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Undertaking the frailty requirements of the GP contract

Practices are now required to routinely identify and review patients over 65 with moderate or severe frailty. Practice manager Fionnuala O'Donnell provides advice on how to do this and highlights some useful resources.

From July practices are required to routinely identify and review patients over 65 with moderate or severe frailty.

Practices will be required to use an appropriate tool, for example the Electronic Frailty Index (eFI), to identify patients aged 65 and over who are living with moderate or severe frailty.

Moderate and severe frailty are defined as follows:

  • Moderate frailty (eFI score 0.25 – 0.36): People who have difficulties with outdoor activities and may have mobility problems or require help with activities such as washing and dressing.
  • Severe frailty (eFI score  0.36): People who are often dependent for personal carers and have a range of long-term conditions/multi-morbidity. Some of this group may be medically stable but others can be unstable and at risk of dying within 6 - 12 months

What next?

Once you have run the eFI tool, you will know:

  • which patients have severe frailty.
  • which patients have moderate frailty: however, clinical judgement is required to determine whether that diagnosis is appropriate.  

The BMA says that a GP or another appropriate clinician should review the results of the eFI before any results are recorded in the patient record.

For those patients identified as living with severe frailty, practices will be required to:

  • deliver a clinical review, including providing an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12 months
  • provide any other clinically relevant interventions
  • explain the benefits of the enriched Summary Care Record (SCR), seeking informed patient consent to activate it.

Template invitation letter

The clinical review

These are some key topics to think about asking at the clinical review

Components for frailty

  • Alcohol excess  
  • Cognitive impairment
  • Falls
  • Functional impairment
  • Hearing problems
  • Mood problems
  • Nutritional compromise
  • Physical inactivity
  • Polypharmacy
  • Smoking
  • Social isolation and loneliness
  • Vision problems
  • Incontinence

Review of the individual’s situation

  • Physical health
  • Mental health
  • Falls review: has the patient fallen in last 12 months, would patient benefit from falls referral?
  • Activities of daily living (washing, dressing, grooming continence and mobility) and for life functions (communication, cooking, shopping etc.)
  • Social support networks and signpost to local voluntary services
  • Individualised goal setting  (who will do what and when)
  • Medication review
  • Anticipatory care planning: starting the conversation around what happens if there is an emergency, if the patient falls, thinking about advanced care planning and end of life where appropriate

Useful resources

Below are some useful resources that could be added to the practice website, emailed or texted to patients or printed for patients when they attend for their review.

General advice

General health advice

Make your home safe

Look after your feet

Fionnuala O'Donnell is a practice manager in Ealing, West London, and a CCG board member

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