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identify frail patients who are at future risk of deterioration practically by 4m walking speed test and then read coding frailty score/eFI.
CGA based assessment of the elderly considering patient's problems and patients concerns rather than diagnosis or compartments of care.
Promote supported self management to all patients.
R Wilson

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Planned review of recently discharged patients to prevent readmission and promote care in the community.
Review of unscheduled admissions to learn from these and implement changes that would prevent future unnecessary admissions.
Judith N.

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Provide supported self management for patients with mild frailty opportunistically.
In providing care and support planning for patient with moderate frailty, it is important to identify and address patient's goals.
Judith N

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Use of simple tests like the 4m walking speed and coding for frailty (Primary care electronic frailty index) is necessary to identify frailty and the severity of frailty. This helps in tailoring management to individual patients especially in providing preventative and proactive care.
Judith N.

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Using codes to highlight people with mild, moderate and severe frailty would be helpful when meeting a patient for the first time. This could also be uploaded in to their KIS, which would provide info to OOH services. I think this would help avoid unnecessary or inappropriate interventions for more frail people (in the same way as the palliative coding acts). Also acts as a reminder that frailty is a clinical condition which should be taken into consideration alongside other long term conditions. K Beardon

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As per the presentation, being aware of the patient's priorities may help guide which approach to take, and allow discussion for a more pragmatic approach. K Beardon

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Acknowledging that it would not be possible for a single GP to carry out an entire CGA in one appointment, I think the idea of using the CGA as a basis to approach managing older people with frailty and multiple long term conditions would be helpful. This may help identify people earlier and allow care plans to be discussed before crisis is reached. K Beardon

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It's possible to act early to improve health for patients with mild frailty

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It's possible to act early to improve health for patients with mild frailty

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As part of our new frailty service can we implement supported self - managment plans?  The lecture made reference to developing these with Age UK - could we link with Age Scotland?
Nicola Lewthwaite

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As we are setting up our NHS Fife frailty service, we need to build links with allied health professionals, especially social work and ICASS so that we can offer the multi-disiplinary component of the comprehensive geriatric assessment
Nicola Lewthwaite

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We need to research how we can stratify our patients into these groups so we can set referral criteria for the different groups into our new service
Nicola Lewthwaite

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Early identification in the frailty process prior to decompensation. Improved access to on the day medical advice.  Regular risk profiling and case finding.  The identification of a named GP and social care-co-ordinator and post-hospital discharge follow-up.

Within our planned community frailty service, we could act as the single point of access or "advice" for patients who are close to crisis.

Lynsey Frew

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Community Based and person-centred, co-ordinated care.

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Community Based and person-centred, co-ordinated care.

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These patients are challenging being likely to have several other co-morbid conditions in addition to frailty.  A comprehensive and holistic approach requires multi-disciplinary team working between health, social, mental health and voluntary sectors.

Having a named GP similar to the system currently used for palliative patients would allow better cohesion.  In advanced cases of frailty, (e.g. NH residents), use of the Gold Standards Framework may be appropriate and relevant.

Lynsey Frew

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Early identification of frailty syndromes.

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Early identification of frailty syndromes.

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Stratifying frailty into 3 categories of mild, moderate and severe is a logical approach.  This will allow a more preventative approach particularly in the "mild" cohort who can have supported self management and slow the progression to "moderate" or "severe" frailty. I liked the idea of using the "Primary Care Electronic Frailty Index" ( eFI) to identify patients.  This will help us identify these patients early prior to decompensation to allow assessment within our planned community frailty service.

Lynsey Frew

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Guideline based care v's Care and Support Planning

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Guideline based care v's Care and Support Planning

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single disease v's multiple comorbidity
look at ways to get away from disease based reviews to patient reviews.
P Treon

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1/risk profiling
2/post discharge follow up --> reduced readmissions
RAFC follow up for discharged patients
3/reviews of unplanned admissions
Suggest to team that ALL admissions from team are reviewed to see if avoidable.
P Treon

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Early identification of Frailty - mild/moderate/severe

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Early identification of Frailty - mild/moderate/severe

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Make use of read coding to add to GP records, and add as diagnosis on intermediate care discharge letters
P Treon