Mild Frailty
Clinical Frailty Score: 5
Jackie said: 'I feel welcome and safe in my local community and can join in activities that are important to me'. So, we offered Jackie (and his family) opportunities to build relationships with other people who share their interests, culture and identity.
Across a person’s life course, offer Universal Personalised Care (including Personalised Care and Support Planning), enabling choice, shared decision making and support based on the person’s needs and 'what matters to them'
| Involve
Enhance the voice of older people, carers and families to tackle the frailty challenge together at a community and individual level.
Visit ‘involve’ on the Frailty ICARE website
| Consider
Risk factors for the development and progression of frailty should not be viewed in isolation as they are not mutually exclusive and many risk factors have a bi-directional relationship.
An awareness of the risk factors and complications of frailty can help with early appropriate support.
Chronic Pain
Two thirds of frail people experience frequent or ongoing pain and 80% indicated it interfered with daily activities
Mobility
Frail people are 11 times more likely to have mobility limitation, balance and walking problems compared to non-frail people and are nearly 9 times more likely to use a walking aid
Falls
Frail people are nearly 3 times more likely to have had one fall or 4 times more likely to have had 2 falls in the last year compared to non-frail people
Loneliness
Loneliness is linked with higher risk of frailty, mortality (equivalent to smoking 15 cig /day) and care home admission
Depression
Frail people are 4 times more likely to feel depressed or sad much of the time and over 5 times more likely to feel dissatisfied with life.
Social Isolation
Frail people are over 5 times more likely to say they feel lonely or socially isolated.
Visit ‘consider’ on the Frailty ICARE website
| Assess
Older people should be assessed using an appropriate frailty diagnostic tool and have their frailty classified by the Clinical Frailty Scale.
Visit ‘assess’ on the Frailty ICARE website
| Respond
Personalised Care is relevant across the whole spectrum of frailty. However, it is crucial to understand a person's needs and 'what matter to them' to target support based on their level of frailty and associated needs.
For mildly frail Jackie, offer ongoing healthy ageing advice and support for Long Term Conditions with a focus on Community Connectivity with access to and involvement of the Voluntary, Community and Social Enterprise sector.
What works?
Adopting shared decision-making to enable choice and engagement to build learning and relationships
Focusing on and invest in recognised ways of working that embrace ‘relationship and asset-based approaches’ and ‘everyone doing their bit’ to improve the health and wellbeing
Enabling professionals to refer people to non-clinical pathways that are co-designed to improve their health and wellbeing
Encouraging community connectivity with access to and involvement of the Voluntary, Community and Social Enterprise sector to prevent social isolation and loneliness.
Visit ‘respond’ on the Frailty ICARE website for what works, useful links and developing evidence
| Evaluate
Frailty has a significant impact on people, populations and health and care systems. The following are examples of possible benefits, outcomes measures as well as impact estimates if we offer embrace community connectivity
Community Connectivity possible benefits
Improves the experience of care, health and wellbeing and prevents mental health
Reduces crises that lead to unplanned hospital or institutional care admissions.
Reduces unnecessary GP/primary care appointments
Benefits fitness, activities of daily living and quality of life
Improves physical function and muscle strength
Reduces the rate and risk of falling
Delays the progression to frailty
Potential Impact
In the North East and North Cumbria region, mildly frail people are 2.6 times more likely to have fallen in the last 12 months than fit people aged over 65.
Potential measures (examples of frailtyicare metrics)
The proportion of people (aged 65+ years) who use services who reported that they had as much social contact as they would like
Carer reported quality of life
Measurement of loneliness / reduced loneliness
Number of people referred into social prescribing schemes
Visit ‘evaluate’ on the Frailty ICARE website for regional metrics
To make change, implement delivery and realise benefits, we must invest in our people, teams and technology through knowledge development, sharing and robust evaluation. Across the North East and North Cumbria we are running a bi-monthly Ageing Well Community of Practice of support this approach
Visit ‘making it happen’ on the frailty ICARE website
Making it happen
