Plan of care for Frail Elderly patients

We will be identifying patients who are considered Frail Elderly (patients over the age of 75 and who have medical problems relating to the ageing process, for example reduced mobility and/or incontinence) when they arrive at the hospital. They will receive a comprehensive assessment which allows us to develop a more tailored, holistic, care plan along with a predicted date of discharge. Therefore, the patient spends less time in hospital and in doing this will improve the patient’s overall experience and outcome. 

The diagnosis of Frail Elderly will be stored on an in-house developed information system, facilitated by a frail elderly co-ordinator, which will be used to shape and guide the care of the patient within the hospital and out in the community going forward. We will be looking to our primary care partners for their support and co-operation as we work towards this common goal. 

This care plan will improve the patient's experience by providing a more holistic treatment plan by treating not only the condition they came to hospital with but the person as a whole, inclusive of all ailments making up their Frail Elderly diagnosis. 

This in turn means they will be in hospital for less time and so less likely to suffer complications from hospital treatments e.g. bed sores from being in bed and side effects from drugs. As the longer patients stay in hospital, the weaker they get and the poorer their outcome. 

The outcome from the CQC inspection last August highlighted that we should look to improve how we care for our elderly patients (over 75 years old).  As we have a high number of elderly people living in the area we need to take a different approach to the in-patient management of those considered ‘frail elderly’. 

We need to reduce the amount of time spent in hospital to achieve the best possible outcome for the patient. This new strategy with support from our primary care partners out in the community will help us to achieve this.

The plan is built around bringing teams together to work towards a common goal; in turn avoiding unwarranted interventions. We will engage with the below staff groups/providers to make sure patient discharge is as efficient as it can be and therefore reducing in hospital length of stay.

• Physiotherapists
• Occupational Therapists
• Social Services
• Out-of-Hospital Teams
• Community Carers

Training will be given to those who will be completing the clinical assessments and those providing care during their stay; as well as general staff awareness. This will be provided by the following methods: 

• In-house Training provided by relevant Clinical staff
• Drop-in Sessions
• Frail elderly communications strategy, including e-Poster, webpage and general staff communication.

We will be reviewing whether the plan is delivering the expected outcomes (i.e. reduced in-patient stay time) and identifying any improvements against a robust governance structure.

We will re-visit the plans and make reasonable adjustments should the expected outcomes not be achieved. 

Yes, we always welcome feedback so we can continue to improve patient care.

If you have any comments you wish to share with us, please feel free to contact:

• Alistair Green (Clinical Lead) - Alistair.Green@jpaget.nhs.uk

•  Philip Weihser (Project Lead) - Philip.Weihser@jpaget.nhs.uk