Introducing a Toolkit to support the management of Frailty in Primary Care: - Understanding the concept of frailty as a long term condition - Understanding how frailty can be managed effectively in primary care - Understand how to access and implement practical tools which can support identification, assessment and care planning for older people living with frailty in primary care.

1. WELCOME
Wednesday 15 April 2015 Webinar
Introducing a Toolkit to support the
management of Frailty in Primary Care

2. Introducing a Toolkit to support the
Management of Frailty in Primary Care
Wednesday 15 April 2015
12.30pm – 1.30pm
Helen Lyndon
Nurse Consultant Older People, Clinical Lead Frailty, NHS England
&
Beverley Matthews
LTC Programme Lead, NHS Improving Quality

3. Beverley Matthews
LTC Programme Lead
NHS Improving Quality
Beverley.matthews@nhsiq.nhs.uk

4. LTC Year of Care
Commissioning Programme:
• 5 Early Implementer sites
• 35 Fast Followers
• Whole Population Datasets
• Implementation Guide
• Simulation Modelling
• Specialist Support Team

5. LTC Person Centred Care
Improvement Programme:
• 40 Early Implementer sites
• 4 regional learning networks
• Snapshot Survey
• Simulation Modelling
• Specialist Support Team

6. Long Term Conditions Learning Community
• LTC Dashboard
• Case Studies
• Lunch and Learn Series
• The Bulletin
• Specialist Support Team
@NHSIQ @bev_j_matthews #LTCimprovement #LTCyearofcare

7. LTC Lunch & Learn Series
….coming soon…
Date Webinar Hosted by Bev Matthews &
17 April 2015
12.30 – 13.30
Information Standards for End of Life Care
(ISB150) supporting the implementation
of Electronic Palliative Care Coordination
system
Adam Hatherly, HSCIC
&
Christine Wike, NHSIQ
29 April 2015
12:00 – 13:00
Information Sharing for Care Coordination Adam Hatherly, HSCIC
&
Christine Wike, NHSIQ
1 May 2015
12:30 – 13:30
Information as a Therapy Mark Duman
MRPharmS Director
Monmouth Partners
6 May 2015
12:30 – 13:30
Prevention & Effective Interventions in
Frailty
Helen Lyndon
Nurse Consultant Older People, Clinical
Lead Frailty, NHS England
27 May 2015
12:30 – 13:30
Primary Care Workforce for the 21
Century Webinar
Sharon Lee
Primary Care Workforce Facilitator
South Kent Coast CCG
9 June 2015
12 noon – 1pm
Health 1000 Rob Meaker
Barking, Havering & Redbridge

8. Introducing a Toolkit to support the management of Frailty
in Primary Care
• Understanding the concept of frailty as a long term condition.
• Understanding how frailty can be managed effectively in
primary care.
• Understand how to access and implement practical tools
which can support identification, assessment and care
planning for older people living with frailty in primary care.
of Care foundation.
Today’s Learning Outcomes

9. www.england.nhs.uk
Devon and
Cornwall Frailty
Toolkit.
Helen Lyndon
Nurse Consultant
Clinical Lead for Frailty
NHS England
Lunch and Learn Webinar 15th April 2015

10. www.england.nhs.uk
• Understand the concept of frailty as a long term
condition.
• Discuss how frailty can be managed effectively in
primary care.
• Access and implement practical tools which can
support identification, assessment and care planning
for older people living with frailty in primary care.
Introducing a Toolkit to Support the
Management of Frailty in Primary
Care

11. www.england.nhs.uk
Frailty – a complex syndrome of
increased vulnerability
11
Life course
determinants:
Biological
Genetic
Psychological
Social
Environmental
Decline in
physiologic
reserves
+
Multiple
long term
conditions
Candidate markers:
Nutrition
Mobility
Activity
Strength
Endurance
Cognition
Mood
Adverse Outcomes:
Disability
Morbidity
Hospitalisation
Institutionalisation
Death
Prevent/delay frailty
Primary prevention
Health promotion
Delay onset
FRAILTY
Delay/prevent adverse outcomes
Rodriguez-Mañas L, Fried LP. Frailty in the clinical scenario. Lancet. 2014 Nov 6
Reversibility

12. www.england.nhs.uk
A definition of frailty
• Frailty is not a disease but a combination
of the natural ageing process and a variety
of medical problems.
• It focuses on the loss of reserve, energy and wellbeing.
• A useful definition is: “Multidimensional loss of reserves -
energy, physical ability, cognition and health”
Rockwood et al (2005)
Ageing Fitness
Disease

13. www.england.nhs.uk
Frailty is a loss of physiological reserve
Clegg, Young, Rockwood Lancet 2013

14. www.england.nhs.uk
Frailty as a Long Term Condition?
A Long Term Condition is:
“A condition that cannot, at present, be cured but
is controlled by medication and/or other
treatment/therapies” (DH 2012)
Frailty is:
• Common (25-50% of people over 80 years)
• Progressive (5 to 15 years)
• Episodic deteriorations (delirium; falls; immobility)
• Preventable components
• Potential to impact on quality of life
• Expensive

15. www.england.nhs.uk
Proactive interventions in frailty
Ten years ago
Two years ago
One month ago ‘He is a
fall
waiting to
happen
“Dad is
slowing
down”
“I’m not
as steady
on my
feet as I
was”

16. www.england.nhs.uk
Proportion
alive
Time
Primary care electronic Frailty Index (eFI):
survival plots (n=227,648; >65y)
Fit
Mild frailty
Moderate frailty
Severe frailty
5 yrs

17. www.england.nhs.uk
Frailty Toolkit for Primary Care
Includes:
• Case finding tools and advice
• How to populate frailty registers and
read coding
• Comprehensive geriatric
assessment
• Care coordination
• Care planning
• Medication review in frail older
people
http://www.nhsiq.nhs.uk/improvement-programmes/long-
term-conditions-and-integrated-care/long-term-
conditions-improvement-programme/house-of-care-
toolkit/national/commissioning/tools-and-
levers/enhanced-services-resources.aspx

18. www.england.nhs.uk
Questions and
discussion