Improving MDT-wide recognition of frailty in general practice

Introduction: 

Timely identification of frailty in the community is essential for implementation of support and strategies to slow progression of frailty, allowing older adults to live safer and more independent lives. Given the diverse MDT within primary, it is important that such members are equipped with the knowledge on how to recognise frailty, and what next steps should be taken to mitigate its course. Delayed recognition of frailty leads to a reduction in access to AHP support and poorer health outcomes.

Our aim was to improve MDT-wide awareness and objective documentation of frailty in a primary care setting, establishing a streamlined pathway for identified frail patients to access targeted Advanced Nurse Practitioner (ANP) and Occupational Therapy (OT) care.

Method:

Baseline frailty coding and which MDT members were coding was assessed prior to intervention, with re-audit at 3 months  and planned for 6 months post-implementation. Informative sessions were conducted for the medical team, and the wider MDT team surrounding common frailty indicators, how to code a patient as frail, the Clinical Frailty Scale, and stepwise management of patients deemed to be frail. The clinical frailty scale (CFS) was embedded into the annual review template undertaken by nursing staff for older patients, and those living with chronic illness.

Results:

Prior to implementation 115 patients were recorded as frail, this coding was done by frailty ANP staff only. All coding was for CFS 5 and above. 

Following intervention, a further 67 patients were recorded as frail with 19% of coding done by the wider MDT team. Patient's coded as frail were invited to annual review, and formal OT referral was recommended. 

Conclusion:

Embedding the CFS into routine annual reviews ensures early identification and facilitates timely, multidisciplinary management by Frailty ANPs and OTs, ultimately moving care from reactive crisis management to proactive community support.