Remote MDT best practice for community working for individuals living with frailty (project in progress)
It is estimated that 12% of people aged 65 or over are living with moderate frailty. Key aims for this group are to provide integrated multidisciplinary teams (MDT) to support people in rehabilitation and reablement and prevent further progression of their frailty.
The NHS Long Term Plan 2019 outlines several important priorities and changes to the way the NHS should work to support individuals living with frailty. It also has a bearing on their carers to support them to age well and stay independent at home. People are now living far longer, but extra years of life are not always spent in good health. They are more likely to live with multiple long-term conditions, or live into old age with frailty or dementia, so that on average older men now spend 2.4 years and women spend three years with ‘substantial’ care needs, The Plan recognises that services are not consistently joined-up or responsive to their needs and describes the need to identify and provide proactive support and enhance rapid community response in times of crisis.
The Wessex Community Frailty Audit was run across 22 PCNs Autumn 2019 with an overall aim of:
• Providing a comprehensive picture of frailty provision at PCN level
• Supporting the PCN network in providing a baseline for improvement in frailty services
• Identifying areas for opportunity in supporting the delivery of national priorities of changing how the NHS works
• Supporting patients and their carers and improving care for older people with frailty.
Questions 21-25 posed in the audit identified the frequency of the MDTs, key stakeholders and whether information was shared with the wider system
The audit recommended the following areas for consideration:
• Ensuring virtual working and technology is enhanced to deliver exemplar MDTs
• Sharing of MDT information with other health and social care organisations
• Ensuring that both the patient, their family/carers are included in MDT discussions
• Standardisation of who attends MDT sessions, including identifying key representatives from health, social care, and voluntary care.
On the 13th February 2020, over 40 colleagues attended a workshop to review the findings, including NHS Benchmarking, frailty clinicians and senior executives from participant organisations and system leaders.
There was system wide appetite for frameworks for delivering MDT meetings to ensure the frailty aspects of the NHS Long Term plan are delivered.
In March 2020, the Community Frailty working group agreed the development of Remote MDT best practice for community working for individuals living with frailty as a resultant service improvement project from the audit. Due to the onset of Covid-19, the project was hibernated and was relaunched in September 2020. The project will complement the work that has been expedited across the health care system in response to Covid-19 to provide virtual care.
Medicines Optimisation
Wessex Academic Health Science Network (WAHSN) is the national lead for the AHSNs’ Medicines Optimisation (MO) Programme and works collaboratively with the other 14 AHSNs to develop, share and spread good practice. The overarching aim of the MO programme is to help patients get the maximum benefit from their medicines. Please take a look at their resources:
