Impact of a Digital Proactive Care tool, Fr EDA (Frailty End of life Dementia Assessment) on improving quality of care & outcomes across an ICS population of 1.34 million

Introduction:

Adults living with frailty, dementia or nearing end of life, frequently experience identification/diagnosis delays, inequalities, avoidable harms, poorer outcomes and premature mortality.

Frailty and End of Life Care (EOLC) evidence based Proactive interventions can improve outcomes, yet delivery across providers is low and inconsistent.                                                                                                      

Mid & South Essex (MSE) has a population of 1.3 million, 114,000 (9%) are estimated to be living with frailty, dementia or may have EOLC needs (most unrecognized), generating over 62% of 999 calls, 90% of hospital occupied bed days, 71% of community activity and 26% of GP appointments.

Aim:

To evaluate the 2023–2025 impact of FrEDA, a digital Comprehensive Geriatric Assessment (CGA) and Advance Care Planning (ACP) tool implemented across multiple provider (primary, community, mental health, hospice) electronic health record (EHR) systems to support consistent, proactive care delivery for frailty, dementia and EOLC needs.

Methods:

Population Health Management data and ICS dashboards measure impact on identification, intervention delivery, hospital admissions and population deaths

FrEDA delivers seven proactive actions: 1. Frailty staging using Clinical Frailty Score (CFS); 2. Cognition and Delirium screening (including Dementia diagnosis); 2. Structured Medication Reviews;        4. multi-factorial Falls Risk Assessment; 5. Personalized Care & Support Planning; 6, Earlier recognition and staging of EOLC needs; and 7. Advance Care Planning (ACP).

Results:

ICS-wide: >20,000 more people frailty scored using CFS. Delivery of proactive interventions including medication review, falls assessment and delirium screening increased by 72%. Dementia Diagnosis Rates improved by >15%. Identification of people with EOLC needs and receiving ACP increased by 50%, Anticipatory palliative medication prescribing rising by 39%.

Population deaths in hospital fell from 46% to 39%. Proportion with three or more hospital admissions in last 90 days of life reduced by 52%. Falls-rates decreased by 50%. Non-elective admissions from care homes fell by > 45%.

Conclusion: FrEDA enables scalable collaborative delivery of proactive frailty and EOLC interventions, significantly reducing admissions, in-hospital deaths and falls. Its digital approach supports wider adoption across more providers and teams.