Graham Hughes

The systematic approach to improving care for Frail Older Patients (SAFE) study: A protocol for co-designing a frail older person’s pathway

Background: Frailty is the age-accelerated decline across multiple organ systems which leads to vulnerability to poor resolution of homeostasis after a stressor event. This loss of reserve means that a minor illness can result in a disproportionate loss of functional ability. Improving acute care for frail older patients is now a national priority and an important aspect of the National Programme for Older People in Ireland. Evidence suggests that an interdisciplinary approach incorporating rapid comprehensive geriatric assessment and early intervention by an interdisciplinary team can reduces susceptibility to hospitalisation related functional decline. The aim of the Systematic Approach to Improving Care for Frail Older Patients (SAFE) is to develop and explore the process of implementing a model of excellence in the delivery of patient-centred integrated care within the context of frail older people’s acute admissions. Methods: The SAFE study will employ a mixed methodology approach, including a rapid realist review of the current literature alongside a review of baseline data for older people attending the emergency department. Semi-structured interviews will be undertaken to document the current pathway. The intervention processes and outcomes will be jointly co-designed by a patient and public involvement (PPI) group together with the interdisciplinary healthcare professionals from hospital, community and rehabilitation settings. Successive rounds of Plan-Do-Study-Act cycles will then be undertaken to test and refine the pathway for full implementation. Discussion: This research project will result in a plan for implementing an integrated, patient-centred pathway for acute care of the frail older people which has been tested in the Irish setting. During the process of development, each element of the new pathway will be tested in turn to ensure that patient centred outcomes are being realised. This will ensure the resulting model of care is ready for implementation in the context of the Irish health service.

161Advance Care Plans - A Day Hospital Perspective

Background: Advance Care Plans (ACPs) aim to involve the patient in all aspects of their care, and are known to improve the quality of end of life care. They may be of particular benefit in addressing the needs of people with dementia. We aimed to examine the presence or absence of ACPs in a frail, older population. Methods: 40 randomly selected charts were retrospectively reviewed of patients who had been attending a day hospital for at least two years, with an established diagnosis of a neurodegenerative disorder. Results: Of the 40 patients reviewed, the most common diagnosis was Parkinson’s Disease with or without dementia (15/40) followed by mixed type dementia (7/40), vascular dementia (7/40), Alzheimer’s dementia (5/40), undifferentiated dementia (4/40) and frontotemporal dementia (2/40). The median age was 85 years (range 68–100), and 38/40 were residing in their own home, the remaining two patients were nursing home (NH) residents. The median duration of diagnosis was 4 years (range 1–32) and the median Clinical Frailty Scale (CFS) was 6 (range 4–8). 11/40 had a hospitalisation in the preceding year. 3/40 patients had a written advance care plan in their notes. A discussion had occurred in a further 2/40, but no formal outcomes had been documented. Neither of the two NH residents had an ACP, nor had any of those who had been hospitalised. Conclusions: The day hospital could be an ideal setting to involve patients and their families in discussing future wishes and care considerations in this particularly frail cohort. Consideration should be given to exploring the barriers to advance care plans, within both the medical profession and the general population. When reviewing these patients in the day hospital, there may scope to introduce specific care planning tools such as the Goals of Care Designation document.