Severe Frailty
Clinical Frailty Score: 7 and more
Jackie said: 'When I am unwell (either at home or in other settings) my wishes are respected and there is a plan of who will do what and all the practical arrangements are in place'. So, we offered Jackie (and his family) access to teams (hospital and community-based) to support him and his family during and after significant crisis to manage ongoing or new support requirements
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.
Prolonged Hospital Stay
Frail patients with acute care needs are especially vulnerable to harm from delays in diagnosis and to ‘deconditioning’ while in hospital
People seen in hospital with a high frailty risk are 1.7 times more likely to die at 30 days compared to people with a low frailty risk
Post-Hospital Discharge
About 40% of over 65s will die within 12 months of leaving hospital. Those with severe frailty are four times more likely to die within 12 months
Half of frail older people discharged home within 72 h from such settings are readmitted and one-third die within a year
Older people have nearly a 40% readmission rate at 6 months after discharge from A&E
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 severely frail Jackie, offer a Comprehensive Geriatric Assessment and Case Management including access to a Multidisciplinary Team for care coordination and development of a personal care plan. If unwell, Jackie should have access to Community Crisis and Recovery services as well as hospital-focused frailty care.
What Works?
A front door MDT to assess frailty and commence CGA - linking to community-based teams
Strategies to avoid unexpected deaths (e.g. warning scores, critical care outreach)
Safer care bundles (e.g. falls, VTE, medication)
Minimised in-patient moves
Offering frailty liaison and in-reach services
Offering crisis response with access to multi-disciplinary teams within 2 hours
Having a Single Point of Access with specialist opinion and diagnostics
Assertive discharge planning, with early senior review and ‘discharge to assess’ approaches
A trusted assessor approach - step-up and step-down home-based and bed-based rehabilitation and reablement services with a 2 days target
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 community crisis and recovery services and frailty-based hospital care
Access to community crisis and recovery services and frailty-based care in hospital possible benefits:
Reduces length of stay for people who can be safely discharged early from acute hospital
Increases the number of patients discharged home, rather than to an institution, after three months (although this was not sustained at six months)
Reduces ongoing care needs
Improves functional status when compared with usual home care
Reduces in falls, medication errors, VTEs, and delirium
Reduces functional decline
Improves experience of care
Improves survival at home after discharge
Potential 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.
In the North East and North Cumbria region the average length of stay in hospital was 7.9 days for a person with frailty compared to 4.4 days for a non-frail person and the 30-day emergency readmission rate for the frail population was 20.7% compared to 16.9% for the non-frail population.
Potential measures (examples of frailtyicare metrics)
People aged 65 years and over with severe frailty who have received an annual medication review
A&E attendance rates for patients aged 65 years and over
Emergency hospital admission rates for patients aged 65 and over
Proportion of stranded patients in hospital: Length of stay 7+ and 21+ days
Emergency readmissions within 30 days of discharge from hospital (patients aged 65 years and over)
Hospital activity in the last year of life (patients aged 65+ years)
Hospital Trust indicator set (Falls with harm, Pressure ulcers, Patient experience of hospital care, A&E waiting time 4 hour standard)
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
