New study to explore whether personalised care plans can reduce hospital admissions

A new research study running in Cornwall will investigate whether personalised care plans for frail elderly people can help reduce hospital admissions, improve quality of life and reduce avoidable early deaths.

Helen Lyndon, Nurse Consultant for Older People at Cornwall Foundation Trust, and Clinical Doctoral Academic Research Fellow at the University of Plymouth, has devised a major new study, which she hopes will change the way elderly people with frailty are cared for in the community across the country.

“We know that once people are aged 80 years and over, between a quarter and a half will show some of the signs of frailty,” said Helen, whose study is supported by the National Institute for Health Research (NIHR) and run by Peninsula Clinical Trials Unit (PenCTU). “Therefore, it is important that we understand the causes and how best to manage the condition for the future. Like many long term conditions, frailty cannot be cured, so we need to understand how to empower people to live well with it.”

Helen (pictured) has worked with frail older people for over ten years and recently completed a two-year secondment as the Clinical Lead for Frailty with NHS England where the idea for this study came about.

“With an ageing population we know that most elderly people will not be able to access services in the way they do now in the next 20 to 30 years and we also know that, generally speaking, hospitals are not the right place for frail older people to be,” said Helen. “When you reach the age of 85 one hospital admission predicts a 50 per cent chance of mortality in the next year and ten days in a hospital bed for an older person with frailty equates to ten years of muscle aging. So it’s no wonder we really struggle to support people to get back home again once they’ve had an acute admission. To be honest, a hospital admission is catastrophic for many older people so we have to do something differently. We have to improve community care to ensure we do everything possible to keep our frail older people out of hospital.”

Helen’s study, called HAPPI (Holistic Assessment and care Planning in Partnership Intervention), will develop, implement and test a nurse-led intervention to improve healthy living in older people with frailty.

“We know there are really easy to spot signs of early frailty now such as slowing down, becoming weaker, starting to have falls, starting to have periods of confusion, and having more side effects from medication. However, what we tend to do is just treat the presenting problem. So, if a person is having falls we might think about how we get them back on their feet or if a person has become unwell with an infection we treat that but what we don’t do is then look to see if these things are happening as a result of frailty.

“This study really has the potential to make a difference to patient care within the next five years or so and hopefully change practice nationally; really helping clinicians who work in that field understand what they need to do to provide a more effective service. I hope it will raise awareness amongst patients and the public too about the symptoms of frailty and the ways in which it can be managed like any other long term condition. There’s a lot that patients themselves can do and that’s why I wanted this to be a really patient-centred intervention to ensure best practice is guided by an achievable plan that will make a difference.

“Our research aims to explore how people can be best supported at home and how community nurses need to work to provide individualised support. We want to explore if we can improve outcomes for patients enabling them to live at home, improve wellbeing, prevent falls and reduce the need for hospital care.”

With the support of the NIHR, the study aims to recruit 60 patients from six GP practices across Cornwall.

Picture (c) University of Plymouth.