older adults and complex care management Flashcards
what is multimorbidity
► Defined as the presence of two or more chronic conditions.
► Can lead to significant challenges in management
► Deterioration in one condition can negatively impact other conditions
► Patients on multiple medications can lead to issues with side-effects and drug interactions
what is frailty
► Characterised by a decline in physical, cognitive and mental resilience, as a
result of multiple health conditions.
► Frailty is progressive and can lead to loss of independence and poor outcomes
from relatively minor stressors, such as a viral infection or minor injury.
► Can be quantified by assessing a number of variables: symptoms, diseases,
blood results, functional limitations, to produce a “Frailty Index Score”
► The estimation of a patient’s frailty as being mild, moderate or severe, based on
this score, can be a useful tool in planning services to aim to reduce negative
outcomes.
how should frail patients be managed?
Multicomponent physical training and multidimensional interventions (physical training, nutrition, vitamin D supplementation and cognitive training) are effective measures to reduce frailty
what is polypharmacy
Polypharmacy is often defined as the use of four or more regular medications
► There are significant risks of this in the elderly population
► Polypharmacy can result from inappropriate issues of medications that are not
needed or attempts to treat multiple conditions at the same time
► Polypharmacy can contribute to frailty
► GPs can support patients by being mindful and proactive when prescribing and
de-prescribing
An example of effective care planning:
Planning All Care Together(PACT)
Identify most clinically complex and vulnerable patients on the practice list
► Pro-active case management involving extended consultations with the GP of their choice to deal with their health concerns and co-ordinate care.
► Management of unplanned admissions
► Holistic review of patients who have had cancer
► Medication optimisation and monitoring
► Carer reviews
► Funding is provided to ensure GPs are able to do this to their best capability
The Role of the Multidisciplinary Team
MDT
► Complex patients need complex care
► Professionals from different healthcare disciplines (e.g GPs, community nurses,
physiotherapists and pharmacists) and different services (e.g. social care and
voluntary sector) working together to support patients.
► A co-ordinated approach can be better achieved by sharing understandings and
skills to plan care that is tailored to the patient.
Community Ward Model
► Support for housebound patients with complex needs to help avoid admission
to hospital through the provision of increased support at home.
► Team comprises of community nurses, a GP, pharmacist, social worker and a
community matron that.
► Community wards can work closely with organisations such as Age Concern,
as well as social care to provide holistic care to vulnerable patients.
Social Prescribing
► In order to best manage health problems, GPs need to play a part in addressing
social care needs.
► Social prescribing refers to non-medical referral to social support services,
community groups and charities that can further enhance their well-being.
► Commonly identified services include Citizen’s Advice Bureau, Age UK,
Alzheimer’s Society and Active Lifestyles groups
what helps reducing frailty?
GPs working within multi-disciplinary teams to develop individualised care plans
can help to reduce frailty and prevent unplanned admissions to hospital
