Moderate Frailty
CFS SCORE: 6
KEY INTERVENTION: Access to CGA and Case Management
| Involve
Enhance the voice of older people, carers and families to tackle the frailty challenge together at a community and individual level.
Visit the Frailty icare website for more on ‘Involve’
| Consider
Always think frailty! An awareness of the modifiable risk factors for frailty and complications related to frailty can help with early appropriate lifestyle interventions.
Bereavement
Frail people who suffer a life-event (bereavement) are 2.6 times 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 ADLs (e.g. bathing, dressing, toileting, eating) and over 48 times more likely to say they need help with IADLs (e.g. shopping, cutting toenails, laundry, managing medication and money).
Housing and supported living
One in three houses where the oldest person is aged 75 years and over have failed the official decent homes standard (17). Deliotte. Better care for frail older people.
96,000 people over 65 years provide unpaid care for a partner, family member or other, but less than 10% receive carer-specific support. Deliotte. Better care for frail older people.
There is a causal link between housing and the main long term conditions (eg. heart disease, stroke, respiratory, arthritis) whilst risk of falls, a major cause of injury and hospital admission amongst older people, is significantly affected by housing characteristics and the wider built environment.
People who live in homes with ≥1 poor conditions have more than twice the chance of developing frailty (odds ratio [OR] = 2.02; CI 1.09–3.75) compared to those not living in poor conditions (see Resources section below for the link to this research).
Visit the Frailty icare website for more on ‘Consider’
| Assess
If there are any signs of pre-frailty or frailty, patients should be assessed using the Clinical Frailty Scale for verification and classification of their level of frailty.
Visit the Frailty icare website for more on ‘Assess’
| Respond
Access to specialist inter-agency teams for a comprehensive geriatric assessment [CGA] and case management including the development of an emergency health care plan to coordinate care and optimise their functioning and environment, nutrition and hydration, bowel and bladder care, vision and hearing, cognition and end of life.
What Works?
Proactive CGA and follow-up for people identified as moderately or severely frail.
An identified keyworker who acts as a case manager and coordinator of care across the system.
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 them in their caring role.
A comprehensive service for those with palliative care need (via GP lists, not one-off, access to specialist teams).
Implementation of the Enhanced Health in Care Homes (EHCH) framework should be considered for people in care homes.
Visit the Frailty icare website for more on ‘Respond’
| Evaluate
To see if you are making a difference, whether at an individual level or within your local area or system, consider the following…
The benefit for individuals
Measuring what you’re doing
The impact on populations, communities and services
Benefits
Reduces mortality and improve independence after admission to hospital
Reverses the progression of frailty
Reduce nursing home admission
Improve functioning (for home- and community-based occupational therapy)
Likely to die in preferred place of death (6 times more likely, including improve quaity and pain relief in last stages of life)
Reduces emergency, inpatient admissions and occupied bed days
Improve patient and family satisfaction with care
Impact
The frail population (moderate and severe combined) makes up 2.44% of the population across the North East and North Cumbria, but account for 19.1% of general and acute bed usage.
Frail patients make up 11.8% of the 65+ population and account for 27.3% of bed usage for that age group.
Visit the Frailty icare website for more on ‘Evaluate’
+ Resources
Comprehensive Geriatric Assessment Toolkit for Primary Care Practitioners (British Geriatrics Society)
Case Management: What it is and how it can best be implemented (The King’s Fund)
Anticipatory Care Planning (NHS Scotland)
Evidence for links between deprivation and frailty:
The Housing and Ageing Alliance Policy Paper - Health, Housing and Ageing
For more useful resources visit the ‘CGA and Case Management’ page of the Frailty iCARE website.
