Joining Up Care For Older People With Frailty

joiningAcross the UK, innovative collaborations between GPs and specialist geriatricians are paving the way to better care for older people with frailty

A new joint report from the Royal College of GPs and the British Geriatrics Society was published on 24 November, showcasing how GPs and geriatricians are collaborating to design and lead innovative schemes to improve the provision of integrated care for older people with frailty.

Advancements in medicine are a great success story, and as a result our patients are living longer, but they are also increasingly living with multiple, long term conditions and that brings a number of challenges for general practice and the wider NHS.

Older patients make up the majority of those attending GP surgeries and acute hospitals so getting the right combinations of care in the right place and at the right time is crucial to avert avoidable admissions and delayed discharge from hospital.

Integrated care for older people with frailty: innovative approaches in practice is being launched today at the British Geriatrics Society’s national scientific meeting where over 700 geriatricians, and other healthcare professionals engaged in the specialist care of older people are gathering to share best practice and the latest scientific research.

The report highlights 13 case studies from across the UK, ranging from schemes to help older people remain active and independent, to those providing better services in the community, to those supporting patients in hospital. Examples include:

  • Southampton: multi-professional teams, led by community geriatricians and GPs, conduct ‘Comprehensive Geriatric Assessments’ and person-centred care plans. These often tap into local resources, for instance, healthy walks based around GP surgeries which have been set up in conjunction with Age Concern.
  • Lothian: Care planning in three questions; St Triduana’s Medical Practice has developed a simple, one page form for relatives of new care home residents. The questionnaire uses three questions to facilitate a discussion with families about how a patient would like to be treated in the event of a serious illness.
  • Nottingham: GPs in hospitals in Rushcliffe support the ward-based community team by offering sessions on the local Health Care of Older People wards.  Re-admissions of patients aged over 65 have been reduced by 8.7% since the initiative began last year, whereas by contrast there has been an increase in re-admissions in neighbouring areas.

RCGP immediate past Chair Professor Maureen Baker said:

“Ageing and frailty are game changers for the health and social care services. GPs, in collaboration with geriatricians and other colleagues, are at the forefront of the response to these significant new challenges.

“This report outlines a number of exciting examples where College members have taken the initiative and put positive talk around integration of care into practice in order to improve patient care, their experience of the health services and health outcomes. The case studies demonstrate the value of the generalist approach that is shared by both GPs and geriatricians in delivering person-centred care. It is vital we learn from these examples of best practice and adapt our ways of working to reflect the changing needs of our patients.

“There is an opportunity with Sustainability and Transformation Plans to recognise the need to change the landscape of the NHS, to invest more in general practice and geriatric medicine, and to support GPs and geriatricians to roll out similar schemes more widely – we need to take that opportunity, in the best interests of our patients and the wider NHS”.

President of the British Geriatrics Society, Professor David Oliver said:

“Older people with frailty and complex co-morbidities are proportionately the biggest users of health and social care services. They are also the most likely to use multiple services and risk disjointed care and support. General Practitioners and Geriatricians are expert generalists, respectively able to help co-ordinate care base on the needs of individual older people and their carers in their own homes or community healthcare settings and to oversee their care when presenting with or recovering from acute illness or injury in hospital settings and beyond.

With a greater drive to more integrated care models, it is crucial that GPs and Geriatricians work closely together across organisational interfaces and in emerging new models of services for older people. Of course, we can’t do it alone and rely on other professional groups and multidisciplinary team. But this paper showcases a number of ways in which, despite current funding and workforce challenges, GPs and Geriatricians can collaborate closely to drive care improvements for older people”.












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