Central and North West London NHS Foundation Trust

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This request to WSIC is for support in identifying a cohort of frail residents who are accessing 2 or more Older Adult services across Kensington, Chelsea and Westminster. We want to know, at borough and PCN level, who are the individuals.

The Bi-Borough Older Adult Integrated Approaches Delivery Group is seeking to utilise a data driven approach to support development and implementation of a more integrated Older Adult pathway model across the bi-borough. We are aiming to improve patient outcomes and reduce health inequalities by delivering more joined up care for older adults with multiple complex co-morbidities including frailty, functional mental health needs and/or dementia We want to do this by taking a population health approach to 65+ offer at both PCN and borough levels. This means using data analysis to undertake: 1. An initial population segmentation of the Older Adult cohort we support across the Bi-borough 2. An audit of patient journeys to understand why needs deteriorate and what we can do as a system to avoid admission and support care in the least restrictive setting. The purpose of this service evaluation request is threefold. We want to identify a cohort of frail residents to understand why their needs deteriorate and inform what we can do as a system to avoid admission and support care in the least restrictive setting. This work will enable us to better understand, at an ICP level, how individuals with complex care needs flow between services, where they enter and exit existing pathways, impact that has on the system and where there is unmet need. This request to WSIC is for support in identifying a cohort of frail residents who are accessing 2 or more Older Adult services across Kensington, Chelsea and Westminster. We want to know, at borough and PCN level, who are the individuals: • Aged 65+ who have accessed both a Mental Health and Physical Health service and whose needs have deteriorated and are now accessing multiple services and/or had a non-elective admission • Aged 65+ who have accessed both a Mental Health or Physical Health service whose needs did not deteriorate and are continuing to be managed in the community. This will include all individuals accessing older adult community mental health teams plus those who are also accessing social care and/or physical health services within the bi-borough (e.g. CIS, My Care My Way, Community Matrons, District Nursing). Multiple cuts of data will be required including by borough and PCN levels if possible to understand spread of individuals with complex care needs locally. The data we have requested should include patient identifiable information so that identified KCW clinicians who are part of our delivery group can audit the clinical/case notes of the cases identified to identify reasons for deterioration and gap and trends. We are requesting this data through WSIC as we need access to all ICP data sets including social care data.

20/01/2022

TRE