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
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
- Functional impairment
- Hearing problems
- Mood problems
- Nutritional compromise
- Physical inactivity
- Social isolation and loneliness
- Vision problems
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
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.
- Improving later life – Understanding the oldest old. This is a detailed booklet from Age UK looking at the latest research and highlighting expert advice on all aspects of ageing.
- Arranging for someone to make decisions on your behalf – information factsheet from Age UK
- More money in your pocket – a guide to claiming benefits for people over pension age – from Age UK
- Care and support planning guide – information for patients and carers from National Voices
General health advice
Make your home safe
- Making your home dementia friendly – booklet from the Alzheimer’s Society
- Patient leaflet on falls prevention from patient.info
Look after your feet
- NHS Choices information on foot care
- Self care guide to looking after your feet - produced by Rotherham Doncaster and South Humber NHS Foundation Trust
Fionnuala O'Donnell is a practice manager in Ealing, West London, and a CCG board member