Fit for Frailty Part 2 - commissioning services for frail older people
Much of the current effort in commissioning services is focused on finding ways to reduce unplanned emergency hospital admissions.
While there is little evidence for a programme which targets those at highest risk of hospital admission, systematic reviews of interventions in patients with frailty (as opposed to long term conditions generally) have demonstrated improvement in several outcomes including reducing hospital stays, maintaining independence and reducing care home admissions.
The British Geriatrics Society’s recent campaigns have all centred around raising awareness of frailty as a condition which is not an inevitable part of ageing; is dynamic by nature (in a single individual with frailty, function can improve or deteriorate depending on several factors related to the frailty), and by failing to identify and manage frailty, a patient with the condition risks considerable harm and disability. We have Frailsafe - the protocol for identifying frailty in the patient who presents at A&E; Fit for Frailty (Part 1) - guidance aimed at health care professionals who do not have specialised knowledge of geriatrics but who come into contact with older people in community settings; and now, Fit for Frailty (Part 2) - guidance for developing, commissioning and managing services for people living with frailty in community settings.
The audience for the guidance includes GPs, geriatricians, Health Service managers, Social Service managers and Commissioners of Services. Fit for Frailty Part 1 was produced in association with Age UK and the Royal College of General Practitioners (RCGP). For Part 2, the RCGP co-authored the guidance.
Despite the evidence for improved outcomes when people with frailty are correctly managed, there is no code for frailty in ICD10, hence it is not recognised as an important issue in secondary care.
The BGS Fit for Frailty guidance (both parts) emphasises the necessity for understanding what frailty is and the risks attendant on failing to identify the condition, Part 2’s particular focus is on the infrastructure required to manage frailty; the need to look for and identify the condition and it sets out the principles whereby services may manage the condition.
While there may be some overlap between the management approaches of people with multi-morbidity, disability and those with frailty, both the BGS’s Fit for Frailty campaigns emphasise that the differences are important and outline the reasons why frailty needs specific consideration. Some people whose only long term condition is frailty, says both documents, may not be frequent users of health services. They may not be well-known to their GP until they become bedbound, immobile or delirious as a result of an apparently minor illness. The relationship between dementia and frailty is also important. People with dementia have an increased incidence of frailty and people with frailty have an increased incidence of dementia. People with frailty may, however, have cognitive problems that fall short of the definition of dementia and which may be reversible with an appropriate treatment approach for frailty.
At the heart of confirming the presence of frailty and managing the condition is the comprehensive geriatric assessment (CGA). Frailty-sensitive services need to make interventions available which improve overall physical, mental and social functioning, using a goal-orientated rather than a disease-focused approach, taking account of individual needs and personal assets, rather than deficits. Fully integrated health and social systems are essential to address the whole pathway across primary care, community care and secondary care. This includes joint working with ambulance services, community teams, geriatricians and old age psychiatrists.
The importance of shared care and support plans which involve the older person with frailty, the family and carers through all the stages of the process is highlighted. The guidance urges a recognition that most of the long-term care and support for those with frailty is provided by family, friends and private carers. These people should be identified, supported and networked into the primary care and community teams.
While services should provide real and safe alternatives to hospital admission, when admission is clinically appropriate, health and social care need to overcome their historical ‘territory’ and develop pathways to ‘pull’ older people with frailty out of hospital and prevent unnecessary days in transfer of care.
To achieve greater integration, services need to develop local training and education packages structured around the application of CGA in frailty for multi-professional teams, working in primary, community, intermediate and secondary care to maximise the sharing of skills.
As with Part 1, the guidance includes a number of case studies featuring aspects of integrated pathways and service models for the management of frailty.
Vice President for Clinical Quality