The outbreak of the Covid-19 pandemic has transformed the NHS in the UK with increased intensive care unit and respiratory bed capacity in acute hospitals, reduced elective work and many outpatient consultations delivered remotely.

The threat from Covid-19 infection and national policies on social distancing meant risks posed to the NHS and the population were outweighed by the benefits of maintaining outpatient appointments. 

It has been shown that the pandemic initially reduced emergency department attendances to a third of total attendances in patients without coronavirus symptoms.1 A reduction in older people attending hospital was attributed to the policy of shielding because of their increased risks to Covid-19.2 These risks include physiological changes of ageing, decreased immune function and multimorbidity with increased likelihood to suffer from a severe form of Covid-19. In ages of seventy to eighty and above there is a greater chance of hospital admission or death from the virus.

Even fit and independent individuals considered at risk ,which lead to the ‘shielding of older people’. 4,5 Furthermore, patients attending ED were discharged home as soon as clinically able using discharge to assess (D2A) models of care.6 

Impact on frailty assessment units

The Frailty Assessment Unit (FAU) in Yeovil hospital (YDH) was one of the units closed to increase acute bed capacity. These factors led to a reduced FAU follow up of emergency department patients at YDH and a back log of referrals from primary care sources.  

Prior to Covid, patients referred to FAU were assessed using comprehensive geriatric assessment (CGA) alongside the clinical frailty scale (CFS) which is considered the gold standard for frailty management.7 This provides a holistic, interdisciplinary assessment across medical, physical, functional, social and psychological domains. This is carried out in partnership with the patient and their carers resulting in a personalised care and support plan and provides timely effective discharge planning. It is recognised that patients that do have CGA as part of their care have better outcomes, they are less likely to be readmitted, deteriorate or die and are more likely to remain in their own homes.8

As the healthcare system became appropriately consumed by acute care needs, a different approach of providing CGA to our pending caseload of frail patients was required. Remote consultation of outpatient appointments was identified as a way of keeping patients safe, removing their need to travel whilst offering patient’s access to community services from the comfort and safety of their own homes.9 

However, there was little evidence about how to conduct CGA remotely. We considered how to achieve remote assessment of some elements of CGA to the patients awaiting a face-to-face hospital based consultation. Video consultation was initially considered as it has been shown of benefit in assessing patient’s mobility in the absence of face-to-face consultations.10 Although this may have given insight to the physical, social and environmental domains of CGA, patients had limited access to video software and it was not established by the frailty team at the start of the pandemic. Telephone triage was adopted as this was readily utilised by patients, carers and the team.

Comprehensive, Remote Assessment and Frailty Triage (CRAFT) 

During the Covid-19 pandemic, advanced clinical practitioners (ACPs) working with older people have been involved in trialing remote consultation. This has provided lots of opportunities to use their skills and knowledge gained during ACP training including all four pillars: clinical, education, leadership and research.11

Conducting this sort of remote consultation required clinical expertise in frailty to recognise ‘red flags’ and provide safety netting. Accurate history taking and incorporating dimensions of CGA were essential skills undertaken by the frailty ACP overseen by the Consultant Geriatrician.

The calls provided Comprehensive, Remote Assessment and Frailty Triage (CRAFT) and was seen as a way to support primary care colleagues in managing some of their most complex patients, promote collaborative working relationships between primary and secondary care and to provide patient centred care utilising local resources in a timely fashion. At the same time it was important to be forward planning and facilitate ‘back to better’ services.

How was CRAFT conducted?

Telephone triage was conducted over the course of three weeks by two trainee ACPs supported by the Consultant Geriatrician and administration. Patients and their carers were contacted explaining that FAU remained closed and they were asked if they were following the ‘shielding’ advice. Covid-19 symptoms were excluded and their general medical condition was ascertained. Patients were discussed with primary care teams to support appropriate care planning, frailty-related interventions and urgent face-to-face appointments were provided as necessary.

Documentation was made in the medical notes and a letter to the referrer was generated notifying them of the triage and outcome. This format identified ‘crisis’ patients requiring urgent hospital assessment by the frailty team and these patients were offered face-to-face hospital CGA alongside ‘same day’ investigations and treatment as clinically indicated.

Other patients were referred to primary care services for ongoing management in the community, this reduced the number of patients requiring hospital frailty assessment. Further signposting could be implemented for those patients identified at risk of deconditioning and isolation including referral to exercise resources and community support programmes.

Results of the programme

Fifty two patients were contacted over three weeks, results are shown in Figure 1.

Frailty triage during Covid pandemic

 

 

Five patients (10%) were already receiving intervention, for example from palliative teams or were inpatients in hospital settings. Eleven patients (21%) required urgent assessment and were offered to attend the hospital on a basis of one patient a day under infection control. Six patients attended the hospital, full PPE was worn and a CGA was completed with appropriate scans and investigations booked in advance. These patients presented with conditions such as delirium, rapid deterioration of memory, falls with injury and pain, syncope, decompensated heart failure and new neurological symptoms. Two patients subsequently required admission.

The other four patients needed medical treatment, one patient being identified with a serious progressive neurological disorder. This particular patient welcomed a discussion regarding advanced care planning having not previously been offered an opportunity to make their wishes known.

Five patients declined to come into hospital due to fear and concern over Covid-19 risk. Unfortunately, one of these patients had a subsequent fall resulting in admission despite our referral to the rapid response team for extra support at home. Twelve patients (23%) required liaison with primary care, for example medication changes, involvement with the complex care team and other agencies. Six patients (11%) required urgent equipment and care needs and were referred to the rapid response/social service teams in community. One patient avoided admission by referral to the urgent dementia service and social worker.

Eighteen patients (34%) required no urgent intervention and were to await to come in for frailty assessment. Many of these patients commented that they were relying on neighbours and family for support needs and it was evident that they were ‘just coping.’ A common theme emerged as patients suggested that the need to stay at home left them feeling deconditioned physically, emotionally and mentally.

They often commented that ‘they had been forgotten’ and appeared vulnerable being unable to access their normal social groups or exercise. Vulnerability was also possibly due to a deterioration in health by not attending routine health care; or anxiety due to Covid-19 leading to not actively seeking this when needed and an increase in sedentary behaviour. These patients often presented with falls, new cognitive or movement disorders and change in functional status. They seemed most likely to deteriorate if not seen in a timely fashion and the risk of presenting more urgently in ED due to the time lapse between referral and assessment. They may have benefitted from ‘routine’ community rehabilitation services within the home, patients often asking if this was available.

Unfortunately, accessing community rehabilitation was challenging as this service had been diverted to D2A and rapid response functions. However, we were able to identify those patients that would benefit from virtual multidisciplinary team (MDT) liaison at a local level. Signposting to community resources, social prescribers and advice regarding physical activity with keeping safe at home during lockdown could be given as appropriate. Many resources had moved online to improve social networks and there were many local community volunteer groups that could be utilised.

Impact of frailty triage for patients

Developing CRAFT for patients on the FAU waiting list utilised the ACP role within the frailty service. Improved access to digital services and agreed, shared information governance arrangements across primary and secondary care facilitated gathering of up to date information, avoided duplication of data and provided continuity of case load management. CRAFT identified that many of the patients felt deconditioned and isolated.

The British Society of Rehabilitation Medicine12 has set out to establish pathways of rehabilitation for adults by bringing together critical care, acute medicine and specialist rehabilitation pathways in the wake of the Covid-19 pandemic.

NHS England,13 has also recognised the role of allied health professionals as key to ensuring population recovery from Covid-19. Rehabilitation strategies need to address both survivors of Covid-19, many of whom are older with pre–existing frailty and illness, and also those who have become deconditioned as a result of ‘shielding’, social isolation and healthcare system disruption. The British Geriatric Society (BGS) has stated that without continued surveillance of frail persons there will be increased hospitalisations from chronic exacerbations and falls. Rehabilitation to the many people in this position is required to reduce their health and care needs.14 

The Chartered Society of Physiotherapy (CSP) also recognises the reduced health and care service capacity to respond to and prevent falls. Subsequently, fall related injuries and increased inactivity amongst self- distancing and self- isolating older people is likely to result in an increased risk of falls and fall-related injuries.15 CRAFT highlighted these patients, some living with long-term conditions, some with gradual functional decline and those that would benefit from rehabilitation.

It has been established that to minimise the impact of proinflammatory illnesses in frail or pre-frail older people, progressive mild- moderate exercise should be encouraged for those able to do so.16 Physical activity and exercise also have an important role in reducing falls risk and in the management of osteoporosis.17 However, implementing interventions to prevent or reduce the level of frailty in community settings is more difficult.

There is evidence to suggest that frail older adults do benefit from exercise interventions although the optimal program remains unclear.18,19 Research has shown beneficial outcomes from a home-based exercise intervention for older people with frailty by promoting strength, endurance and balance to maintain basic mobility skills and self-management.20 There have been many different mediums for promoting exercise that have been utilised during this pandemic, such as providing exercise sheets, video links, discouraging sedentary activity and encouraging independence. The CSP has provided resources to support and motivate older patients at risk from inactivity during the Covid-19 pandemic.15 

The BGS recommend that a nationwide regular exercise programme is broadcast both on television and radio and have produced ‘Keeping older people safe and well at home’ resources.14 Throughout CRAFT the ACPs were able to signpost patients to these resources, however due to the Covid-19 lockdown it was not possible to refer patients to many of the evidence based interventions such as strength and balance training programmes in the community.21 It was also challenging to advise patients on level of physical activity due to difficulties in accurately assessing current levels of activity remotely.

The feeling of loneliness and low mood was apparent during the telephone calls. Patients had not seen or spoken to anyone for days and they were missing their social gatherings and having company. The British Psychology Society recommendations for people recovering from severe coronavirus is a stepped, needs-based, approach to providing psychological care for symptoms including significant cognitive impairment, anxiety or low mood.22 It has also been predicted that confinement may create both deterioration of mental as well as physical health in the ageing population and contribute to frailty.23 It was evident that some of the patients would have benefitted from routine home-based rehabilitation but non-urgent planned care and non Covid-19 patient’s need for rehabilitation is yet to be reintroduced as demand for D2A services remains high.

The NHS RightCare Community Rehabilitation Toolkit in England,24 adopts a multi-condition approach and suggests that commissioners responsible for community rehabilitation services for their population should focus on whole system improvement. Nationally there has been recognition of transformation in community services and as lockdown restrictions ease these essential community services are being restarted where local capacity is available.25 

CRAFT enabled connecting people and access to ‘social prescribers’; patients’ comments were positive in that they felt ‘not forgotten.’ Interventions to tackle social isolation and loneliness were also limited due to Covid restrictions, however many community based organisations had developed remote interventions.26 Interventions adopting a community development approach with adaptability and productive engagement are thought to be successful features, with group-based, one to one or solitary activities not showing greater effectiveness.27 Isolation and having fewer close relationships in later life has been associated with dementia risk.28 It is not sure how the sudden lack of contact with loved ones throughout the Covid pandemic will impact on those suffering cognitive impairment and dementia or how this will manifest.

Telephone triage was challenging as it was difficult to fully gain functional, social and environmental components of CGA which can be gleaned from face-to-face consultation.29 

If remote consultations become part of the routine frailty pathways of care, video triage may provide more insight into these domains. However, limitations of video consultations have been highlighted during the pandemic and hence its use may not be practical in the care of older people.30 Another option is weekly virtual MDT meetings with primary care colleagues which seems more promising in collaborative care of patients overall. CRAFT enabled review and discussion of complex but superficially clinically stable patients with primary care teams at these meetings.

This process proactively identified those patients in need of rehabilitation and other community services. It anticipated this need and could be used to plan sufficient capacity to respond to future demand in services and prevent hospital admissions. However, it was equally important to identify clinical reasons for people to be in hospital and triaging was completed with the guidance of the Consultant Geriatrician prioritising urgent patients to attend the hospital. This enabled identification of patients going into crisis and utilising ‘same day’ secondary care expertise delivered by the frailty team.

The decision to bring patients into the acute hospital setting required careful consideration by both clinicians and patient. CRAFT gave opportunity to exclude Covid-19 symptoms prior to any ongoing discussions regarding management. Despite reassurance of the ‘cold ‘area for treatment and adhering to infection control, some patients declined to attend hospital appointments offered.

This highlighted the issue of the publics’ unwillingness to come back to hospitals where they fear infection until the lockdown restrictions are lifted. There are many models of care in different parts of the country such as locality hubs, complex care teams and virtual wards to look after people with frailty. These models of care allow older patients to remain at home in familiar surroundings instead of hospital admission, or to return to them quickly from hospital to receive complex clinical care once at home.31 CRAFT enabled linking with the local complex care team supporting older people to do better at home with therapists providing equipment and adaptations for frail people within their homes.

The need for integrated health and social care planning for those with long term care needs is essential to adequately respond to those requiring both acute admission and those requiring services in the community without admission.13

There has been a rapid acceleration of integrated care of patients with complex needs delivered in the community, with a number of community-specific elements of the NHS long-term plan31 already in operation in South Somerset. These elements enabled appropriate implementation of resources following CRAFT. Flexibility and the need to sustain this long term will be crucial as more patients are discharged from hospital in need of ongoing support and crisis mangement.32 Some of the triaged patients required rapid response services for urgent care and equipment provision and appropriate links were made with the D2A teams in community.

CRAFT fostered good communication between local community and voluntary support networks and gaining their input to help patients cope and manage change was viewed positively by both patients and carers. Having a knowledge of the local resources enabled flexibility in the care provided and ensured appropriate resources were targeted to avoid delay and prevent patients reaching a crisis point.

Conclusion

The FAU team has aimed to provide the best possible collaborative care to frail older people in crisis in addition to normal circumstances. CRAFT recognised the role of the ACP frailty specialist in remotely supporting provision of appropriate, system wide, frailty-related interventions in partnership with primary care, even in the absence of a face-to-face CGA.

This ensured a pathway of assessment and treatment of social and environmental dimensions of CGA influencing a person’s loneliness and physical wellbeing. The CRAFT process helped navigate community and secondary care giving frail patients access to quality healthcare and focus on local resources.

The future appears to be a proactive interface between primary and secondary care and a ‘pulling together’ of health and social care systems. To continue our ‘back to better’ service the frailty team continues to pilot a proactive case finding model to identify and support people living with frailty. The weekly virtual MDT meetings between secondary and primary complex care teams continues enabling working seamlessly between community and hospital services, which is of particular urgency in view that there is an aim to improve care for older patients.32

 


Susan Bridge, Trainee Advanced Clinical Practitioner, MSc, Dip Grad Phys, MCSP (Yeovil District Hospital, Frailty Assessment Unit)

Dr Deborah Lane, Consultant AHP DProf, MSc, PGCHE, BSc (Hons), Dip Grad Phys, MCSP (Yeovil District Hospital) 

Dr Rani Sophia, Consultant Geriatrician (Yeovil District Hospital, Frailty Assessment Unit) 

Dr Jazia Rasheed, Associate Specialist Frailty/Care of the Elderly (Yeovil District Hospital, Frailty Assessment Unit

Juliet Pankhurst, Trainee Advanced Clinical Practitioner, RGN, BA (hons) (Yeovil District Hospital, Frailty Assessment Unit)

Conflicts of interest: none declared

Acknowledgements: To the multidisciplinary Frailty team at Yeovil District Hospital for their work in supporting this project.


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