Frail older people face medical crises that current NHS services are not designed to handle, leaving them stuck in hospital beds for too long or cycling through emergency departments without proper support. The problem is that four specific groups of older patients—those in hospital with both medical and mental health issues, frail patients who turn up at A&E but don't need admission, people with hip fractures, and care home residents—all receive fragmented care that leads to poor outcomes. Coordinated multi-disciplinary care, known as comprehensive geriatric assessment, has improved results for stroke patients and some other groups, but has never been properly tested in these four high-risk populations. Over five years, the research team will develop and evaluate four new specialist services: a combined medical and mental health hospital unit, a rapid-response geriatric service for emergency patients who can go home, an orthogeriatric service for hip fracture patients, and a monitoring system for care home residents. Each service will be tested against usual care using randomised trials or before-and-after comparisons. If successful, these services could reduce long hospital stays, prevent unnecessary admissions, improve hip fracture recovery, and help care home residents avoid crises that land them in hospital. The findings will produce at least 15 major publications to guide how the NHS should reorganise care for its fastest-growing patient group.
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Primary aim and objectives (8)The aim is to develop and evaluate novel services delivering specialist co-ordinated multi-disciplinary care to frail older people presenting with or at risk of medical crises. The objectives are to develop and evaluate such services for1. medical patients in hospital with significant co-morbid mental health problems2. frail patients presenting to an acute medical unit who do not require hospital admission3. patients with hip fracture4. residents of care homesBackground (9)Clinical problems facing the NHS due to the ageing of the population include the management of medical patients in hospital with significant co-morbid mental health problems (length of stay is long and the quality of service is poor), frail people who present to a hospital acute medical unit but who do not need admission (they are at high risk of future episodes of care and death), people with hip fractures (length of stay is long and outcomes are poor), and people in care homes (long term conditions are not well managed, hospital admissions are too frequent and end of life care is inadequate).Co-ordinated specialist multi-disciplinary care (which for frail older people is called comprehensive geriatric assessment - CGA) improves patient outcomes in studies of stroke services and some geriatric services, but has not been tested in the four groups listed aboveResearch plans (10)The research programme will last for 5 years and have 4 workstreams:Workstream 1: Development and evaluation of a Medical and Mental Health Unit – a specialist in-patient unit for the management of medical patients in hospital with significant co-morbid mental health problems. The service will be evaluated using a RCT. Workstream 2: Development and evaluation of a comprehensive geriatric service for frail older people presenting to the acute medical unit with an emergency, but who do not require immediate hospital admission. The service will be evaluated using a RCT.Workstream 3: Development and evaluation of an orthogeriatric service in which early medical assessment and routine multi-disciplinary assessments are used to provide optimal pre and post surgical care. The service will be evaluated using a pre and post study.Workstream 4: Development and evaluation of a process for the assessment, monitoring and early response to worsening health for residents of care homes. The service will be evaluated using a stepped wedge cluster crossover RCT.In each workstream there will be • a preparatory phase (literature review, ethics committee and R&D issues)• a cohort / register study to describe the population, identify risk stratification variables, and provide data to plan subsequent research (such as entry criteria and sample sizes)• a developmental phase during which the services are developed, optimised and described• an evaluation to examine the benefits and costs of the novel service compared to usual practice Research Team (11)The project team comprises multi-professional academic clinicians to provide clinical leadership, academics to provide statistical, health economics and methodological expertise, an NHS manager to run this R&D programme as core Trust business, and user representation. The team has a long and successful track record for high quality pragmatic clinical research in older people.Research environment (12)The programme will be supported by a reference group, comprising other academics, other clinicians, and user representation. The programme will draw upon academic and research resources (e.g. research training, research students) of the University of Nottingham which employs several of the research team. It will also draw upon the resources of the local Clinical Research Network, and of the NUH Trust.Outputs and impact (13)Publications, presentations and other materials will emerge within two years of the start of the project. The main outputs will be a body of work of at least 15 major publications to advise on the best management of fr
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