Frail & Older People
Journey of the Event
6
Value Agenda Overview
David Cryer
Jim Dodsworth
1
4
Identifying Our Outcomes
Introduction & Context
7
2
Terms of Art
5
3
What is an outcome and why are they important?
Prioritising Our Outcomes
Exploring the Value Agenda
& Next Steps
Frail & Older People
Outcomes for each Borough
Barnet
Ann Mount
Irina Goodluck
Jean Aldous
Juliana Bersani
Karen Spooner
Martins Charters
Muyi Adekoya
Tim Bowler
Haringey
Catherine Herman
Delia Thomas
Greg Battle
Helen Joyce
Helen Pelendrides
Helen Taylor
Jonathan Carmichael
Liz Evans
Maurice Cohen
Nicole Klynman
Rachel Lissauer
Rosaire Gray
Sherry Tang
Shirley Ip
Camden
Anne Schlattl
Ben Ellis
Celia Smith
David Cryer
Fran Gertler
Fredrik Johansson
Helen Dunford
Inti Khan
Mousumi Basu-Doyle
Nadia Raja
Naser Turabi
Pramod Prabhakaran
Sam Jones
Stuart Mackay-Thomas
Suzanne Joels
Tracy Brown
Islington
Andy Murphy
Clare Henderson
Clarissa Murdoch
Dan Windross
David Davis
Liz Brutus
Martin Kuper
Michelle Wheeler
Sue Newton
Tina Jegede
Sheena Nixon
Susanna Dale
Enfield
Adam Webber
Graham MacDougall
Jennie Bostock
Naheed Rana
Nasrin Hafezparast
Paul Allen
Rachna Chowla
Sian Therese
Frail & Older People
Older People with Frailty
Cohort definition
Included
Excluded
All people aged
A. Patients under end of life care
B. Patients with organ system failure (eg end
75+ years
and
pre-frail and frail
stage renal failure, end stage heart failure)
C. Patients who require specialist care teams
(e.g. immediate care following acute event
(e.g. MI), surgery related care, psychiatric
care, all cancer care)
D. Patients who are not frail
Local context: current provider landscape
Providers whose services for 75 years+ are in scope for the patient cohort in 2015/16
Primary care
Primary Care
Acute
Providers
Community
Care
North
Middlesex
Core
contract
Haringey x 4
localities
Royal Free
(BCF)
Whittington
Health
Whittington
Health
Social Care
Other
Domiciliary
Care
Housing
Adult Social
Care, LBH
Barnet Enfield
and Haringey
MHT
Third Sector
Care Homes
UCLH
Estimated frail and pre-frail population number
6,955
IPU design proposal
GPs
Social Services
Short or medium-term acute
& community interventions,
including self-management
intermediate care,
enablement &
Rapid response functions
Specialist functions to
help assess, care plan,
case manage and deliver
Patient/family/carers
Acute Trusts
Single Point of Access
To The Hub
Assessment
& case
management
Primary and Community
Management and
risk stratification including
low level prevention
Diagnostics and treatment
Care co-ordinator
& The Patient
UNDERPINNED BY:
Infrastructure issues such as co-location, shared records,
workforce development, 7 day working etc
Outcomes Shortlist: Older people with frailty