'Health detectives' helping to prevent hospital admissions
18 March 2025
A multi-disciplinary team from Hywel Dda University Health Board’s (UHB) Prince Philip Hospital is having success in preventing frailty related hospital admissions.
Since May 2024, the South Carmarthenshire Rapid Access Multidisciplinary Service (SCRAMS), an intermediate care falls and frailty service, has received more than 200 referrals. Each case is investigated to understand patient needs and calling on the right services to provide care and support where needed.
Part of the SCRAMS team is Integrated Care Sister, Ann-Marie John, who explained: “Frailty is a distinctive state of health related to the ageing process in which many of the body’s systems gradually lose their in-built reserves. Around 10 per cent of people aged over 65 years have frailty, rising to between a quarter and a half of those aged over 85 years.
“Being frail means a relatively ‘minor’ health problem can have a severe long-term impact on someone’s health and wellbeing.
“Many factors combine over time to make a person frail including dehydration, weight loss, loss of muscle strength and balance, falls, loss of confidence, fatigue and mental health conditions such as depression and anxiety.
“Frailty is not an inevitable part of ageing; it is a long-term condition which can be managed with patient-centred care.”
Once a patient has been identified by a GP and triaged by a consultant, the SCRAMS team spring into action. Ann-Marie together with Ceri Evans, Frailty Assistant Practitioner, visit the patient at home and carry out a full assessment.
“We’re like health detectives,” said Ceri. “We try to understand the whole person. Is this person eating and drinking enough? Is that causing them to fall or is there something else?”
Ann-Marie added: “During our weekly multidisciplinary team meeting we report our findings and then referrals to other services such as dietetics, falls prevention or occupational therapists for example are made. Each care plan is personal to each patient.”
Consultant Geriatrician Dr Zena Marney, clinical lead for Llanelli SCRAMS said: “Adults aged over 65 years comprise a quarter of the population of Hywel Dda UHB and this is projected to increase significantly over the next 20 years. This means we have an impending frailty crisis and the work and care that the SCRAMS team are delivering is vital.
“I am privileged to be able to work with the experienced members of our SCRAMS multidisciplinary team who are dedicated and work extremely hard to provide holistic person-centred care in the community via Comprehensive Geriatric Assessment. Assessment of nutrition and hydration is an integral part of this.”
Emma Catling, Malnutrition Strategic Lead, added “Poor nutrition and hydration overtime can make a person frail. Without any fuel in the tank, patients begin to lose weight, strength, mobility and their mental health can decline all of which can leads to falls. This can all be prevented.
“Ceri and Annmarie will provide nutrition and hydration information packs during their initial patient assessments, so they have immediate information to help them before the dietetics team contact.
“The SCRAMS team are working to keep patients healthy and active at home preventing hospital admissions. They are giving back a patient’s quality of life.”
Case study:
When ‘Betty’, an elderly lady, came to the attention of the SCRAMS team she had suffered a series of falls and had hospital admissions due to a hip fracture and chest infection.
Betty was living in her own house with the support of her family, friends and her community. She has limited vision and walked slowly with the aid of a stick and zimmer frame. She was taking medication to help with postural hypotension, or low blood pressure when you stand up.
After each admission, Betty became frailer but was determined to return home and to receive help from family and friends. She didn’t want care packages offered at the time.
Betty’s final admission to hospital was a prolonged stay and she became frailer and lost her confidence. Betty agreed that she needed help and moved into a residential home.
The SCRAMS team reassessed Betty in her new home and found that she had lost her independence and now needed assistance with moving around. She became frailer, wasn’t eating as well and had lost a significant amount of weight.
Referrals were immediately made to various teams including dietetics and physiotherapy and a patient centred care plan was put into place, in conjunction with her family.
The dietetics team monitored her weight and dietary intake, adding fortified meals and snacks supplemented with homemade milkshakes and juices based on Betty’s likes and dislikes.
Physiotherapists implemented a structured strength and balance programme to improve mobility and independence delivered by the team weekly. Care home staff were familiarised with the exercise programme to assist Betty in-between visits.
The SCRAMS team arranged weekly visits to monitor weight, blood pressure and take strength readings using a dynamometer, a device to assess the strength of muscles in the hand and forearm.
It took a long time for Betty to show signs of improvement but there were improvements and pressure areas she had developed have now healed.
And now...
Betty is almost back to her original weight and walking to the dining room with minimal assistance. According to her loved ones, “Betty has her cheeky sparkle back now.”
And Betty hasn’t been back to hospital since.