Improving Frailty Care in CKD: Implementing an OT/PT Integrated Renal Frailty Service

Introduction

The Trust’s Advanced Kidney Care (AKC) outpatient clinics support people with stage 4 chronic kidney disease (CKD) and those on conservative kidney management. Best practice recommends early frailty identification and targeted intervention through integrated multidisciplinary care. Despite over 60% of AKC patients having a Clinical Frailty Scale (CFS) score ≥4, no structured frailty pathway existed, and occupational therapy (OT) and physiotherapy (PT) were absent from the service. This improvement project aimed to design, implement, and evaluate an integrated frailty pathway incorporating OT, PT, and geriatrician input over a two‑year period.

Methods

A multidisciplinary steering group co‑designed the pathway using iterative feedback from clinicians and patients. A formal referral criterion enabled direct referral to the frailty team. All patients received a Modified Comprehensive Geriatric Assessment (mCGA), including “What Matters to Me” goal setting, collaborative problem‑list formulation, and identification of functional, cognitive, and environmental risks. OT/PT interventions were tailored to clinical need, and patients were followed up at 6 and 12 months to collect repeat outcome measures, including CFS.

Results

307 patients were assessed by the therapy team and received an mCGA. Over 65% received exercise prescription, 35% fatigue‑management support, 10% equipment provision, and more than 240 onward referrals were made to community teams, social services, and other healthcare professionals. Patient‑reported outcomes demonstrated strong clinical effectiveness: 97% agreed therapy input provided unique benefit and improved their ability to manage health and wellbeing. Qualitative feedback emphasised feeling heard, valued and supported. Follow‑up CFS scores over 6-12 months showed no significant change, indicating functional stability in a population typically expected to deteriorate.

Conclusions

Integrating OT and PT into AKC clinics delivered clinically effective improvements in functional ability, symptom management, and patient self‑efficacy. Therapy‑led frailty management is feasible, acceptable, and provides a clinically impactful model for improving frailty outcomes in advanced CKD.