By Dr Anne-Marie Spooner, GP Clinical Lead and Chair of Chesterfield Place Alliance.
Since 2017 Chesterfield Local Place Alliance members have been developing their vision of a holistic model of care for the housebound and frail, including care home residents. After accepting kind offers of support and with partners committing to using their workforce slightly differently to develop this model, an embryonic frailty team was established in early 2019 in one neighbourhood in Chesterfield.
The aim has been to make a difference for the residents of Chesterfield and aspire to seamless, efficient health and social care allowing avoidance of unnecessary hospital admissions and the best care being provided by the right person in the right place.
A recent case study is ‘Mavis’ who is 92-years-old and lives in a care home with several chronic medical conditions. On admission to the home, the frailty team clinician spent time agreeing a clear and detailed care plan with Mavis and her family. This comprehensive plan covered a range of potential scenarios and replaced her previous plan ‘for ward-based treatment only’. During a recent episode of deterioration, the frailty team was able to provide continuity with a clinician that knew Mavis well and was able to diagnose and manage her condition effectively. The clinician also liaised with the family and supported video contact with a portal device. The clinician was able to monitor Mavis at frequent intervals and the care home was able to seek rapid responsive advice from this clinician when Mavis sadly deteriorated further.
As the clinical decisions became more complicated, the clinician sought quick support and appropriate advice from the community frailty team GP who was also able to assist in more complex prescribing. In addition, the community GP liaised with the frailty Geriatrician of the day for some reassurance and advice. The teamwork provided a positive outcome for Mavis who recovered well and avoided an unwanted admission.
Similar cases pre-frailty team often involved multiple different practice clinicians, including out of hours who were not always clear on the care plan and who lacked the time to liaise effectively with the family and care home staff.
Often, patients like Mavis would end up being reluctantly admitted, at times not just once, and sadly this would frequently lead to some deterioration in their general condition and mobility as a result.
So, in summary, our multiagency frailty team in Chesterfield has proved that joining up and integrating care is possible and provides a positive difference for patients, families, care homes, clinicians and the health and social care system. We are therefore planning to expand our teams now to cover all the Chesterfield and Dronfield Primary Care Network (PCN) geography.