New frailty pathways are being developed by the Frailty Network with Helen McKee, Frailty Associate Medical Director, Hazel Gilmour, Frailty NMAHP Consultant, Leigh Dobson and Jackie Duncan, Rehabilitation Co-ordinators, leading the team.
The Frailty Network started in November 2023 with the aim of providing a collaboration between the multi-disciplinary teams on our acute sites and the partnerships who have experience and enthusiasm in frailty work. This has led to richly informed conversations which has been at the forefront of driving realistic and patient-centred change for the people living in Lanarkshire.
With continued engagement with both North and South Health and Social Care Partnerships, including GP localities, District Nurses and Third Sector organisations, there has been an understanding on how staff work with frailty patients and the challenges around this. It has also ensured more joint working between acute and community teams.
Helen McKee, Frailty Associate Medical Director, said: “The staff who provide care for frailty patients do it with dedication and passion, but there was a recognition that with more cohesive working we could improve this for both the staff and patients.
“We have worked hard with colleagues in both the acute setting and community setting to identify areas for improvement and support the early identification of individuals in the community to facilitate pre-frailty interventions.
“We have supported the development of local response teams who will respond to any concerns with individual patient to avoid hospital admissions. These teams work with patient’s families and carers to offer a focused approach for the patient including review of medication, whether there is a need for particular tests and if additional home support is required.
“The aim is that that every older person in Lanarkshire with, or at risk of, frailty is supported to be healthier, to remain independent for longer and to live their best lives.
“To achieve this it is extremely important that all partners work together, and with older people, unpaid carers, families and communities, to prevent, detect and delay the escalation of frailty through proactive, personalised, co-ordinated support at home, or as close to home as possible.”
The Network also recognises the importance of focusing on promoting health and well-being and tackling inequalities to help deliver sustainable healthcare.
The use of digital technology is also being developed. PeacePlus provides a platform to explore digital monitoring programmes which can help support people at home with the identification of early frailty. We are working to establish if this can be used to highlight a deterioration in function at an early stage by using this digital technology.
Hazel Gilmour, Frailty NMAHP Consultant has worked with frail patients for a number of years. Her and the frailty teams across Lanarkshire have been instrumental in establishing frailty pathways across the three acute sites and promoting alternatives to admission to hospital including Hospital at Home and strengthening the support from Consultant Connect.
Hazel added: “There are a range of actions we have taken to support older and frail patients at home but we have also looked at how we can make their stay in hospital, if required, as easy and comfortable as we can.
“We have put in place a number of steps to get older and frailty patients seen, treated and discharged as quickly as possible as we know getting them back to the comfort of their own home or care home is important for them.
“NHS Lanarkshire has introduced earlier geriatric assessment at all our acute hospitals and, we as soon as a patient is admitted, set a planned date of discharge at the earliest opportunity. This is all done by the multi-disciplinary team in charge of the patient’s care.
“Simple things like getting patients home in the morning on the day of their discharge, or ensuring patients needing support at home is not delayed by more than 72 hours can make a massive difference to the patient’s wellbeing as they are returned to a familiar environment, whether that be home or a care home.
“There are still areas where we can improve but by developing an integrated leadership culture to support continuous improvement, and shared learning and goals around frailty pathways across both our acute and community teams, we hope that the pathway for frail patients will be the gold standard of care for the people of Lanarkshire.”
We would welcome contact from anyone who shares our passion for improving pathways and services for older people or who has questions around this work. You can get in touch by emailing Frailty.Network@lanarkshire.scot.nhs.uk
