Initiatives such as the Enhanced Services Initiative (ES) are designed to help reduce avoidable unplanned admissions by improving services for vulnerable patients and those with complex physical or mental health needs, who are at high risk of hospital admission or re-admission.
One of the aims of the ES is to ‘identify patients who are at high risk of avoidable unplanned admissions, establish a minimum two per cent case management register and proactively manage these patients’.
Identifying patients requires the use of a risk-stratification tool or an alternative method to identify vulnerable older people, high risk patients and patients needing end-of-life care who are at risk of unplanned admission to hospital.
Risk stratification tools in general use in the UK have included patients at risk of rehospitalisation (PARR) model, PARR++ and the Combined Model which to varying degrees make use of information which is readily available (e.g. presence of long term conditions, A&E admissions and outpatient appointments).
The main limitation to this approach is that the data does not catch those who may be high risk but have not been in recent contact with the NHS. The main consequence of this is that tools identify too few patients such as the ‘frequent flyers’ who are already well known or those with complex issues already receiving extensive services. It is the ‘known unknowns’, whose first contact is with an admission to A&E that need to be found.
Several studies show that in order to significantly impact admissions intervention needs to be able to reach these larger cohorts that have a lower average risk. However when attempts are made to relax the constraints so as to catch more cases the stratification becomes too flat and fails to prioritise between higher and lower risk cases. The cost of collecting the additional data needed to overcome this is prohibitive using clinical resources.
The relevance of frailty
If it was feasible to collect additional data what would this be? Based on practical clinical experience the Intelesant team believe data relevant to frailty would be most valuable. We use a definition of frailty as a term used in health and social care to describe people who have a decline in their ability to cope with life challenges such as a fall or a chest infection. Frailty means that a person is vulnerable and this can have significant impact on their quality of life. It can impact on the burden of care required from their support network such as a person’s family or professional networks of support.
Proving the case for a link between frailty and unplanned admissions is a key element of Intelesant’s work. Anecdotally however, geriatricians tell us that knowing about a patient’s daily activities and social and emotional factors is just as important to them when assessing risk as knowing their long term conditions. A 2013 consensus study states that “The European Union has placed specific importance on defining frailty, as frail persons are high users of community resources, hospitalization, and nursing homes. It is assumed that early intervention with frail persons will improve quality of life and reduce costs of care.”
Mobility is a key element of daily activities and in a small study (n=131) of a series of acutely admitted patients found that 33% were identified as avoidable or somewhat avoidable. The study found that admissions due to poor mobility / falls or confusion were more likely to be avoidable or somewhat avoidable. Our experience tells us that the GP record is unlikely to have an up to date measurement of mobility, let alone daily activities and social and emotional factors.
Community frailty checks
In 2013 Intelesant started building its Howz platform, initially for Trafford CCG where Intelesant has enabled care homes to record and share Advance Plans with GP’s and the Electronic Palliative Care Information Co-ordination System (EPaCCS). The platform was then extended to provide a way in which patients, families, care providers, social services and the NHS to share non-clinical information securely over the N3 network. A central idea was that anyone in contact with an elderly person could, with the right tools, provide a series of valuable observations that could provide more up to date intelligence on a patient’s health than by simply relying on the GP record.
To provide appropriate context to the observational data Intelesant needed an index of frailty. After extensive research and discussion with clinicians at University Hospital South Manchester (UHSM) Intelesant selected the Groningen Frailty Indicator[i] (GFI) as its main stratification tool in the platform. The reasons for this is that the GFI has a self-assessed version, it covers health, daily living and social and emotional domains and allows for grades of frailty to be identified.
We originally conceived of the Community Frailty Checks as an application of crowd-sourcing, the main benefit of which would be the ability for the NHS and social services to acquire intelligence at low cost, more regularly than relying on clinical contacts and at very low risk.
However our work to date has shown that there are several other benefits. We have found that the conversation that occurs when carrying out the Check allows patients to recognise problems that they would not have admitted to. We have uncovered some issues that can be remedied very readily (for example deafness due to ear wax) and via self-referral that do not require a GP intervention and can avoid much more serious problems later on.
[i] Measurement properties of the Groningen Frailty Indicator in home-d… – PubMed – NCBI . 2014. Measurement properties of the Groningen Frailty Indicator in home-d… – PubMed – NCBI . [ONLINE] Available at:https://www.ncbi.nlm.nih.gov/pubmed/22579590. [Accessed 18 November 2014].