How to look after older people in an ideal world

There are several aspects to the care of Mrs Andrews, the elderly patient who never made it home from hospital profiled in a recent HSJ video, which are striking: first: was it recognised that she had frailty beforehand? Did she need to be in hospital at all? And once there, who needs to be responsible for getting her out of hospital?

Although it is true that all older people need a diagnosis when a change in function occurs, this doesn’t necessarily have to happen at the moment of the crisis or indeed in hospital – it’s always easier, however, if it has already been established that frailty is present and  the crisis anticipated. Once frailty is known about in a community setting, several actions need to be taken to help plan for the future:

• The patient needs a holistic medical review (along the lines of the comprehensive geriatric assessment) to consider reversible medical conditions.
• Referral to a geriatrician or old age psychiatrist at this stage might be needed for help with diagnosis or particular complexity.
• The review will also need to consider their own treatment goals.
• A plan should be produced which documents what they and their family are prepared to do to achieve the goals , plus what all other members of a community team will be doing to maintain her independence. This single patient centred, individualised plan needs to reflect the input of  and be owned by  all disciplines including any  private care agency involved.
• It will also document plans for escalation of care and actions which might be appropriate in the case of a potential and anticipated crisis – in this case a fall. In this way it could have helped the out of hours doctor and ambulance crew make the decision that hospital care might not be needed and given them an alternative plan.

However, the crew might have been concerned about a broken hip – which certainly would merit a visit to the emergency deaprtment. Once excluded, however, the emergency department staff alerted to the previous plan could have implemented the escalation plan and sent her home with the support of the local community team.

Let us suppose, however, she did need admitting because of the need for treatment that could only be delivered in hospital (and I would not include the treatment of a dubious UTI in this), then the integrated community care team who knew Mrs Andrews would have been responsible for pulling her out of hospital once the immediate need for hospital care was over – ie: within 48 hours (no more section 2s or 5s). They could implement the urgent care necessary and enable her to recover, with support as needed in her own home. The original care plan would be revisited and revised if necessary, support and care put in place and she and her husband would be back to the status quo.

Whether she needed to go into hospital or not, she might have needed urgent access to specialist input from a geriatrician – but local arrangements need to be made so that this does necessarily need admission to hospital – either by geriatricians working in the community settings alongside other members of an integrated care team, or through rapid access assessment units.

‘Hospital and community care are not alternatives, neither are they in competition; they are both parts of a comprehensive pathway’

Effectively we are describing a mulitprofessional team working together to pull an older person with frailty along a pathway of care including admission to hospital when this is needed.

Hospital and community care are not alternatives, neither are they in competition; they are both parts of a comprehensive pathway for frailty and both need to be used at times but planned for appropriately. Fiscal restrictions mean that we need to find imaginative ways to deliver these pathways and this will probably mean hospital specialists and other staff providing input outside of the hospital  to support older people where they need to be. It also needs as a complete review of the current payment systems so that the money really does follow the patient out into the community as well.

So how do we recognise that someone has frailty even before they reach a crisis and how does the care planning work? The British Geriatrics Society has published guidance to help. Under the title Fit for Frailty, part one describes the recognition and management of individuals with frailty in community and outpatient settings.

The society recommends that frailty is actively sought by all health and social care  professionals in the individuals they encounter and the actions that they then need to follow to ensure that health and social care is of proper service to the likes of Mrs Andrews.

Dr Gill Turner is vice-president of the British Geriatric Society