Summary
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
An awareness of the risk factors and complications of frailty can help with early appropriate support. However, risk factors should not be viewed in isolation as they are not mutually exclusive and often have a bi-directional relationship.
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 with Care and Support Planning is relevant across the whole spectrum of frailty. However, it is crucial to understand a person's needs and 'what matter to them' for targeted support based on the person’s level of frailty and associated needs.
Healthy ageing and caring approaches with signposting to keeping active, engaged and independent, including access to frailty-friendly living and homes.
Community connectivity with access to and involvement of the Voluntary, Community and Social Enterprise sector.
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.
Access to specialist interagency teams for a comprehensive geriatric assessment [CGA] and case management with the development of an Personalised Care and Support Plan (including an Emergency Health Care Plan) to coordinate care and optimise nutrition and hydration, bowel and bladder care, vision and hearing, cognition and dementia care, and end of life.
Access to community crisis and recovery services (with active recuperation, rehabilitation and reablement) including frailty-focused transport and timely transfers of care from hospital involving families and carers.
Access to experts offering frailty-based care in hospital with frailty assessment, diagnostics and pathways.
Visit ‘respond’ on the Frailty ICARE website for what works, useful links and developing evidence within each response section
| Evaluate
Trying to understand whether you are making a difference can be challenging.
It is important to appreciate qualitative and quantitative [the data] information; to analyse this within the context of service delivery [the intelligence] and above all know the impact on people, teams, populations and services [outcomes].
The Frailty ICARE toolkit has 23 metrics looking at the impact across the spectrum of frailty and can be used to support local areas to set appropriate goals, develop plans and provide a means for evaluating progress.
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.
