Frailty is now recognised as a long-term condition (Skills for Health, 2018). It is widely known that people with frailty are frequent users of acute services, but it has also been documented that this group comprises vulnerable individuals, and unnecessary hospital admissions put them at risk of harm (NHS England, 2017). The National Institute of Healthcare Research (NIHR) (2017) found that 12% of people aged over 70 years experience functional decline following a hospital stay, and long waits in emergency departments are stressful for those living with frailty, as well as increasing mortality (Theou et al, 2018). Further, multiple ward moves put frail people at risk of developing delirium (Health Improvement Scotland, 2019). As a previous hospital discharge team nurse, I witnessed some of these effects first hand, and this experience gave me a passion for the Home First agenda (Newton Europe, 2017). I am now determined to avoid unnecessary admissions for my patient group.
As a practice care coordinator (PCC), I am employed by a GP practice, and I case manage the severely frail and those living with dementia. The fundamental role of the PCC is to avoid unnecessary hospital admissions and support the person to live as independently as possible. This is done by detailed assessment, regular proactive reviews in order to identify potential problems early and swift intervention in times of crisis. Patients in the entire caseload are monitored for falls, undergo annual blood tests and regularly have their observations taken (e.g. blood pressure, pulse and oxygen saturation). Everyone is offered a yearly medication review and the option of advance care planning (ACP)-to provide a thorough understanding of people's wishes in terms of medical management amd long-term care as well as resuscitation status. Having all of the above documented and readily available to the wider NHS system is invaluable when it comes to making a decision on whether an admission is appropriate or not.
My caseload is constantly evolving, with people being highlighted by the whole practice team; non-clinical staff seem to identify issues almost as often as the clinicians do. The community nursing team also highlights concerns to me. Often, new patients are in crisis, while others are in a steady functional or cognitive decline. Regardless of the presentation, I always complete a holistic assessment in the patient's own home, following the principles of Comprehensive Geriatric Assessment (Blundell and Gordon, 2015). I then formulate a problem list, create priorities and identify areas of risk. The main focus of this assessment is to get to know the person and their support network and to develop an understanding of what is important to them and how willing or able the support network is to step up in a crisis. I find that being able to see people in their own home helps to give a greater picture of their coping strategies.
I have excellent support from my surgery team, with frequent case discussions and guidance from the GPs and practice manager. I also have support from the neighbourhood team. The neighbourhood team offers a multidisciplinary approach to the coordination and escalation of issues, and it has links with local health and social care teams, as well as social prescribing and voluntary services.
I find that being able to assess and analyse all aspects of a person's daily activities, taking into consideration their psychological, social and environmental needs, is like putting together a jigsaw puzzle that is different for each person. Having the opportunity to work proactively and maintain the person at their optimum is a real privilege and ultimately saves time for the practice in the longer term. Although this may be considered to be time consuming and costly, the alternative would be increased unnecessary admissions, which would cost considerably more and potentially risking harm to the patient.