Long term conditions and frailty

Long term conditions are defined as health problems that require on-going management over a period of months, years or decades. This includes a wide range of health conditions including neurological conditions, non-communicable diseases (e.g. cancer, diabetes and cardiovascular disease), communicable diseases and on-going impairments in structure (e.g. blindness, joint disorders).

Frailty is a distinctive health state relating to the ageing process in which multi-body systems gradually lose their built in reserves. Older people with frailty are at risk of unpredictable deterioration in their health resulting from minor stressor events. (BGS, 2016)

Principles

The rationale of long term conditions and frailty management is that through the application of case management principles combined with timely health and social care interventions to support people to self-manage and remain living independently in their own home whenever possible. This approach seeks to manage episodes of instability and deterioration as close to home as is possible, thus avoiding or reducing admissions to acute, residential or nursing care beds.

Where

Home, clinic, local community, community hospital, care home, urgent care

How

Recognise phase of illness and tailoring of supportive information and interventions to enable person to remain at home or in preferred place of residence.

Proactive planning in collaboration with person, family/carers and Neighbourhood Team partners to ensure strategies are in place (including supportive technologies) to:

• maintain optimal function/condition
• recognise early signs of deterioration or acute or unstable illness/crisis
• know what to do and/or who to contact in the event of deterioration, acute illness or crisis
• ensure robust mechanism to respond in a timely manner
• ability to deliver additional care in community as required.
• use case management and/or specialist intervention as indicated.

Supportive tools and processes

• Skilled communication
• Holistic assessment undertaken over up to three visits.
• Use of appropriate tools to support clinical judgment and patient-centred decision-making, examples are Edmonton frailty scale, Prognostic Indicators and Triggers.
• Utilising locally and nationally recognised information resources, such as leaflets, supportive technology, social media, local support groups, classes or meetings.
• Provision of links to support network of patient/ carer experts.
• Identify where support is required to enable people to go online, use medical devices and write things down (Health Foundation)
• Referral for one to one support or specialist interventions where required.
• Setting goals that are achievable.
• Having agreed individual plans for what to do in the event of deterioration, acute illness or crisis.
• Development of ”My Plan” in partnership with patient, family/carer
• Empowering people to live as independently as possible by improving self-confidence and alter personal behaviour.
• Use of Proactive Caseload Review (Kings Fund, 2011) within ICT identifying where the level complexity and risk prompt further discussion at the Multi- Disciplinary / Agency Team Meetings (Neighbourhood Team).
• MDT Working (NHS England, 2014) – Health and social care professionals collaborating as experts to support people with complex care needs which have been identified through risk stratification and case finding.

Who

The Integrated Community Team from LCHS includes:

• registered nurses, allied health professionals, health care support workers and support staff who work together to provide a skill mixed team that will provide consistent high quality care to support people in our local community who require healthcare.
• this team is supplemented by specialist practitioners who can be called upon for advice or to co-ordinate and provide complex case management where required. Specialists clinicians provision includes district nurses, palliative care, respiratory and heart failure management, cardiac and pulmonary
• Rehabilitation, continence, tissue viability, diabetes and Parkinson’s disease. Senior professionals are often non-medical prescribers and are able to diagnosis and treat/manage many conditions in the community.

Referral and care transfer sources

Transfer in:

• Referrals from Health and Social Care Professionals Self-referral in some circumstances
• Transfer between ICT teams
• Neighbourhood Team referral – defining who should take the lead, Nurse, Therapy, Adult care, CPN

Transfer to:

• Self-Management
• Episode of Care is Complete
• Movement into other pathways, end of life, long term conditions 3rd sector/ Voluntary
• Independent sector Transitional Care Pathway
• Urgent care – home visiting service / review by a senior practitioner Customer Service Centre
• Onward heath referral e.g. CPN Community Hospital
• Case Management
• Patient-centred care
• MDT – How health and care professionals work together to support people with complex care needs that have been identified through risk stratification and case finding.
• Multi-Disciplinary Approach – Involves drawing appropriately from multiple disciplines to explore problems outside of normal boundaries and reach solutions based on a new