Community Geriatrics

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Community Geriatrics

• Prof John Gladman
• University of Nottingham
• Nottingham University Hospitals NHS Trust

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Summary

• The case (for outsiders)
• The practice (for insiders)

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The case to answer

• Why do we need community geriatricians?
• We already have GPs who look after old people
• And Matrons
• And intermediate care
• And Consultants are expensive
• And geriatricians are general physicians
• And hospital based
• And should be shortening length of stay /
  attending to trim points
• And not avoiding admissions / income
• And there are no large RCTs and meta-analyses of
  community geriatricians with cost benefit
  analyses

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What community geriatric medicine is not

• Trying to replace core geriatric hospital care
• Trying to provide inefficient and ineffective
  out-patient services
• Perpetuating all that is bad about the
  traditional domiciliary visit
• Becoming a GP

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From the basics let us accept

• 16 of the population are old
• 2/3 of beds are filled by the old
• 39 of health care spending is on the old
• 49 of social care expenditure is on the old
• gt the old are core NHS business
• gt GPs, hospital doctors and everyone should be
  able to deal with issues about the old
• Treatment benefits are often larger
• Activity limitations (disabilities) are often
  present
• But treatment principles are largely the same as
  adults of lesser years
• gt it is impossible as well as groundless for all
  old people to be managed by geriatricians

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Lets get this old thing right
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Old people

• NSF describes three types of older person-
  healthy retirees, in 60s- those in transition,
  in 70s- the frail, in 80s
• Community geriatrics (all geriatrics) is for the
  latter

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About frailty

• Vulnerability disability (activity limitation
  and participation restriction)
• Physiology of old age
• Multiple chronic diseases (aka long term
  conditions)
• Proximity to death
• Particularly heavy service users
• Particularly represented in complaints

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Long term conditions Kaiser / NHS model
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Top of the pyramid BGS model
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CORE PROCESSES FOR HEALTH CARE OF OLDER PEOPLE
Acute care
Chronic disease management
Frailty management
Comprehensive assessment review
Rehabilitation enablement
End of lifecare
Populationmanagement
Robust teamworking for with older person
Evidence evaluation
Teaching research
Societal values
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Frailty management

• Comprehensive assessment- medical psychiatric
  conditions- psychological state- impairments-
  activity limitations (disability)- participation
  restriction (handicap)- physical and social
  environmental facilitators and hindrances-
  personal factors
• Co-ordinated delivery of multiple interventions
• Specialist, inter-disciplinary
• It needs medical specialists
• Holistic

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Evidence base

• Stroke units save lives, reduce
  institutionalisation, reduce dependency cost
  saving
• Comprehensive Geriatric Assessment does the same
• SO THERE IS AN EVIDENCE BASEneedy people
  benefit from specialist co-ordinated
  comprehensive care and it is affordable. This
  means specialist medical input too.
• FAILURE TO PROVIDE THE ABOVE IS TO DENY (these)
  OLDER PEOPLE EVIDENCE BASED CARE

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So we know what we have to do for frail older
people, but where are they to be found?
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Where frail older people are found

• AMU
• Acute hospitals (stroke, hip fracture)
• Community hospitals
• Day hospitals
• Matron caseloads
• Care homes
• Intermediate care (temporary frail)
• Cant come / wont come / shouldnt come(the
  looked after elderly)

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Community Matrons

• Principles there is a cohort of frail people,
  care and its co-ordination by a matron can
  prevent admissions
• The first evaluation of the Evercare model showed
  they didnt prevent hospital admissions radical
  system re-design requiredBMJ,
  doi10.1136/bmj.39020.413310.55 (published 15
  November 2006)
• Targeting (a problem for frailty management too)
• Intervention delivery of CGA, which requires a
  geriatrician (and many other necessary
  conditions, such as rapid access to social care)
• Examples horrendous fluid balance, polypharmacy
  / polysymptomology, neuropsychiatry, PD

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Care homes

• 5 of all people gt65
• Immobility, confusion, incontinence
• RCTs medication review, end of life planning
• Long term conditions not well managed
• Primary care haphazard
• Anecdotes leg ulcers that wont heal, faecal
  incontinence
• See BGS Primary Continuing Care SIG session,
  Harrogate, November!

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Intermediate care

• Admission avoidance / Early discharge / At home /
  Residential
• Some of this can be cost effective and virtually
  geriatrician freeAge Ageing 200433246. Sooner
  and healthier
• Capacity (our trial took lt3 of older people)
• Closure of Bramwell
• Clearing of Leawood- Parkinsons- advice,
  information, prognosis
• Step-ups- from the at home service (CCF and
  PD)- from the residential service (CCF,
  delirium, brain tumours)

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Cant come / wont come / shouldnt come to
clinic (DVs)

• Cant come too disabled (arthropathy, PD)
• Wont come too frightened, themselves a carer
• Shouldnt come disorientation worsens history,
  informants cant come, others are part of the
  problem or solution (esp care homes)
• Reflection patient centred care!
• The case of the ?pheo

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Things a community geriatric service could support

• Care home services- matrons- out reach iv
  teams- assessment panels- medication reviews-
  end of life planning- CDM programme eg
  glidepaths
• CGA from the ED or AMU- DV urgent clinics-
  virtual caseload- access to Matrons- access to
  Intermediate Care
• CG access from- primary care / community falls
  teams- rapid response social services teams-
  old age psychiatry services (health and social)
• System wide education
• System wide governance / audit

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Ideas that havent worked / are mis-understandings

• Provision of emergency opinions
• Pre-admission assessment for emergencies
• Clinics in GP surgeries
• Substantial community prescribing
• Replacing primary care instead of supporting it

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Clinical matters geriatric medicine!

• Death in non-malignant conditions
• End stage CCF (end stage anything!)
• Parkinsons and related disorders
• Anxiety, depression and dementia in physical
  illness
• Non-specific presentations with complex
  formulations
• Prognosis (goal setting care planning)

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Community CGA
INTERMEDIATE CARE
COMMUNITY MATRON
CARE HOME SECTOR
PRACTICE BASED COMMISIONING
RAPID RESPONSE NURSING, SOCIAL SERVICES
COMMUNITY GERIATRICIAN
FALLS TEAMS
LONG TERM CONDITIONS
BED CRISES
COMMUNITY HOSPITAL
DAY HOSPITAL
GERIATRIC OPD
FRONT DOOR GER MED
DGH
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BGS RCGP model for frailty management

• Practices / clusters should identify their frail
  older people
• And have a designated team for them
• And a regular review of this case load
• Referring to the community geriatrician when in
  need
• Larger teams should be responsible community
  hospitals, intermediate care, care home support
  services members drawn from local teams and
  community geriatrician
• http//www.bgs.org.uk/Publications/Compendium/comp
  end_4-14.htm

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My prediction for clinical duties of geriatric
departments

• 1/3 acute care not undifferentiated general
  medicine but specialist support to CGA in front
  door settings (ED, AMU)
• 1/3 ward based care (e.g. orthogeriatrics)
• 1/3 community care (community day hospitals,
  intermediate care, care home, matrons, etc)
• New arrangements with PCTs not solely primary,
  secondary or intermediate care but all three
• Leading other hospital based specialties in
  this matter
• Even more managerial roles

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Summary messages

• The care of frail older people requires CGA this
  is evidence based practice
• There are frail people in community settings
• A community geriatrician is one necessary
  condition for the delivery of community CGA
• My workload supports matrons, intermediate care,
  care homes, the cant, wont shouldnt come
• I provide expert opinion, offers secondary care
  where needed also education, governance, etc
• Develop with primary care