Mid and South Essex integrated care system set out to create a comprehensive system-wide data tool to improve the identification and quality of care for people with frailty, dementia or at the end of life. Implementation has resulted in reduced hospital admissions and occupied bed days with the potential for £79.1m total system benefit by the end of 2028. Dr Sarah Zaidi explains more.
The Mid & South Essex (MSE) integrated care system (ICS) has the combined challenges of an older population plus higher deprivation levels that drive the earlier onset of long-term conditions. About 110,000 of the 1.29 million in our population were estimated to be living with frailty, dementia or a life-limiting terminal stage condition(s) and likely to be nearing the end of life.
However, data revealed that 80% of our expected population with frailty was mostly unrecognised, and 65% of our expected end-of-life (EOL) population prevalence was not identified. There was also an unwarranted variation in dementia diagnosis performance rate across our four place-based alliances in the system.
Analysis of the highest frequency users of primary care and other urgent care parts of the system, such as emergency acute hospital care, from all adults aged over the age of 40 revealed that more than 80% of this cohort had frailty/dementia or were adults nearing EOL. Our population data also identified that this group has, on average, 15 per capita patient contacts with primary care – almost five times higher than the rest of the population – 55 per capita contacts with other community teams plus nearly 3X per capita higher demand on acute hospital care, than the rest of the population. This is driven mainly by the multi-complexity of patients’ needs and often their circumstances changing, which means they move across different teams, care settings and even geographies more frequently.
It was clear that the only feasible way to tackle this problem was for providers to join forces. Silo working would be replaced by shared care delivery across teams and providers in the four Place geographies and 27 PCN neighbourhood localities. It was deemed crucial to unite partners with the right tools and mechanisms to facilitate more efficient collaboration, improve continuity of care and capture more meaningful performance data.
To achieve this, we created a system-wide data tool – FrEDA, which stands for Frailty, End of life, Dementia Assessment. FrEDA is an all-provider frailty assessment, care coordination and data capture tool that delivers seven evidence-based best practice actions to improve outcomes for this population group (see box). It is also structured on the domains of the comprehensive geriatric assessment framework to ensure holistic assessments of a person’s needs are conducted.
The initiative has provided a firm foundation for new ways of working, which are now being recommended nationally, such as the Integrated Neighbourhood Team (INT).
Aims
The key aim of this project was to achieve a paradigm shift away from reactive care towards higher quality personalised, proactive and preventative care across different providers.
We wanted a better capability to track and follow the person’s journey as their needs or circumstances changed, even across different teams/providers and care settings. This would help to reduce avoidable repeated same-day urgent episodic reactive care demands on all teams.
To assess our efforts, we needed to measure the impact at patient, population and system levels – and make that data performance visible to all teams across the system so they could more accurately identify and inform their priorities.
We created an expert collaborative – our ICB ageing well stewardship group, comprising frailty consultants, primary care leads, community teams, palliative care clinicians, and dementia leads. In 2021, during the blueprint design stage, we also engaged with 800 patients and carers to get their views.
Collectively, FrEDA was designed and sits in the electronic patient record system and can be used by all NHS providers and services in our whole ICS – primary care, community health, mental health, hospices and even potential for utility by our acute trusts.
Method
Simultaneously, we developed an ICS-wide frailty register data platform – electronic Frailty Care Coordination System (e-FraCCS). All patients identified with frailty or dementia in our population can be uploaded to this platform so they remain known, their changing needs prioritised and their data shared between all teams. That means no matter which team may see the patient, their care inputs are captured, giving us an all-provider population-level view of our performance.
The project cost £65,000 to launch, which was chiefly needed to run the ICS-wide register e-FraCCS. Funding was secured in January 2022 following a successful ICS project bid to NHS England Personalised Institute.
In April 2022, we launched both the FrEDA tool and e-FraCCS to all our providers in our whole ICS, including all 147 GP practices in our 27 PCNs.
Implementation was supported by ICS-wide training. And to support the whole urgent and emergency care system, we created a seven-day-a-week hotline where frailty medics can provide urgent advice to frontline staff, including GP practices/PCN staff, 999 paramedics, community provider staff and virtual ward teams.
Community health provider teams, frailty virtual wards and older people’s mental health and dementia teams have been the most enthusiastic early adopters of FrEDA. They make up about 70% of Freda users so far, with 25% coming from PCNs and the remaining 5% from other providers in our hospices and acute trust.
Outcomes
In the two years since FrEDA was launched, we have seen promising signs of significant impact across the four Place geographies and our 27 PCN neighbourhood localities.
Our system-wide data tool has identified and assessed nearly 16,000 new people with frailty, dementia or EOL needs who had previously been unknown as belonging to this group.
At PCN level, the highest FrEDA adopters have seen a 70% reduction in their patients suffering 30-day hospital readmissions, reduced from 21% to 6%. There is early evidence of some reduction – nearly 15% – in demand for same-day unplanned reactive urgent PCN home visiting.
On analysing five PCN populations across MSE, covering a population of about 250,000, we found that the highest impact actions from FrEDA were:
- Advance care planning, which reduced emergency hospital admissions by 46% and occupied hospital bed days by 35%
- Falls risk assessment, which reduced hospital admissions by 40% and occupied bed days by 35%
- Higher quality poly-pharmacy structured medication reviews, which reduced hospital admissions by 28% and occupied bed days by 25%
The frailty medic hotline has also been effective for urgent & emergency care demand – 82% of the calls they receive avoid conveyance to hospital. This has saved 10,000 occupied acute hospital bed days a year, which would cost an estimated £4.5 million.
Future
The data from our e-FraCCS frailty register is now feeding into an ICS-wide population health management ageing well performance dashboard. This is accessible to all our place-based alliances, community providers, acute trust, PCN networks and local authority footprint. Primary care can view their own performance data down to GP practice level and can identify patients for proactive care inputs via our population health management segmentation data tool.
Based on the evidence of the impact of our system-wide data tool, we have modelled the effect of wider adoption. A very conservative aim to deliver FrEDA proactive care to just 10 more patients per 50,000 population per week has the potential for £79.1m total system benefit by the end of 2028.
For this, we will need ongoing administrator costs of £50,000 per year. This is to manage both FrEDA template version control and the running of the electronic frailty register for all providers, as well as making any improvements, if needs be, based on frontline user feedback. We are currently seeking ongoing funding from our ICB and community provider collaborative.
FrEDA and eFraCCS data
FrEDA and eFraCCS capture and deliver the following best practice metrics from all frontline teams:
- Frailty scoring using clinical frailty scale and dementia/delirium cognition screening
- Comprehensive geriatric assessment delivery
- Polypharmacy medication reviews and frailty-focused structured medication reviews to reduce avoidable harm from multiple medicines.
- Falls risk assessment and falls prevention measures
- Delivery of personalised care and support planning. This includes the identification of unpaid informal carers and assessment of their needs, if necessary.
- Identifying adults of all ages with any life-limiting advanced stage conditions, including severe levels of frailty/dementia, who may be more likely to be nearing end of life.
- Delivering timely and early advance care planning for those with palliative and end-of-life care needs so that care from all teams is better focused on what matters most to the patient.
Dr Sarah Zaidi is Mid and South Essex ICB ageing well steward, NHS England east regional clinical lead for frailty and Home First GP and alliance clinical director South East Essex.
A version of this story was first published by our sister publication Pulse PCN.
