A new service is helping to keep frail, older people in South Tyneside out of hospital and in their own homes.
Earlier this year, South Tyneside NHS Foundation Trust introduced its Rapid Elderly Assessment Care Team (REACT), which comprises a nurse practitioner with a vast amount of hospital and community experience, an occupational therapist, a physiotherapist and a healthcare assistant.
Frailty can lead to poor mobility, difficulty doing everyday activities, or simply ‘slowing up’. It results in large increases in health costs for care settings such as hospitals and nursing homes.
Frailty progresses with age and, as the population of England ages, the prevalence and impact of frailty is likely to increase.
REACT works across Accident and Emergency and the Emergency Assessment Unit at South Tyneside District Hospital to prevent hospital admissions.
The team assesses patients using a recognised ‘frailty tool’; the higher the score, the greater the risk of adverse outcomes for the patient.
If frailty is identified, the team looks at the options regarding interventions and a treatment plan.
The aims of REACT are to:
l Identify and screen for frailty disorders early in the patient pathway;
l Stream patients attending emergency care on to an agreed frailty pathway;
l Reduce unnecessary admissions / readmissions to hospital;
l Reduce the length of time frail, older patients spend in emergency care;
l Improve patient experience and outcomes of frailty disorders;
l Ensure all frail older patients have a comprehensive geriatric assessment;
l Increase the number of patients with frailty with an emergency health plan;
l Improve communication with primary care and community partners.
Patients referred to REACT are: those aged over 75 with functional impairment and two or more pre-existing medical conditions; those who have been diagnosed with dementia; those who have had two or more falls, or any fall resulting in a fracture, and care home residents.
All patients identified as frail receive a comprehensive assessment through a rigorous diagnostic process that aims to determine the patient’s medical, psychological, social and environmental needs and functional capability in order to facilitate the planning and treatment for their individual, long-term care.
Consultant geriatrician Dr Becky Wiseman said: “People with frailty are likely to have a number of different issues or problems which, taken individually, might not be very serious but when added together can have a major impact on their health, confidence and wellbeing.
“If frailty goes unrecognised, the adverse consequences can be severe and it may be made better or worse, depending on the care received.
“If frail older people are supported in living independently and understanding their long-term conditions, and educated to manage them effectively, they are less likely to reach crisis, require urgent care support and experience harm.”
In a crisis, rather than being admitted to hospital, which can be a confusing experience for them, many people with frailty manage better in the familiar surroundings of home with support systems that meet their health and care needs.
In such cases, REACT is able to support their discharge home from Accident and Emergency.”
The team also carries out telephone assessments for all patients over 75, anyone 65 or over who has presented with a fall to hospital, and for all patients who have attended Accident and Emergency out of hours and at weekends.
The telephone triage assesses if they are managing at home following their visit to hospital and, where appropriate, they are referred to other services such as the Trust’s dedicated falls team and community nursing teams, a community frailty nurse, voluntary organisations, social services, ‘telecare’ (support and assistance provided using technology) and equipment provision.
The team works in partnership with the hospital’s discharge team and elderly care consultants.
It also has very close links with the community frailty nurse, sharing information, with the consent of the patients, which is then used to formulate follow-up plans for the patients at home.
REACT attends regular multi-disciplinary team meetings with primary care colleagues, including GPs, to look at individual patient care plans and emergency health care plans, to ensure patients receive care at the right time, in the right place and from the right person.
REACT is already looking at future development. South Tyneside NHS Foundation Trust is working together with City Hospitals Sunderland NHS Foundation Trust in a strategic alliance known as the South Tyneside and Sunderland Healthcare Group and REACT is working with the frailty service at Sunderland, sharing experience and best practice.
It is also linking in with other neighbouring Trusts, including The Newcastle upon Tyne Hospitals NHS Foundation Trust and Northumbria Healthcare NHS Foundation Trust.
It is intended that the nurse practitioner will work closely with the elderly care consultant in clinics at the District Hospital. There are also plans for four frailty assessment beds on an elderly care ward to ensure that patients who require admission for further assessment and treatment of frailty can have a short stay and benefit from a multi-disciplinary approach to discharge and follow-up.