Sarah De Biase, improvement programme manager for the Healthy Ageing Collaborative at Yorkshire and Humber AHSN Improvement Academy, looks at how frailty diagnosis can play a vital role in improving care
Someone described as frail is not simply getting old; it means they are at risk of sudden, dramatic changes in their health such as a fall or delirium when they have what seems to be a minor illness. It affects about one in 10 people aged over 65 years, rising to between 25-50% of over 85 year olds. People living with frailty are the biggest users of health and social care, and their frequent moves between services and organisations puts them at particular risk of experiencing disjointed care.
There is widespread agreement that health and social care systems need to be better aligned to meet the needs of older people with frailty and their carers, but less agreement on how this should be achieved.
A collaborative approach
To tackle this issue a Healthy Ageing Collaborative was set up to support the development of new, evidence-based models of care for older people with frailty as part of the Yorkshire & Humber Academic Health Science Network Improvement Academy. The Healthy Ageing Collaborative is a network of primary care clinicians, academics, CCGs, local authorities and industry partners.
GPs and CCGs are improving the quality of care for people living with frailty through systematic identification and diagnosis of frailty. This allows improved planning of support and better targeting of resources to offer people with frailly more timely, proactive, goal-orientated care to help improve health and wellbeing. Examples of the interventions in primary care for people living with frailty include:
- Identifying people with severe frailty to include in the GP practice top 2% Avoidable Unplanned Admissions register.
- Medication reviews and deprescribing for people with severe frailty
- Falls prevention support for people with moderate frailty
- Practice nurse-led, home-based frailty assessments
- Identifying people with severe frailty to include in the GP practice palliative care register, and to offer advance care planning
- Identifying patients with moderate and severe frailty for geriatrician-led frailty clinics
- Offering self-management support interventions to people who are showing signs of mild frailty.
What have we learned?
The collaborative is helping us understand how to identify frailty, how to train the staff, how best to engage older people and their carers, how to commission services for the frail elderly and how to evaluate them.
We have tried several screening tools, and the electronic Frailty Index (eFI) tool has proved particularly popular. It is based on the cumulative deficit model – in other words, the more things that are wrong with a person, the more likely they are to be frail. It does not need any additional clinical assessments.
We found that clinicians tend to see frailty at the more severe end of the spectrum when there are obvious characteristics such as very slow walking, marked muscle wasting and dependency. The problem with this is that, by focusing on advanced frailty, there is less emphasis on those with mild forms who offer better opportunities for prevention and engagement.
Staff need to be trained to understand the different levels of frailty
The lesson here is that staff need to be trained to understand the different levels of frailty, and how each can be addressed. This needs to include all parts of the workforce, including voluntary workers, social workers, generalist physicians, and specialists in areas such as geriatrics and palliative care.
Engaged individuals and their carers
Older people generally reject the term ‘frail’ as conveying unpleasant and negative connotations, so clinicians and managers need to use language which resonates with the older person’s desire to retain their independence and avoid the consequences of getting older.
This has proved a particularly sensitive area within the collaborative, particularly for staff just beginning their journey towards understanding frailty. They have found it difficult to explain to patients why they are being offered new proactive care services without using the term ‘frailty’. Alternative language such as “at risk of frailty,” or “slowing down,” seems more successful in engaging an older person in a care partnership.
Commissioning for frailty
Current management of frailty is disjointed and largely falls to emergency and urgent care services. So it makes sense to identify populations and individuals living with, or at risk of, frailty and develop more robust primary care-based systems to offer a graduated response.
There is widespread recognition of the limitations of the Quality and Outcomes Framework (QOF) in relation to frailty. The QOF promotes a single long-term condition focus in which each one is addressed through separate protocols and reviews. This becomes increasingly problematic in frail people with several conditions. Existing QOF processes allow for the use of patient exemptions but this can result in increased scrutiny from NHS England. Based on feedback from Healthy Ageing Collaborative partners, guidance is anticipated from NHS England for CCGs related to the development of local QOFs, for example a Frailty QOF.
Older people with frailty are strikingly sensitive to adverse effects from taking several different types of medication and it is a common trigger for (possibly avoidable) hospital admissions. Feedback from older people living with frailty who have been offered interventions supports a need for services to be provided closer to the person’s home. Patients, especially in rural areas, declined referrals to community hospitals because of the burden associated with travel; multiple referrals were also declined. Indeed, the identification of the apparent need for multiple referrals provided CCGs with an important practical trigger to streamline care pathways.
For frailty to be managed across entire systems, commissioning strategies need to support information sharing through shared health records/summaries. Communication of a frailty diagnosis in referral letters is a useful way to support increased frailty recognition.
Evaluating frailty services
The British Geriatrics Society Fit for Frailty guidance has pointed out that service level outcomes (such as reduced emergency admissions, and reduction in health and social care costs) are unlikely to be seen in the immediate aftermath of a service change. Outcomes across a range of person-centred indicators is more likely to provide evidence. NHS England is working on a set of indicators which should form an important tool to support outcomes based commissioning for older people’s services.
Case Study: falls prevention at Outlon Medical Centre, NHS Leeds South & East
Oulton Medical Centre used the electronic Frailty Index (eFI) to identify patients with moderate frailty to offer a falls prevention support. Patients were asked to complete a falls questionnaire and medicine information was collected from their electronic health record. Then they were invited to the GP practice for a lying and standing blood pressure measurement, a mini medication review, health promotion related to falls prevention, and referral to other services such as a full clinic if necessary.
Findings from the pilot showed documentation was lacking in the patients’ EHR about falls – only 15% of patients had a fall recorded record but 60% patients reported a fall or stumble in the past 12 months. Many patients presented with polypharmacy (between 4-24 medications; average number 9); many were on medications which can increase the risk of falling.
No patients had a lying/standing blood pressure documented in their electronic records. However, 16 patients had attended A&E in the previous 12 month. Of the patients who received the falls prevention intervention, 44% had evidence of a significant lying/standing BP drop and 78% required interventions to reduce their falls risk, such as medication changes, or referrals to secondary care (see figure 1).
Case study: practice nurse-led frailty assessments at Hambleton, Richmondshire and Whitby CCG
In NHS Hambleton, Richmond & Whitby CCG a cluster of GP practices are piloting a service which offers patients at risk of frailty home based frailty assessments delivered by a practice nurse. The team are using the eFI to identify patients with whom the practice nurses will work to develop individualised care and support plans following assessment which reflects the British Geriatric Society Fit for Frailty guidance. The nurses will link patients with other local services such as GP integrated multidisciplinary team meetings, comprehensive geriatric assessment clinic, voluntary and community services, and community nursing services.
Outcomes include patient reported quality of life, and health and care use including primary care and A&E. Early findings suggest proactive frailty assessments in primary care are effective in identifying unmet need among patients identified using the eFI.
Case study: care of the frail elderly scheme at North Durham CCG
North Durham CCG has developed a frailty model of care across primary, community and secondary care which aims to improve identification and diagnosis and to drive up the quality of assessment and care and support planning.
The CCG is aiming for practices to create a frailty register, assess at least annually around 1% of their non-institutionalised population for frailty, and create a care plan for patients diagnosed with it.
First published October 2016 in Commissioning Magazine