Proactive care intervention for moderate frailty in primary care: developing the Brighton & Hove West Integrated Community Team

Introduction 

There is growing evidence that proactively intervening in frailty improves outcomes, though some have concerns about implications for GP workload. This project aimed to establish an integrated community neighbourhood health approach to proactively support adults living with frailty whilst minimising additional GP input.  

Methods 

General practice, Sussex Community Foundation Trust, Adult Social Care and VCSE organisations Age UK West Sussex, Brighton & Hove and Hangleton and Knoll Project worked together to deliver a modified-Comprehensive Geriatric Assessment to adults aged 65 years and older with moderate frailty including those on an Adult Social Care or Falls Team waiting list. Exclusions were severe frailty, dementia or severe mental illness (needs met through a different service), palliative care, or care home residents.

Patients underwent an interview with the social prescriber who completed the Arden's Over 75 Frailty Template (V18.6) and signposted to further community support and/or flagged unmet medical needs to the GP) and a clinical pharmacist who completed a structured medication review (SMR). 

Outcomes included patient-reported EQ-5D-5L, number and types of referrals, anticholinergic burden (ACB) score pre- and post- SMR, and number of medications stopped. 

Results

Forty-eight patients from two practices were included. Almost all reported increases in EQ-5D=5L (range +2 to +15); improvements correlated with safety interventions, social connection, and medication changes. Twenty-seven medications were stopped, 10 were changed or reduced, and 7 were added to reduce harm; ACB did not change. Two-hundred-and-eighteen onward referrals were made across 28 distinct pathways. Positive feedback highlighted the joined-up holistic approach. 

Conclusion

This simple proactive frailty intervention can be delivered well to those with moderate frailty by a wider community team without it becoming burdensome for GPs. Enablers of success included involving interest-holders in agreeing governance and operational processes, establishing information-sharing pathways, and a shared understanding of roles and requirements of each involved organisation.