Frailty projects evidence positive outcomes for residents in 2024

The BBP frailty programme brings together health and care partners, colleagues, and stakeholders to address barriers and deliver improved integrated services that work together to support outcomes for residents.

Key projects delivered during 2024, include: 

Intermediate Care nurse solutions

This two-year pilot provides two Rehabilitation Nurses/IC nurses to support CRS team with case management, take on their own cases where required, offer guidance, and provide support including medication advice and management.

The nurses have been able to support patients with long term conditions in particular self-management, pressure sore management and wound assessment.

The pilot has evidenced:

• Improved staff confidence in supporting patients around e.g. skin integrity.
• Continued reduction in the number of readmissions during active CRS episode of care
• Reduction in onward avoidable referrals to other community services e.g. district nursing.

Let’s Go Outside and Learn (LGOAL) Pilot

This two-year pilot supports residents in receipt of the Community Recovery Service (CRS) has evidenced:

• Increased patients confidence to go outdoors, and go for a walk
• An improved sense of wellbeing and reduced fear of falls
• CRS staff are confident in the discharge process, as patients are better supported in the community
• A reduction in the average number of therapy contacts.

The pilot provides initial telephone befriending calls to build trust before 1-2-1 walks can commence, where a LGOAL team member meets the resident at their front door and joins them for a local walk in their area to help re-build their confidence to leave their home and go outside and carry out activities of daily living. The team also provide group walks where residents can connect with others and continue to stay active/mobile.

In July 2024 this pilot was extended to also support patients who received care from the Falls Prevention and Bone Health Service, Enhanced Dementia Care Service, and Integrated Community Response Service.

There has been outstanding positive feedback from patients who are noting positive changes in their confidence and mobility.

Acute Frailty Service

This new multidisciplinary specialist service provides high quality rapid Comprehensive Geriatric Assessments to frail older adults presenting to the emergency care areas in West Middlesex Hospital, it aims to avoid unnecessary hospital admissions and improve quality of life for the patient.

By the service working collaboratively with acute and community teams it has delivered:

• a reduction in non-elective admissions
• a reduction in non-elective length of stay for those who are seen by the front door and subsequently admitted.
• a 15% increase in patients seen within 4 hours in the emergency department.

The team consists of mixture of nurses and therapists who take referrals for patients who are 65 years and have a minimum clinical frailty score >=5. Common referrals to this service include patients who have had a fall with no significant injury, worsening of cognitive impairment with no know diagnosis, reduced mobility, dizziness, postural hypotension. – (data is for the patient cohort seen by the front door frailty team).

The BBP is looking forward to further collaborative working in 2025.