Frail & Older People
What is an outcome and why are they important?3
Journey of the Event
Introduction & Context1
David Cryer
Jim Dodsworth
Terms of Art2
Identifying Our Outcomes4
Prioritising Our Outcomes5
Value Agenda Overview6
Exploring the Value Agenda
& Next Steps 7
Frail & Older People
Outcomes for each Borough
Barnet
Haringey
Camden
Islington
Enfield
Anne Schlattl
Ben Ellis
Celia Smith
David Cryer
Fran Gertler
Fredrik Johansson
Helen Dunford
Inti Khan
Mousumi Basu-Doyle
Nadia Raja
Naser Turabi
Pramod Prabhakaran
Sam Jones
Stuart Mackay-Thomas
Suzanne Joels
Tracy Brown
Adam Webber
Graham MacDougall
Jennie Bostock
Naheed Rana
Nasrin Hafezparast
Paul Allen
Rachna Chowla
Sian Therese
Ann Mount
Irina Goodluck
Jean Aldous
Juliana Bersani
Karen Spooner
Martins Charters
Muyi Adekoya
Tim Bowler
Andy Murphy
Clare Henderson
Clarissa Murdoch
Dan Windross
David Davis
Liz Brutus
Martin Kuper
Michelle Wheeler
Sue Newton
Tina Jegede
Sheena Nixon
Susanna Dale
Catherine Herman
Delia Thomas
Greg Battle
Helen Joyce
Helen Pelendrides
Helen Taylor
Jonathan Carmichael
Liz Evans
Maurice Cohen
Nicole Klynman
Rachel Lissauer
Rosaire Gray
Sherry Tang
Shirley Ip
Frail & Older People
Older People with Frailty
Cohort definition
Included Excluded
All people aged
75+ years
and
pre-frail and frail
A. Patients under end of life care
B. Patients with organ system failure (eg end
stage renal failure, end stage heart failure)
C. Patients who require specialist care teams
(e.g. immediate care following acute event
(e.g. MI), surgery related care, psychiatric
care, all cancer care)
D. Patients who are not frail
Local context: current provider landscape
Providers whose services for 75 years+ are in scope for the patient cohort in 2015/16
Estimated frail and pre-frail population number 6,955
Primary care
Core contract
Primary Care
Haringey x 4 localities
Acute Providers
North Middlesex
Royal Free (BCF)
Whittington Health
Community Care
Whittington Health
Social Care
Domiciliary Care
Adult Social Care, LBH
Other
Housing
Third Sector
Care HomesUCLH
Barnet Enfield and Haringey
MHT
IPU design proposal
Assessment
& case
management
UNDERPINNED BY:
Infrastructure issues such as co-location, shared records,
workforce development, 7 day working etc
Primary and Community
Management and
risk stratification including
low level prevention
Single Point of Access
To The Hub
GPs Patient/family/carersSocial Services Acute Trusts
Diagnostics and treatment
Specialist functions to
help assess, care plan,
case manage and deliver
Short or medium-term acute
& community interventions,
including self-management
intermediate care,
enablement &
Rapid response functions
Care co-ordinator
& The Patient
Outcomes Shortlist: Older people with frailty