Embedding Routine Clinical Frailty Scale Screening with a Frailty Care Bundle in Primary Care: A Quality Improvement Initiative

Introduction:
Frailty is associated with falls, hospitalisation, functional decline and mortality, but routine frailty assessment is rarely embedded in primary care. Early identification enables proactive, person-centred interventions. This quality improvement (QI) initiative aimed to implement routine Clinical Frailty Scale (CFS) screening for patients aged ≥65 years and evaluate its impact on frailty identification and delivery of evidence-based frailty care.
Methods:
A before-and-after QI initiative using three Plan–Do–Study–Act (PDSA) cycles was conducted in a family medicine clinic. The intervention comprised staff training, electronic medical record (EMR) templates, automated reminders, and a structured frailty care bundle comprising medication review, falls risk assessment, nutrition screening, vaccination review, and referral for Comprehensive Geriatric Assessment (CGA) when indicated. Data were collected from the first 190 consecutive eligible patients seen during the two months before implementation and the first 190 consecutive eligible patients seen during the two months after implementation. The primary outcome was documented CFS assessment. Secondary outcomes were completion of key frailty care bundle components among patients with CFS ≥5.
Results:
Documented CFS assessment increased from 26% (49/190) before implementation to 71% (135/190) after implementation (p<0.001). Among patients with CFS ≥5, medication review increased from 27% to 79%, falls risk assessment from 31% to 72%, nutrition screening from 24% to 68%, vaccination review from 45% to 81%, and appropriate CGA referrals from 19% to 58% (all p<0.05). Following the third PDSA cycle, routine CFS screening was embedded in standard clinical workflow with sustained compliance of approximately 70%.
Conclusion:
Embedding routine CFS screening alongside a structured frailty care bundle was associated with improved frailty identification and delivery of evidence-based frailty care for older adults in primary care. This scalable QI model provides a practical framework for proactive frailty management and may facilitate wider implementation of frailty screening across community healthcare settings.