriatrics.
Early experience at St Pancras, London
Lancet, 1951
Look at the age in 1950
Progressive patient care – first model
designed to optimise use of acute beds
Lancet, 1962
30 beds, predischarge
32 beds,
long stay
106 beds, post acute +rehab
22 beds LOS mean 10 days
Two models emerged in 1970s
Age defined model (Sunderland)
(O'Brien TD et al , No apology for geriatrics. BMJ 1973;i:277–80)
• Became predominant model till 1990 as old hospitals closed
and DGHs absorbed older medical patients
Integrated model (Newcastle)
(Grimley Evans J Integration of geriatric with general medical
services in Newcastle. Lancet 1983;i:1430–3)
• Recommended by RCPL in 1977
• Reduced beds and reduced doctors’ hours galvanised this
• Withdrawal from rehab and long stay as consequence
Where are we now?
• People aged 65+ are ~ 17 % of the population
• And use 65% of acute hospital bed-days
• >50% of the patients having surgery, (>major)
=================================
• More older people
• Older people are older
• And older people are different
older people are older
( rectangularisation to elongation of age distribution)
Distribution of death England 1841 - 2006
100%
Around 18% of all
deaths were
before 65 in 2006
–same proportion
as in 1991
90%
1981
1991
80%
1941
70%
2001
60%
50%
1841
2006
40%
30%
20%
10%
0%
1
5
9
13
17
21
25
29
33
37
41
45
49
53
57
61
65
Source: mortality.org, originally ONS
69
73
77
81
85
89
93
97 101 105 109
10
As a result…………
• Most older people now live long enough
– To have several long-term conditions (+ multiple
medications)
• eg Respiratory, cardiac, diabetes
– to develop sensory impairment, sarcopenia,
inflammaging
• Many also develop
– dementia, osteoporosis, cataracts etc
– homeostatic dysregulation
• Resulting in frailty and “geriatric syndromes”
People with long-term conditions have high health
service use, especially hospitals (69% total spend).
People with limiting LTCs are the most intensive users of the most expensive services
100%
Limiting
LTC
percentages
% of services used
80%
60%
Non
limiting
LTC
40%
20%
No LTC
0%
Number of people
consultations
Practice Nurse
and A&E
Older
people GPGPconsults
Practice
nurseOutpatient
Outpatients
appointments
attendances
Type of service
Type
of Service used
Source: 2005 General Household Survey.
No LTC
Non-limiting LTC
Limiting LTC
Source: 2005 Household Survey
12
Inpatient bed days
Inpatients
And older people vary
Genetics inc chance changes in development
Maternal and early life factors
Society and Lifestyle etc
Events and illnesses and chance
Frailty
Specific diseases
Spectrum of health and capacity
Frailty “summarises” prediction of outcomes
Rockwood and Mitniski A J Gerontol 2007
Implications for health care
(Tinetti Am Med J 2004)
Age attuning health services
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Expect older people with problems
Identify frailty and geriatric syndromes routinely
Use comprehensive geriatric assessment (CGA)
Predict “complications”
Use experts judiciously
Up-skill general services
Promote multidisciplinary clinical practice and
clinical governance
Better care is often cheaper care in the end, so NHS
must get better to survive economically
The scope of geriatric medicine
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Acute and episodic illness
Post acute recovery and rehabilitation
Long term management of diseases and frailty
Support for people living with high dependency
End of life care
Acute and episodic illness
• Interface geriatrics - between community and hospital in
response to acute clinical change
– support Emergency Departments
– liaison with intermediate care (IC)
• Provide part of the acute medical admission service
– proactive case finding in acute medicine
– CGA approach with selected patients
• Support hospital approach to age attuning all services
– design and delivery of services
– leadership in quality improvement with geriatric syndromes
– Support education and training of the workforce
Implications for Surgery
NCEPOD Report 2010
• >1000 deaths of surgical patients 80+ years
• Report highlights suboptimal management of common
post-operative complications
• Gap between policies, guidelines and clinical practice.
• Assessment and clinical skills were too narrow
• Likely events not anticipated or responded to
• Interdisciplinary collaboration sporadic
Systematic responses 1
• Proactive support for frail older people
having surgery
– developing risk assessment in surgical
services
– pre-op CGA for selected high risk patients
– ongoing medical input to peri- & postoperative care
Eg. Local proactive joint care - example
from GSTT: Proactive care of Older People
having surgery -“POPS”
Surgical Outpatients/PAC
Pre-operative CGA
Proactive referral of patients aged 65+
Consultant
Screen to identify risk
Clinical Nurse Specialist
Including “medically unfit for surgery”
Occupational therapist
Physiotherapy
Post Discharge
Social worker
Intermediate Care
Patient education
Links with primary care/ social care
Specialist clinic follow up (falls etc)
Preadmission Liaison
Hospital Admission
Surgical team
Post-op consultant geriatrician and
specialist nurse interventions
Anaesthetists
Therapy liaison
Discharge planning
GP and Community services
Patient
• Provide shared care for patients with
fragility fractures
– Co-design and supervise the hip fracture
clinical pathway
– Provide daily medical care to selected
patients
– Share clinical governance responsibility to
achieve the best practice standards of care
and secondary prevention
Eg Fracture services
National inter-disciplinary collaboration
The Blue Book and the NHFD
Post acute recovery and rehabilitation
• Design and quality assure post acute care pathways
– assist clinical systems to identify inpatients’ ongoing needs
– specialist input to bed based or domiciliary IC services
(EVIDENCE?)
• Provide “hot clinics” for CGA and other key conditions
– Link to A&E, acute admission units and community
assessment in a whole system approach to urgent care
– Link with community based services to optimise recovery,
ameliorate frailty and target secondary prevention
(EVIDENCE PATCHY AND NARROW)
Long term conditions and Frailty
• Estimating potential benefit is complex
– Attributing risk in context of co-morbidity
– Effects on LE, independence and quality of life
• Estimating risks and burdens is complex
– Factoring in frailty
• So geriatrician- primary care co-working is needed
• So far, relatively evidence free zone
Support for people living with high
dependency
• CGA for older people at transitions of dependency
– diagnostic input prior to institutional care
– design and delivery of pathways for frequent
hospital attendees
(LOTS OF INITIATIVES, LITTLE EVIDENCE)
• Specialist support for care home residents
End of life care - recognition
Trajectories in the final 12 months of life
Summary
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Its not just about our wards anymore
Its still about diagnosis but through CGA
Its more about frailty more than age
Its about getting it structured and simple and reliable
It will be about new therapies for frailty etc
Geriatrics is coming of age