Moderate Frailty
Clinical Frailty Score: 6
Jackie said: 'I have care and support that is coordinated and everyone works well together and with me'. So, we offered Jackie (and his family) access to named care coordinator and Multi-disciplinary Team for a personalised assessment (Comprehensive Geriatric Assessment) and development of an integrated personal care plan
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.
Bereavement
Frail people who suffer a life event (bereavement) are 2.6 times of an increase risk of mortality compared to non-frail people suffering a life event
Functional Dependence
Frail people are nearly 20 times more likely to say they need help with bathing, dressing, toileting, eating and over 48 times more likely to say they need help with shopping, cutting toenails, laundry, managing medication and money
Housing and supported living
People who live in homes with 1 or more poor condition(s) have more than twice the chance of developing frailty compared to those not living in poor conditions
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 moderately frail Jackie, offer ongoing healthy ageing advice, support for Long Term Conditions and Community Connectivity with a focus on the consideration for a Comprehensive Geriatric Assessment and Case Management including access to a Multidisciplinary Team for care coordination and development of a personal care plan
What Works?
Consideration for a proactive and responsive CGA for people identified as moderately and severely frail
An identified key worker who acts as a case manager and coordinator of care
Case management via integrated locality-based teams (access to community geriatrics)
The case manager or MDT designs the care plan with the person and carer (informed decisions)
The care plan is shared and updated (e.g. in crisis)
Carers assessment and signposted to support
A comprehensive palliative care approach (via GP lists, not one-off, access to specialist teams).
Consider personal care budgets and direct payments.
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 access to a CGA and case management
CGA and Case Management possible benefits
Reduces mortality / improve independence after admission to hospital
Reduces nursing home admissions
Improves functioning
Likely to die in preferred place of death
Reduces emergency, inpatient admissions and occupied bed days
Improves patient and family satisfaction with care
Potential Impact
In the North east and North Cumbria, an additional 506 people may develop dementia due to increasing numbers of people with frailty.
Comprehensive Geriatric Assessment (CGA) is estimated to avoid one long-term care placement for every 20 people with a CGA.
https://www.england.nhs.uk/wp-content/uploads/2017/03/toolkit-general-practice-frailty-1.pdf
Potential measures (examples of frailtyicare metrics)
People aged 65 years and over with moderate or severe frailty who are recorded as having had a fall in the preceding 12 months
People aged 65 years and over, with depression or dementia, and who have moderate or severe frailty
Measurement of loneliness / reduced loneliness
The proportion of people (aged 65+ years) who use services who have control over their daily life
A&E attendance rates for patients aged 65 years and over
Emergency hospital admission rates for patients aged 65 and over
Visit ‘evaluate’ on the Frailty ICARE website for regional metrics
Making it happen
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
