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Frailty, Falls & Fragility

Frailty, Falls & Fragility. Dr Dai Roberts - Programme Development Lead Farah Irfan-Khan – Project Manager Health Innovation Manchester. Falls & Fractures - the facts.

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Frailty, Falls & Fragility

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  1. Frailty, Falls & Fragility Dr Dai Roberts -Programme Development Lead Farah Irfan-Khan – Project Manager Health Innovation Manchester

  2. Falls & Fractures - the facts Falls and fractures in people aged 65 and over account for over four million hospital bed days each year in England alone There are ~65,000 hip fractures in the UK each year 33% of people >65 will suffer a fall rising to 50% for people >85  Costing the health and social care £2 billion a year £ Hip fractures account for 4000 inpatient bed days daily

  3. Greater Manchester Hospital admission rate for falls averages at 44% across GM Around 10%of people aged over 65 years have frailty Expected annual costs for falls £62,275,961 £ NWAS data shows that 11% ambulance call outs were for falls

  4. Ambition for frailty… ‘Everybody should know what to do next when presented with a person living with frailty and/or cognitive disorder’

  5. Frailty is not good for you

  6. Emergency bed days by age If the 08/13 years and 12/17 years are compared by age (under 65 vs over 65s), the biggest changes are for those who are over 65 years. Bed days have been split for the under 65’s and those aged 65 years and over. Whilst the pattern is essentially the same for the two groups, the biggest absolute changes are for those age 65+.

  7. Greater Manchester Strategic Case Reducing the number of falls is a key priority articulated in the GM HSCP Sustainability and Transformation Plan ‘Taking Charge’ GM HSCP Five Transformation Themes Reducing 2750 serious falls

  8. Project aim To reduce falls and fractures related to frailty across Greater Manchester through early identification, treatment and management of patients at risk

  9. Tameside & GlossopNeighbourhood Frailty MDT Model eFI This MDT model aims to identify, review and manage severely frail patients at risk of falls and fractures using the electronic Frailty Index (eFI), Fracture Risk Assessment Tool (FRAX) and Falls Risk Assessment Tool (FRAT) Key enablers to support T&G Transformation Programmes 1. Collect baseline data on severely frail patients using eFI 2. Risk stratification using FRAT & FRAX Neighbourhoods across Tameside & Glossop

  10. The model eFI FRAT FRAX

  11. Potential Interventions This project aims to reduce falls and fractures related to frailty across Greater Manchester through early identification, treatment and management of patients at risk • Community physiotherapy • Medicines optimisation of bone sparing therapy drugs • Falls programme • Relevant local authority, domiciliary care and voluntary services • Community Response Service • Complete Summary Care Record • Social dimensions • Social isolation • Short form questions –to impact on resilience and adherence to treatments –e.g. local community groups for referral on to • E.g De Jong Gierveld

  12. Outcomes This project aims to reduce falls and fractures related to frailty across Greater Manchester through early identification, treatment and management of patients at risk • Early identification, treatment and management of patients at risk: • Reduction in hip and fragility fractures • Decrease in mortality rates due to hip fractures • Early and increased identification of osteoporosis and high risk patients • Reduction in non-elective admissions related to falls and fractures • Better outcomes for patients with a reduced risk of disability and loss of independence

  13. Milestones achieved • Stalybridge Frailty MDT pilot launched on 31 January 2018 • Data Sharing Agreement produced for Frailty MDT which has been approved by the West Pennine LMC • Opportunity to deploy population health toolkit, Vision Outcomes Manager, being progressed • Engagement with: • Martin Vernon, National Director for Older People, NHS England • Industry partners • Bury GP Federation • Northern AHSNs as part of the wider ‘Bone Health Programme’ • Stalybridge Neighbourhood Team • Public Health Trafford Council

  14. Finances • IT costs • Cost for FRAXlicensing is £20,000 • Deployment of Vision Outcomes Manager is available via the GP Systems of Choice contractual framework • No costs associated with integrating FRAT • Frailty MDT model costs • The cost to backfill a GP/team for Frailty MDT is £300 per practice • Transformation Funding to Stalybridge Neighbourhood • Predictive ROI: £3,925,276

  15. Risks and Challenges • Establishing baseline data for each Locality • Engagement with Localities to take up project will be challenging due to increasing demands on general practice • Delays in approval of Data Sharing Agreements • Low uptake of the Vision Outcomes Manager • Continued variation, falls & fractures!

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