The Atlas of Shared Learning

Case study

Introducing a ‘practice frailty nurse’ into the community setting

Leading change

The Lead Nurse for the Care Home Vanguard Programme at Newcastle Gateshead Clinical Commissioning Group (NGCCG) led on the commissioning and implementation of a new role and service for those living at home with frailty. This service has led to improved outcomes, experiences and use of resources across the region.

Where to look

In England, a fifth of hospital admissions in 2014–15 were among people aged 75 years and over, accounting for around 40% of all days spent in hospital (NHS Digital, 2017). For some older people, hospital admission is associated with an increased risk of harm over and above the presenting clinical condition (Hubbard et al, 2017). Furthermore, hospitalisation can be the initial event that heralds an intensive period of health and social care use, especially for ‘older people with frailty’, a distinctive late-life health state in which seemingly minor stressor events are associated with adverse health outcomes. Focusing on frailty is an exercise in risk stratification – identifying a cohort at especially high risk of adverse outcomes (NHS Improvement). Turner (2014) suggests the Comprehensive Geriatric Assessment (CGA) is the key assessment process for the management of frailty in older people. This process involves a holistic, multidimensional, interdisciplinary assessment of an individual and has been demonstrated to be associated with improved outcomes in a variety of settings.

The Lead Nurse identified that whilst Newcastle Gateshead CCG had a successful history of delivering enhanced health care to older people living in care homes, there were several older people living in their own homes who could benefit from a similar approach to having their needs anticipated and met. The unwarranted variation in services provided to people in their own homes highlighted an opportunity to lead change and add value locally to Newcastle & Gateshead residents.

What to change

Newcastle Gateshead CCG is passionate about the care of older people, especially those living with frailty and complex needs. The CCG has worked collaboratively with partners from across the health and care system, especially those in community and primary care teams, to enhance care delivery. Prior to the change, frailty assessment for those in their own homes was variable. True figures of the size of the challenge weren’t available and it wasn’t clear whether some older people living at home would have had their health and wellbeing compromised because of a lack of access or awareness of the support available in their home.

People living at home could have been experiencing limited access to preventative measures, leading to an increased reliance on unscheduled care, a reduction or loss of independence or function in terms of social and daily living activities, and could have suffered a health crisis resulting in them having to leave their own home, either long or short term.

The nursing leads within the CCG and local NHS provider recognised the need to systematically identify those living in their own homes who appeared to have complex needs, so that a person-centred comprehensive assessment could be undertaken to verify the needs and introduce a plan of care that would seek to address each in turn. It was anticipated that this would see both short and long-term case management improvements.

Development of an innovative nursing role and service that could improve the lives of patients, ensure adequate access, reduce health inequalities and improve care coordination locally, was agreed and commissioned. The Practice Frailty Nurse post was developed and introduced via a local NHS provider.

How to change

The collaborative relationship between the commissioner and the provider was key, supported by a clear contractual outline, key deliverables and frameworks. With this, the provider nursing lead began to develop the post and its associated remit in practice. The nurse leader used extensive frailty knowledge and expertise to see the commissioning vision of safely reducing unscheduled care needs through improving health and wellbeing. Working in partnership and collaborating with the local health and social care system, the nursing leads recruited to posts and agreed the service framework and specifications to meet expected targets.

A key objective of the service was to reduce the unwarranted variation between older people with the same complex needs living in care homes compared to those their own homes. Patients at a local primary care practice were identified using a risk identification digital software system and explored further with local General Practitioners (GPs) and Practice Nurses (PNs). The information gathered from these primary care teams was invaluable in ensuring the correct approach for the new frailty post as well as the direction of the service as these teams were frequently found to have been providing long term condition management to these patients. Using this information, a process of consultations and comprehensive assessments of individuals and their circumstances was undertaken using the CGA framework and case management of these individuals was rolled out.

Adding value

The primary purpose of this project was to reduce reliance on unscheduled care for those who were frail and living in their own homes through the provision of high quality assessments and care planning early in their care. Qualitative and quantitative evaluations have been undertaken as part of a routine audit of the new post and service provision.

Better outcomes – For those seen by the new Practice Frailty Nurse, their health and wellbeing has improved as indicated by the sustained reduction in unscheduled care use. Furthermore, there hasn’t been an increase in long term care home admissions. Comparing the unscheduled care use to the preceding year, case management by the practice frailty nurse has demonstrated:

  • 80% reduction in GP home visits;
  • 56% reduction in A&E attendance;
  • 54% reduction in hospital admissions.

These figures are all below the local averages which is a positive indication of success.

Better experience – The new role has been well received by staff and patients, their families and carers. Many patient and family stories have been collected and there is a sense of value in the involvement of the nurse in their lives. Feedback from patients and their families/carers has included:

Since she came into my life, I’ve been full of confidence, same problems, but I’m better somehow, my life is worth living again, I get pleasure from things I’d stopped getting pleasure from.

It was the first time I felt somebody cared about me as a carer.

In terms of the nurses involved, they have also fed back how valuable the role has been in terms of their own development. As well as having a positive impact on the lives of patients and their families, a positive impact can be seen across the care system as transfer of care points become less challenged and older people are living more independently for longer which reduces the need for health and social care services.

Better use of resources – Assessing vulnerable people to identify their needs and plan care for them is a strategic shift from a reactive model of care delivery to one that is more proactive and individually focussed. This maximises the opportunity for self-care and reduces the need for unplanned services meaning resources can be better used by those that need them in a timely fashion. The reduction in reliance on unscheduled care has been a beneficial product of this change.

Challenges and lessons learnt for implementation

Small scale, short-term pilots can bring extensive benefits and should be considered alongside large-scale changes.

Nursing older people is a rewarding and specialist area and must be supported so that the field can grow and rise to the challenges of the ageing population.

It is important to ensure you are using the evidence base, understand the needs of patients and keep them at the centre of all you do, and don’t lose sight of this in day to day details.

Due to the success of the initial pilot, the primary care team involved substantiated the practice frailty nurse post and a further three smaller practices have collaborated to introduce a further post to care for their older people living with complex needs and frailty.

Working collaboratively with the local commissioning support unit, the nursing leads are using data gathered from the service to begin consideration as to workforce needs locally.

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