Pre-Frail
Clinical Frailty Score: 4
Jackie said: 'I am supported to manage my health in away that makes sense to me'. So, we offered Jackie (and his family) up-to-date information in a format tailored to his needs to support healthy ageing and self-management of his Long Term Conditions.
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.
Deafness, Hearing and Oral Health
Frail people are four times more likely to have vision problems affecting activities, 2.5 times more likely to have hearing problems and over 5 times more likely to have poor oral health affecting eating and speech.
Emotional and Mental Health
Frail people are nearly 6 times more likely than non-frail people to say they have emotional or mental health problems moderately interfering with their daily activities.
Polypharmacy
People have nearly 2 times the odds of frailty with polypharmacy (5 or more medicines) and nearly 5 times the odds of frailty with excessive polypharmacy (10 or more medicines) respectively.
Chronic Diseases
Frail people are over 5 times more likely than non-frail people to say they have 3 or more chronic diseases.
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 pre-frail Jackie, offer ongoing healthy ageing advice with a focus on specific, tailored support for Long Term Conditions, including supportive self-management with the development of an Personalised Care and Support Plan optimising falls and immobility, medicine/polypharmacy and mental health.
What works?
Involve everyone in co-ordinating support
Offer education tailored to need and literacy
Consider TECS to self-manage Long-Term Condition(s)
Screen and advise about falls, encouraging Strength and Balance Training
Tackle polypharmacy
Identify and manage depression and anxiety.
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 personalised support for Long Term Conditions
Specific, tailored support for Long Term Conditions possible benefits
Improves a person’s knowledge about their conditions, coping ability and use of health care
Streamlines management of LTCs
Fewer unnecessary GP appointments
Fewer medicines prescribed, adverse drug reactions and hospitalisation (adverse reactions)
Improves medication use (when staff trained in SMR receive training)
Reduces the risk of falls
Potential Impact
In the North East and North Cumbria region, nearly 10, 000 more people may progress to mild frailty as a result of increasing diagnoses of hypertension
Potential measures (examples of frailtyicare metrics)
People aged 65 years and over with 10 or more unique medications
Dementia: 65+ years old estimated diagnosis rate
The proportion of people (aged 65+ years) who use services who have control over their daily life
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
