Integrated
Care
Research Knowledge Exchange
Health and Wellbeing Group
for
Frail
Mark Rickenbach
GP
Visiting Professor Healthcare and Education Innovation
Abigail Barkham
Consultant Frailty Nurse
Patients
Mark Rickenbach
General Practitioner and Educator
[email protected]
[email protected]
Park Surgery, Chandlers Ford
Education website
www.docrick.co.uk
Wiki index
Fourteen Fish/ Doc Rick
www.fourteenfish.com/communities
95yr old
Lives Alone
Neighbour concern Monday
Podiatry concern Tuesday
Links to healthcare
Decline
Emergency admission Sunday
Frailty:
Carer needs
poor mobility
+- Memory problems
Environment
Financial restraint
National drive - Kings Fund
Regional leaders 2014
Secondary care lead, Dr John Duffy
Multi-care Specialty Provider Model,
Better Care, Local Care, Dr Nigel Watson
Consultant Nurse for Frailty,
Abigail Barkham
Locality meetings 2015
Multi-professional
Community based
Research Cycle
Problem
Reflection
"a spiral of steps,
each of which is composed
of a circle of
planning, action and fact-finding
about the result of the action"
Lewin from Action Research and Minority Problems 1946
Reflection
Action
Research
b.1890 – d.1947
Behaviour = f (Person, Environment)
Leadership - autocratic, democratic, facilitative
Cycle 1 – Shared vision
Gap in proactive care
for Frail patients
Problem
Dec 2015
Reflection
Reflection
Co-ordinated care
Earlier Review
Shared approach
Holistic
Action
Park Surgery, Hampshire
Research
Cycle 1 – Shared Vision
Poor proactive care
for Frail patients
Focus on clinic
Focus on IT
Problem
Reflection
Reflection
Volunteers for a clinic
April 2016
Co-ordinated care
Earlier Review
Shared approach
Holistic
Action
Research
Feedback positive
Outcome = Shared vision
• Local Frailty clinic
• Increased IT links
• Information Access
Facilitated meeting
Shared viewpoints
Sharing Cascade
Cochrane review
Comprehensive Geriatric Assessment
22 trials of 10,315 patients in 6 countries (Ellis 2011)
Greater likelihood of improved cognition, being alive or in own
homes at 6 months
Reduced institutionalisation, death, or functional decline
NICE guidance on Multi-morbidity
Establish what is important to the patient.
Consider all conditions and treatments simultaneously
(Farmer, BMJ 2016)
Spiral
June 2016
Sept 2016
Nov 2016
Vision
Clinic
Process
Embed
April 2016
Cycle 2 - Frailty Clinic June 2016
How to establish clinic
Problem
Reflection
Reflection
Action
Research
Team meeting
Facilitated discussion
Sub meetings
Community based clinic
1st and 3rd Wed pm
Consultant Nurse Frailty Care
Older Persons Mental Health
Consultant physician
Abigail Barkham
Barry Edwards
Yasir Al Rawi
Community Independence Team
GP(s) move
Alison Dalmas
Mark Rickenbach
Access Community care team – MIG access for RIO records
Access Transformation team – vision 360 access for EMIS
Drop by consultant elderly mental health Kavitha Babu
MSK physio - Southern Health
Wellbeing (frailty) clinic
2pm
patients
Patient 1
Patient 3
Comprehensive
assessment (CA)
Social care + action plan
4pm
patients
Patient 2
Patient 4
Social care + action plan
Comprehensive
assessment (CA)
Cycle 2 – Frailty clinic
Sept 2016
How to establish clinic
Problem
Reflection
Improve process
Revise documents
Pre assessment
Reflection
Wider access
Stagger times
Action
Team meeting
Facilitated discussion
Sub meetings
4 patient clinic
Research
Early cancer
Supported carers
Positive healthcare providers
GP feedback – who actions is unclear
Process unclear
Frailty Service
Pre assessment
Co-ordinated team
Expert access
Improved care
Reduced admission
Safer patients
3 surgeries
30,000 patients
Brownhill surgery
Fryern surgery
St Francis/Park surgery
Spectrum of frailty care
Intensity of care should relate to the level of frailty
and rate of decline.
GP
GP
Nurse Physician Assessment Hospital
+ social +nurse
Unit
Admission
7min 20min 1hr
2hr
6hrs
5days
Commission intensity of care and cost to match
need and benefit.
Healthcare provider Access
The level of access varies with severity.
Face to face……Nurse, volunteer sector
Immediate phone /skype ……GP, consultants
Early access……Physiotherapy, OT, social services
Routine access……follow up
Cycle 3 – Revised processes
How to improve process
Problem
Full Outcome
awaited
Reflection
Reflection
Action
Research
Full Outcome
awaited
Sept 2016
Review of documents
Group discussion
Meeting
Improved metrics
7 patient clinic
Wellbeing (frailty) clinic
Consent + leaflet + wellbeing plan + prior questions
1.30pm
patients
Patient 1
Patient 3
Social care + action plan
Patient 5
Comprehensive
assessment (CA)
Patient 6
3.30pm
patients
Patient 2
Patient 4
Social care + action plan
Patient 7
Comprehensive
assessment (CA)
Cycle 3 – Revised processes
How to improve process
Problem
Reflection
Protocol
Funding
Nurse navigator role
Core functions
Reflection
Frailty level 5-6
Action
Research
Admin workload
Core = assessment + social
Step on way versus end point
Sept 2016
Review of documents
Group discussion
Meeting key players
Improved metrics
7 patient clinic
Best combination and cost?
Consultant diagnostic but not core
Develop holistic, IT and community links
Higher cost
GP focused, linked but cannot replace experience.
Support for time, social care
Needs locum + on costs. Increased Admin load
Nurse systematic
Support for diagnostic, prescribing, admin load.
Social support and time to assess each problem is
the real key. 1hr slot + social care + main surgery
Wellbeing (frailty) clinic
Consent + leaflet + wellbeing plan + prior questions
Patient 1
Patient 3
Comprehensive
assessment (CA)
Social care + action and care plan
Patient 2
Patient 4
Social care + action and care plan
Comprehensive
assessment (CA)
St Francis Surgery
Hampshire
Cycle 4 – Regional support
Nov 2016
How to maintain service
Problem
Awaited
Reflection
Reflection
Action
Research
Outcome awaited
Regional meeting
Joint bid
Shared goals
Involve financial leads
Wider metrics
Expanded group
Meeting 30.11.16
co-option,
compliance,
consultation,
co-operation,
co-learning,
collective action.
Waterman et al. (2001:17)
Components of action research
Research
Reflection
Action
Cycle
Spiral
Participation
Message
* Rickenbach 2015
Proactive, co-ordinated
care can be achieved
Personal effort and skills count
Thankyou
Any Questions?
Mark Rickenbach
Education website
www.docrick.co.uk
Wiki index
Fourteen Fish/ Doc Rick
www.fourteenfish.com/communities
Frailty clinic
Publications:
Inhaler fullness and floatation
Postgraduate medical education
2003 Phd Action Research Medical Education
Appraisal
Counselling
Integrated care
General Practitioner
1993-
2014 regional
wiki index…..
Lecturer 1994Visiting Professor 2010-
2014 Contraception
IUCD……
2016 Pre consultation
Questions…..
Associate Dean
Collaboration
Park and St Francis
Research Unit
NIHR adviser
RCGP assessor
BMJ reviewer
2015 Frailty care…..