Improving frailty coding through a systems approach in primary care

3683

Helen Kingston , Richard Podmore, Dan Tucker

Frome medical practice

Abstract

Introduction

Frailty is a strong prognostic predictor. By incorporation routine frailty scoring as part of routine primary care this can help as guide to clinical teams

Method

In 2021 we recognised that our we needed to improve identification of frailty.

We undertook whole team training of nurse, GPs and Health Care Assistants , and incorporated scoring the Rockwood Clinical Scale as a routine part of regular chronic disease reviews and template for those over 80. An alert was added on the clinical system to highlight last Rockwood score or where this remained outstanding.

Results

In May 2020 we have proactively recorded frailty status as mild moderate or severe frailty or a Rockwood score in only 22% patients and 27% patients in May 2021 and 33% in May 2022

With implementation of a systematic approach the completeness of our data has improved from to 66% by may 2023 and has since steadily increased to 81% in May 2024 and 90% in May 2025.

Comparison with neighbouring practices in Mendip where this change was not implemented shows a smaller incremental rise in completeness of recording from 33% in 2020 to 47% in may 2025

Conclusion.

Although in 2021 our proactive coding for frailty lagged behind the performance of other Mendip practices, we have been able to make improvements from coding 24.3% of those over 80 to now having coded 90.1% of this group through a systematic approach.

Working as a whole practice team it has been possible to identify those living with frailty using Rockwood scoring.

The coding of those at advanced age who are not frail can also help ensure this group continue to have full medical interventions and are not subject to age discrimination

Presentation

Comments

could this be rolled out more broadly?

This is really interesting and informative. What training did you do for the practice team? Do you think this could be rolled out more broadly for INT use in future? I think that the identification of NOT frail elderly people is helpful in highlighting that there are still differentiations to be made despite aging and that interventions need more targeted approach than just age as discriminatory factor

Further roll out

Arden’s has now included rock wood frailty score as an element of their combined chronic disease template for primary care

We found that training and addition of system alerts and a template prompt really helped to ensure broad range of opportunities to review were used.

Coding of those who were not frail helped ensure they continued to receive active care appropriate to their status

The remaining 9% is now a manageable number to focus upon and take proactive steps to establish their status

Thanks for this interesting…

Thanks for this interesting poster. In UK primary care services, are there guidelines about caring for patients who are flagged as being frail?

This is indeed interesting…

This is indeed interesting work. Thank you. Do you also use the eFI to identify those with frailty?

Rockwood scores

We have not found the electronic frailty index reliable and frailty needs clinical verification. It is not uncommon for patients with an efi on primary care records where it is inaccurate to take offence and contact the surgery to query this. Patients now have access to gp records via the nhs app.

Rockwood is an objective observation and clinically useful as well as being accepted by patients