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Background Anxiety and depression are common in patients with COPD, particularly in those with physical disability and more severe disease. It is under-diagnosed and under treated yet has profound consequences on the patient and their carers resulting in increased social isolation, heightened sensation of dyspnoea, poor treatment tolerance and increased hospitalisation. There are validated screening tools for anxiety and depression in COPD but they are underutilised. When patients present with an exacerbation to secondary care services, this becomes an ideal opportunity to assess for anxiety and depression. Aims To evaluate our current service in assessing older (over 78 years) inpatients with end stage COPD, presenting with an exacerbation, for symptoms of anxiety and depression as recommended by NICE guidelines. Method Retrospective clinical case note audit of eighteen older patients with an inpatient admission resulting from an exacerbation of COPD. Results Sixteen of the 18 patients had WHO performance status of three or four indicating physical dependency. Only one patient had a prior diagnosis of anxiety and depression and was on treatment. Despite medical and nursing observational entries in the clinical notes indicating possible underlying depression and/or anxiety in seven patients (‘low mood’, ‘poor eye contact’, ‘anxious’), none of the 18 patients had a recorded mental health assessment or completed screening tool for identification and diagnosis of anxiety or depression. Conclusion Despite extensive evidence that anxiety and depression is common in patients with end stage COPD and has significant consequences on their quality of life, we are not following national guidelines and assessing for anxiety and depression in our older inpatients presenting with exacerbation. We see this as a missed opportunity to intervene to improve symptoms and optimise physical and psychological functioning towards the end of life. Our audit presents plans for service development and improvement and re-audit schedule.

Introduction Hull CCG recognised system’s over-reliance on reactive, hospital care and workforce deficits, requiring a modernised service model for frail older people that moved from individual provider focus to system-wide perspective, with emphasis on proactive care. Methods Electronic Frailty Index (eFI) in primary care system identified 3,200 out of 300,000 Hull residents Hull with severe frailty. Recruited 9 GPs with extended role in older people’s care and Advanced Nurse Practitioners to support 4 Community Geriatricians. Redesigned roles for pharmacy, social services and non-clinical care coordinator teams. New therapy roles created, multiple third sector organisations involved, including carer support, and purpose-built location with older people in mind. Interventions Structured and anticipatory comprehensive geriatric assessment of all 3200 residents (either at home or in care homes) by the multidisciplinary multiagency team. Pre-assessment home visit by support worker to complete patient concern’s questionnaire. Dedicated patient transport and one-stop multi-disciplinary team assessment in one building. Proactive discussion of RESPECT and advance care planning, electronic personalised care plan delivered with system-wide record sharing across providers, Same day basic diagnostics available. Complex care coordinators ongoing support in community. Multi-disciplinary outreach to care homes and truly housebound. Results 99.7% patients and carers extremely likely/likely to recommend the service 21,000 interventions for 2,500 patients seen since June 2018 Majority of patients moderately frail by Clinical Frailty Score Average saving on drug costs - £110.17 /patient/year 15% reduction in ED attendances, 29% reduction in emergency admissions Patients’ survey: adequate time and opportunity to discuss health problems/concerns, felt informed and empowered during consultation and in future planning Very high levels of staff satisfaction Conclusions and future Innovative high quality, cost-effective new model of care delivering improved patient care and experience with emphasis on proactive care and future planning High levels of patient and staff satisfaction Future expansion with disease specific teams including COPD, parkinsonism and diabetes and targeting moderately frail by eFI. Redesign of community services with improved integration across teams and providers can be a blue-print for other services.

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