SMARTCARE- The ‘Frailty Passport’ for advance care planning

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Case Study Summary
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Overview summary:
Dr Amit Arora at University Hospital of North Midlands (UHNM) has developed a Frailty Passport for frail elderly patients. The Frailty Passport is a patient held diary that holds the patient’s statement of preferences and wishes for the rest of their life.

This project aims to discuss advance care planning with frail elderly patients and as a by-product also reduces unplanned admissions and length of stay by communicating a personalised integrated care plan that is agreed by all parties involved- putting the patient right at the centre of care.
Challenge identified and actions taken :
It has been reported that frail elderly patients often have multiple hospital admissions. They often get readmitted to hospital because they are not always asked what they want when approaching the end of life. These discussions often happen at an inevitable or imminent stage of end of life rather than when approaching end of life. The aim is to issue the Frailty Passport and extend it to those frail patients ‘approaching end of life’ to enable ‘dignity in death’ rather than discussing advance care plans when death is imminent.

Therefore, this project strives to create an intervention service that puts the patient at the centre of their care plan. It aims to reduce unplanned admissions and length of stay, by establishing an integrated personalised care plan- bridging communication and care between all providers. This is done by the passport being completed in conjunction with the patient, their families and the medical teams. A Multi-Disciplinary Meeting (MDT) is organised to create an inclusive environment where all information can be shared regarding the Frailty Passport. The patients GP is also involved and is informed of the passport. It only becomes valid if the GP agrees to the contents after discussions with the patient, or their representative. This then enables patients to spend more time out of hospital.
Impacts / outcomes:

The Frailty Passport is intended to be used by health and social care professionals. The passport incorporates advanced care plans, supporting the patient or a new or revised care plan(s), in relation to the social situation, activities of daily living, crisis management plans, ceiling of care, and end of life plans including DNACPR documentation. Therefore, documenting and respecting patient wishes. This has achieved many positive outcomes which are mentioned below:
  • By streamlining care and improving communication across the traditional boundaries of primary care, secondary care, ambulance services, social care, housing and care homes it improves the whole experience for both health and social care in later years.
  • The written information is given to relevant staff in health, social care, carers and care home as guidance about matters that have been discussed in detail with patients (and/or representatives) and their medical records. This improves the quality of life, dignity, choice and autonomy.
  • As the passport streamlines care it avoids unwarranted hospitalisation, facilitate discharges, readmission and lists patient’s wishes and preferences. It also aims to improve the patients experience across the whole NHS for the rest of their life.
  • As this written plan is agreed by the MDT it will give enough confidence to health and social care staff to follow patient’s wishes.
  • The Frailty Passport has been listed as a good practice example by NHS England.
Overall, the Frailty Passport has been effective by clearly communicating the patient’s wishes and putting them at the centre of the care plan. It also gives written information to health and social care staff and provides medico-legal assurance.
Supporting quote for the innovation from key stakeholders:
Dr Amit Arora said- Traditionally Health and Social Care professionals are widely acknowledged to use syntactic language, current practice within the project when liaising with patients is to use terminology that can be understood by all involved. Acting as an advocate on behalf of the patient and family ensures that patients were given opportunity and support to discuss their wishes, concerns and suggestions for advance care planning. Also, highlighted was that the Frailty Passport is vital to ensure that patients and family fully grasped what was being communicated. The Frailty Passport also provides the reassurance of a clear documented and agreed written care plan to the care home staff when deciding what to do in the event of clinical deterioration in condition.

Here is some feedback that was given about the Frailty Passport in a few short quotes from individuals who have utilised the Frailty Passport:

“The best service I’ve had.”

“I wish every old person can have one of these”.

“This is the first time I have been asked about such an important issue”.

“This is absolutely fantastic”.
Which local or national clinical or policy priorities does this innovation address:
At the moment the Frailty Passport is being used at UHNM and has plans to spread to other Trusts who are interested in the innovation. The priority this innovation addresses is: • To reduce healthcare related harm as complex elderly patients are at risk when admitted as an emergency (NHS England). • Preventing individuals from dying prematurely. • Enhancing the quality of life for individuals with long term conditions. • Helping individuals to recover from episodes of ill health. Furthermore, the Frailty Passport innovation ensures: • Ensures that patients have a positive care experience. • That the treatment and care for patients is in a safe environment, protecting them from avoidable harm.
Plans for the future:
The USP of this innovation is that the boundaries between Acute Community, Primary, Social and Mental Health Care are able to successfully align to another. The introduction of the Frailty Passport results strong communications with all parties involved improves hand overs and improves the quality of patient care and satisfaction.
  • The next step for the Frailty Passport is to work towards the sustainability of the project and possibly modelling and scaling to meet the current demand.
  • Parameters could also be developed, which will enable identification of groups of high-risk patients at an earlier stage. This will facilitate early intervention and allow a more effective use of resources.
  • It could be hoped that a predictive model could be introduced in the future.
At present the teams can be alerted about the presence of the Passport by a notice at the back side of front door and is only available in a paper copy but an electronic format is being planned for further roll out. Evidence showed that health and social care can be difficult to understand and navigate as only 55.5% knew how to access further information or support. This will be an area for future improvement.
Tips for adoption:
Adopting the Frailty Passport includes utilising a multi-disciplinary case management approach, which is linked to the management of multi-morbid patients can facilitate a reduction of reliance on acute based care.

Adopting the Frailty Passport enhances communication and has proven to be a valuable tool in enabling all stakeholders to fully understand and comprehend what’s planned how it will be facilitated and who is responsible.

By adopting the Frailty Passport patients, carers and family have been fully involved in the project and always include their own planning and MDTs.

If you would like more information on the Frailty Passport please contact Amit Arora: amit.arora@uhnm.nhs.uk
Contact for further information:
If you would like more information please contact Dr Amit Arora: amit.arora@uhnm.nhs.uk
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