Search

1. Frailty is a common syndrome affecting 25% of the population aged 70+ in Australia, equating to approximately 26,000 people residing in Northern Sydney. People living with frailty have 2-3 times the healthcare utilisation and poorer outcomes in hospital compared to their non-frail counterparts.2. Sydney North Health Network is working collaboratively with Northern Sydney Local Health District, health professionals and consumers, to co-design and implement targeted interventions to identify and reduce frailty, avoid inappropriate hospital admissions and improve health outcomes for our elderly population. Phase one includes delivery of education and support to health professionals, to increase understanding and implementation of:• The concept of frailty• Appropriate screening using the FRAIL scale• Preventive and reablement management plans in primary care.This included consultation with clinicians and consumers to understand existing knowledge and screening practices, co-design of resources, including protocols to support handover of care and development of pathways to support appropriate referral and management.Phase two will identify service gaps in the community and develop a co-commissioning strategy to shape service delivery to meet local need.3. Implement recommendations from the Asia Pacific Clinical Practice Guidelines for the Management of Frailty.4. The target populations for phase one are health professionals from primary care, community and acute settings.5. Phase one, 2 years. Phase two, 3-years.6. Education and awareness events were implemented in both settings:- 82 LHD health professionals and 79 general practice and allied health professionals have participated to date. - 53 general practices have received intensive, in-practice training on use of FRAIL scale and resources available to help them navigate service and management options. A trial of screening has been implemented in 2 acute hospitals. Screening of 387 patients identified high prevalence of frailty and pre-frailty (82-93%)Screening results and management plans have been included in patient discharge summaries to improve handover to primary care.7. Primary care is most likely the more appropriate setting to continue screening on an ongoing basis and likely to yield more sustainable, long term results, particularly on hospital avoidance.8. This framework includes a multi-disciplinary team approach to care and encourages screening at any point during the patient journey, in any care setting.9. Screening for frailty and implementing management plans to improve patient outcomes is possible in both the inpatient and community setting.Further data is required in primary care to measure impact and outcomes.10 & 11. Hospital screening is feasible, but capacity for intervention is limited. With some patients receiving appropriate intervention in hospital, aiming to prevent deterioration, analysis in progress will confirm impact and gaps.A vendor has been engaged to develop a screening app that integrates with GP clinical software systems, to support data collection in primary care.Next steps include:- development and implementation of primary care data app- follow up with general practices, to gauge acceptance of interventions and tools provided- utilise data from screening and mapping of community services to inform development of commissioning strategy.

Introduction : Dementia is a complex and chronic disease and is currently the second leading cause of death in Australia, three in ten people over the age of 85 and almost one in ten people over 65 have dementia. In Northern Sydney, there is projected growth of 23% in the population of people aged 75 years and older between 2011 and 2021, indicating a substantial increase in the number of people with dementia in the region over the next 6 years. There are a wide range of services available in Northern Sydney for people with dementia and their carers; however access and information about support services has been problematic. Information is often fragmented and difficult to find for consumers and Health Care Professionals. A partnership between Northern Sydney Local Health District (NSLHD), Sydney North Health Network, CCNB Ltd and Alzheimer’s Australia NSW was established to improve the journeys of people with dementia in Northern Sydney. Method : People with dementia (3) and many more carers (20) told us their stories, with key themes from these journeys identified. Over 40 health professionals from across sectors were separately engaged in mapping a number of typical journeys as well as an ideal journey. Gaps and issues were identified and prioritised, with a range of solutions then identified and prioritised. A project plan was implemented by the partnership, including strategies to address identified gaps in information, service access, referral pathways and education. Major project outputs include clarification of referral pathways for General Practitioners, a “Memory Problems?” booklet outlining the range of services available for people with dementia and their carers, distribution of the same across health sectors, government and non-government services throughout the region, a dementia hospital discharge follow–up service commissioned by Sydney North Health Network (SNHN), and a number of education events targeting different groups across the region. Other initiatives in progress being led by SNHN are the development of national quality indicators for dementia care in general practice and a localised dementia pathway for health professionals. Results : A number of typical journeys for people with dementia and their carers have been mapped, highlighting the range of complex interactions experienced and many opportunities to enable better journeys. The impact of the resulting initiatives are being evaluated through a range of indicators including the timing of referrals to memory clinics in patient’s journeys, unplanned hospital admissions for people with dementia and provider satisfaction. Results are expected to be available by the time of the conference. The NSW Agency for Clinical Innovation is undertaking evaluation of the partnership and it's benefits as part of a statewide program for integrating care for older people with complex health needs. Conclusions : This partnership has resulted in implementation of a plan which will have a substantially greater impact than if one organisation had undertaken this work alone. The project outputs are practical, sustainable and are expected to improve the journeys of people with dementia and their carers in Northern Sydney.