NATIONAL
https://www.england.nhs.uk/ourwork/clinical-policy/older-people/frailty/frailty-risk-identification/
Ageing well and supporting people living with frailty
We are working to develop patient-centred services that enable people to age well. Frailty is where someone is less able to cope and recover from accidents, physical illness or other stressful events. It should be treated as a long term condition throughout adult life. This means starting with prevention and early identification of frailty and supporting people appropriately on the basis of their needs through to the end of their life.
Many of the factors that cause people to age differently can be influenced by interventions based on preventative healthcare, lifestyle choices and exercise. Frailty (rather than age) is an effective way of identifying people who may be at greater risk of future hospitalisation, care home admission or death. For example, people living with severe frailty have over a four times greater annual risk for these outcomes. Older people with frailty who need to undergo surgery can have less successful outcomes if the frailty has not been identified prior to the operation.
This means population-level frailty identification and stratification can help plan for future health and social care demand whilst also targeting ways to help people age well.
Frailty is relatively easy to recognise when severe, but identifying it in older people with less advanced frailty can be challenging. It’s important that people who are defined by the electronic Frailty Index (eFI) as fit, mildly or moderately frail are supported to manage their health and wellbeing as they age, while those identified as living with severe frailty are properly supported according to their needs.
REGIONAL
ICS
ICB
PRIMARY CARE
Somerset’s Complex Care Team ( NHSE exemplar)
A complex care team in Somerset, working in an integrated neighbourhood team model, has supported more than 21,000 people in the last two years, helping to reduce unplanned hospital visits by 14%.
They take referrals from across the system and advise on complex management, service co-ordination, care planning and ensuring gold standard communication.
SFT
LOCAL AUTHORITY
VCSFE