Many frail elderly people in hospital could be cared for more effectively in the community, or could avoid admission altogether if more robust preventative services were in place.

1. NHS
Improving Quality
Long Term CondiTions CAse sTUdY
Frailty pathway integrates service to provide
more and better care outside of hospital
summary
• Many frail elderly people in hospital could be
cared for more effectively in the community,
or could avoid admission altogether if more
robust preventative services were in place
• Lincolnshire West CCG led the creation of an
integrated frailty pathway, supported by a
wider range of services including a
community response team, to enable the frail
elderly to remain healthy and safe at home
• The Canadian Frailty Scoring Tool was used to
identify people at risk of unnecessary hospital
admissions so that they can receive
appropriate care planning and proactive
support
• Following the introduction of the new
pathway, unscheduled hospital admissions
and excess bed days for the over 75s have
fallen and people are more likely to be cared
for at home by the clinician best placed to
help them
Background
Like many parts of the country, Lincolnshire
West has a growing older population. One in
12 people are over 75 years old.
An analysis of elderly wards in Lincoln County
Hospital found that one in five patients over the
age of 75 could have been treated more
effectively in a community setting, or may have
avoided admission altogether, had more robust
preventative measures been in place. This was
backed by anecdotal evidence with patients
telling their GPs that they struggled to get
timely social care support and ended up in
hospital as a result.
This situation was not only an issue in terms of
patient experience and safety, it also had a
significant financial impact on the local health
economy, as relatively expensive secondary care
costs were being allocated to patients who
need not have been admitted had more
effective community care been available.
Lincolnshire West CCG established a project to
develop a more integrated healthcare system
for local people. It aimed to ensure that the frail
elderly can remain healthy and safe at home
with a rapid community response to offer a
viable alternative to hospital admission.
1

2. Action
A steering group was established which
brought together secondary care clinicians, the
ambulance service, mental health providers,
community nurses and social care. The CCG
also brought in external support to identify
gaps in current services and offer additional
service redesign expertise. Over 1,000 local
people were involved in a consultation to seek
their views on the current system and the
proposed model.
The CCG created a frailty pathway, integrating
services to ensure that:
• People’s health can be maintained well and
safely in their own homes
• People can be supported to remain safely at
home in times of crisis
• People admitted to hospital return home
safely and in a timely manner.
The project team worked with clinicians,
patients and carers to develop an effective
pathway of care to identify and manage frailty,
from prevention through to end of life care.
Implementing the pathway required a number
of service changes, including:
• Developing the range and accessibility of
third sector services (transport and
befriending services, etc)
• Creation of a community geriatrician post
• Establishment of integrated community
response teams
• Additional training and enhanced GP
involvement for local care homes.
GP practices used the Canadian Frailty Scoring
Tool to identify patients at risk of unnecessary
hospital admissions. The use of the tool was
initially embedded in primary care, as the most
frequent point of first contact. It has since been
rolled out for the wider community team to use
to ensure people are receiving appropriate care
planning and proactive support.
During the consultation with local people, a
pilot group was asked to score themselves using
the same criteria as the tool to check that it
made sense to them. There was a remarkable
similarity between self-reported scores and
those from clinicians, building confidence in the
reliability and effectiveness of the scoring tool.
Frontline staff received training in the use of the
scoring tool and the new pathway from the
multi-disciplinary team and a care of the elderly
consultant. The training taught staff how to
track patients through the entire health system
and sought to secure buy-in to the new
pathway with an evidence-based case for
change. CPD points were awarded for the
session run by clinicians and the high-level
support for the initiative ensured that
organisations reorganised rotas to release staff
for the training.
The project did not require any financial
investment and was funded by using existing
resources more efficiently and effectively
through the new frailty pathway.
impact
Since the pathway and the associated service
changes were introduced, almost three quarters
of patients over 75 years in West Lincolnshire
have a registered frailty score. This means that
these patients are in a position to receive the
most appropriate care from local health
providers. As a consequence:
• There has been a 3% reduction in
unscheduled hospital admissions for the over
75s – at a time when figures have been
increasing nationally
2

3. • There has been a 36% reduction in excess
bed days – again as national figures have
been increasing
• Recent data shows an 8-9% reduction in
emergency admissions for frail people
• People are more likely to be cared for at home
by the clinician best placed to help them
• Patients and carers are more likely to have access
to appropriate information, advice and support.
next steps
This is an ongoing programme. The next steps
will involve GP federations in setting up
neighbourhood teams to develop more
community-based services, including mental
health and acute outpatients, so that patients
are only referred to specialist care where necessary.
ToP TiPs
Don’t underestimate the time needed:
Implementing new assessment and
management approaches takes time. it was
vital to secure buy-in from all partner
organisations from the start and this was
more time consuming than envisaged.
Steering group to engage stakeholders:
The steering group played a crucial role in
involving all partners and strong
relationships have been built as a result. All
participating organisations are very
energised by their involvement.
Identify a GP lead: While all steering group
members played a part in engaging GPs, with
every practice visited by one of the group, the
appointment of a GP lead was seen as very
valuable in creating a focal point for securing
GP support.
involve patients and explain what will be
different: The patient and carer involvement
was very valuable, but to make it meaningful it
was important to focus on detailed
explanations of how the new service will be
different in practice and how this will improve
the care they receive.
Further information
• West Lincolnshire integrated frailty pathway case study on NHS England learning
environment website: https://learnenv.england.nhs.uk/pinboard/view/42
• Canadian Frailty Scoring Tool
http://geriatricresearch.medicine.dal.ca/pdf/Clinical%20Faily%20Scale.pdf
Contact
To discuss this project, please contact Dr Sunil Hindocha, Chief Clinical Officer,
Lincolnshire West CCG: sunil.hindocha@lincolnshirewestccg.nhs.uk
3
improving health outcomes across england by
providing improvement and change expertise
To find out more about ‘Long Term Conditions’ programmes:
www.nhsiq.nhs.uk | enquiries@nhsiq.nhs.uk | @NHSIQ