up

Healthy Ageing

In a nutshell: Our Healthy Ageing Collaborative is implementing the electronic Frailty Index (eFI) tool to help identify older people with frailty in primary care using routinely collected information within a patient's electronic health record This is enabling health care professionals to recognise and diagnose frailty earlier, and better address the complex needs for this vulnerable group through individually targeted evidence-based pathways of care.

The Challenge

Population ageing is a global trend affecting many countries around the world (WHO, 2012). The number of people aged 85 years and older is projected to rise from 14 million to 19 million by 2020 and to 40 million by 2050.  In 2012, the estimated average life expectancy for females was 79 years, and for males it was 71 years. The result of increased life expectancy offers opportunities and challenges as people who live longer are at risk of developing health conditions related to the ageing process which are likely to have a significant impact on individuals, their families and society. Major shifts in health, social and economic policies are therefore required to support an ageing population.

A commonly heard clinical expression is “he/she is very frail”. It provides a summary statement of an older person that implies concerns over vulnerability and prognosis. This is how we tend to understand ‘frailty’—as a descriptive label: ‘the frail elderly’. Instead, we need to examine ‘frailty’ as a long-term health condition – a state of vulnerability to many, often related, conditions. This view of frailty opens up new approaches to helping people who are frail. Older people with frailty are at risk of disability, falls, cognitive impairment and dementia, complications of chronic diseases, as well as diminishing independence and capability. The understanding of frailty and its cumulative effect on older people is vital if services are to develop to support and care for vulnerable individuals living in the community.

What are we doing about it?

The Healthy Ageing Collaborative is supporting primary care to implement the electronic Frailty Index (eFI) which is a validated tool which searches primary care records to identify patients who have frailty or are at risk of developing frailty. The eFI has been developed in a collaborative partnership between the University of Leeds, TPP, the University of Birmingham, the University of Bradford, and Bradford Teaching Hospitals NHS Foundation Trust. The work was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) programme. The eFI was launched in the SystmOne EHR in July 2014 following internal validation and launched in the EMISWeb EHR in April 2016 following independent external validation. Publication in Vision elevtronic health care record is planned for March 2017.

The eFI comprises of 36 'deficits' (clinical signs, symptoms, diseases and disabilities), which are constructed using around 2,000 codes related to a patient's diagnosis, which are entered by GPs on the individual's electronic patient record (see box 1 below for the list of deficits). The overall eFI score is calculated by dividing the actual number of deficits present by the 36 total possible. The score is strongly predictive of adverse outcomes and has been developed and validated in the ResearchOne database using data from around 500,000 patients aged over 65 (Clegg et al, 2016).

GP Practices across the Yorkshire & Humber region (and nationally) are piloting the eFI and/or using it to design services around the needs of older people with frailty. More information on the rationale behind the eFI and its development and validation is available in this short (20 minute) webinar. NHS England and the British Medical Association General Practitioners Committee have negotiated a new contract starting in July 2017 which requires GP practices to use an appropriate tool, such as the eFI, to identify patients aged 65 and over who are living with moderate and severe frailty. For those patients identified as living with severe frailty, the practice will deliver a clinical review providing an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12 months and provide any other clinically relevant interventions.

The Connected Health Cities (CHC) is a programme of work aimed at uniting local health data and advanced technology to improve health services for patients in northern England. The Connected Yorkshire programme (part of CHC) is supporting the Healthy Ageing Collaborative to:

  1. Evaluate evidence based interventions for people with frailty and frailty care pathway changes. The interventions we are evaluating are: a supported self-care intervention for older people living with frailty; and de-prescribing intervention to reduce potentially inappropriate prescribing for older people. More information about these two projects which are being supported by the Health Foundation, an independent health care charity, as part of its £1.5 million Innovating for Improvement programme is available here and here.
  2. Improve public health intelligence by risk stratification and identifying health needs of the population to enable more effective resource allocation 
  3. Understand patient flow through frailty care pathways and developing quality improvement projects to reduce treatment burden and provide supportive care to those people living with frailty who need it most.

For more information on the Connected Health Cities programme, go to: https://www.connectedhealthcities.org/. Or go to the resources section to read the Connected Bradford briefing note.

Supporting Evidenced Base Practice

An easy- to-read summary of the evidence from research related to the care of older people with frailty in primary care has been written for commissioners, primary care clinicians and service providers. See our Effectiveness Matters publication: Recognising and Managing Frailty in Primary Care. An Evidence Synthesis: Improving Outcomes for Residents of Care Homes has also been written to inform the commissioning of and provision of healthcare services for care home residents.

Further resources include: an educational supplement for primary care professionals 'Living with Frailty: A Guide for Primary Care'; and an easy to follow resource for older people 'A Practical Guide to Healthy Ageing' with advice which will help older people remain fit and independent. Copies of the resources described above are available by contacting Sarah.De-Biase. Useful literature and articles related to frailty as a long –term condition and communicating frailty as a diagnosis are listed under 'Resources'.

Demonstrating Impact through Case Studies

The appetite for the eFI is demonstrated through the extent of uptake of the tool, illustrated on the eFI Engagement Map. Case studies describing the different approaches primary care has used to implement the electronic Frailty Index are provided below. These case studies also capture how the Healthy Ageing Collaborative is supporting primary care to explore how best to meet the needs of people with frailty through improved, evidence-based pathways of care for those with frailty and their carers, and through testing new ways of working.

1: NHS West Lincolnshire CCG – Using eFI to identify patients for unplanned admissions

Older people should be assessed for the presence of frailty during all encounters with health and social care personnel (including reception and clerical staff). The NHS England Enhanced Service suggests the use of risk-stratification tools or other methods to ... >>>

2: NHS Leeds North CCG – Use of eFI to identify patients for medication reviews by Practice Pharmacists

Older people with frailty should receive individualised medication reviews because certain medications are associated with increased risk of falls and delirium in older people with frailty. NHS Leeds North CCG Practice Pharmacists are identifying people with frailty using the eFI to ... >>>

3: NHS Airedale Wharfedale & Craven CCG – A tiered Elderly Care Service

Improved care for older people with frailty will necessitate more robust primary care-based systems capable of routinely identifying people living with different severity grades of frailty and applying a graduated response of supported self-management; case management that is well integrated with community, mental... >>>

4: NHS Leeds West CCG – Improving Care to the over 75s by enhancing pro-active case management using primary care based Clinical Care Coordinators

The BGS Fit for Frailty Part 2 describes the six essential characteristics of a good service for frailty. These are: "effective recognition, diagnosis and referral for frailty", "a person-centred ethos and practice", "integration of care in multiple settings", "expertise of staff" ... >>>

5: NHS South Devon & Torbay CCG – A Frailty Clinic

Transforming Primary Care policy (NHS England 2014 and the Department of Health) calls for safe personalised and proactive out of hospital care for those with the most complex needs. The recently published Five-Year Forward View indicates that “primary care of the future will build on the traditional strengths of ‘expert generalists’, proactively targeting services ... >>>

6: NHS Leeds South & East – Proactive Falls Prevention in Primary Care

Older people presenting with one of the frailty syndromes (such as falls or immobility) may well already have established frailty. Frail older adults are more likely to fall than those who are not frail. NHS Leeds South & East CCG is exploring the role of primary care in falls prevention and in reducing hip fracture incidence by using the eFI to identify people with moderate frailty and offer proactive falls screening, medication review and health promotion ... >>>

7: NHS Hambleton, Richmond & Whitby CCG –Understanding the Needs of People with Frailty through Proactive Primary Care Practice Nurse Led Frailty Assessments

: There is increasing evidence and guidelines with regards to the importance of recognising and addressing Frailty in terms of improving Quality of Life and reducing unplanned admissions and mortality in our increasing older population. The British Geriatric Society (BGS) in association with the Royal College of General Practitioners produced a guide ‘Fit for Frailty’ to aid the diagnosis and management of this syndrome. The guidance suggests it is ... >>>

8: NHS West London CCG – Whole Systems Integrated Care

Effective and efficient community services are the foundation of healthcare in the NHS. Shifting specialist care into community settings has been the focus of recent health policies in the UK to provide more flexible, accessible and timely care closer to people’s homes. The aim is to encourage people to live independently, and to give them greater choice and control over their health, as well as ... >>>

9: Healthy Ageing and Risk Stratification using electronic Frailty Index Birmingham Pilot

The Five Year Forward View (NHS England, 2014) argues that the sustainability of the NHS depends on a radical upgrade in prevention and public health. People with frailty are more likely to fall than those who are not frail; and older people presenting with one of the frailty syndromes (such as falls or immobility) may well already have established frailty. Birmingham’s Falls and Fracture Public Health Programme Lead is using the eFI to understand more fully the needs of frail older people to provide a deeper understanding of current service provision and... >>>

10: NHS Harrogate & Rural District CCG – Using the SystmOne STOPP protocol to support deprescribing among care home residents

‘STOPP’ stands for Screening Tool of Older People’s potentially inappropriate Prescriptions. Frailty is currently a ‘hot topic’ with the British Geriatric Society in conjunction with the RCGP having published their ‘Fit for Frailty’ Best Practice Guidance for the care of older people living with frailty in community and outpatient settings in 2014. Conducting a personalised, evidence based medication review is one of the key recommendations of the guidance. HaRD CCG tested the role of the SystmOne STOPP protocol as a decision support tool for primary care clinicians to help improve ... >>>

11: NHS North Durham CCG – Care for Frail Patients Scheme

Older people should be assessed for the presence of frailty during all encounters with health and social care personnel (including reception and clerical staff). The NHS England Direct Enhanced Service (DES) suggests the use of risk-stratification tools or other methods to case find and populate the register of at-risk patients. NHS North Durham CCG has commissioned ... >>>

  

Future plans

The eFI will be developed further within the GP electronic health record systems (for example, through clinical frailty templates and/or protocols synchronised with the eFI) to support and optimise clinical utilisation of the eFI within primary care. Work is underway within the Healthy Ageing Collaborative to implement medication reviews for all older people with frailty using a STOPP protocol developed for SystmOne, based on the original Gallagher et al et al (2008) STOPP/START criteria. Additional projects aim to design a self-care intervention for older people with mild frailty which utilises 'A Practical Guide to Healthy Ageing' and is suitable for groups of older people at risk of mild frailty. Data linkage through Connected Bradford will inform the understanding of: healthcare resource utilisation relative to frailty severity, and the relationship between frailty severity and access to timely end-of-life care planning for people with frailty.

The value added by the eFI will be demonstrated through the health economic analysis of discrete case studies/projects undertaken as part of the Healthy Ageing Collaborative, in partnership with York Health Economics Consortium. It is hoped the cost consequence analyses will provide insight as to which interventions work for people with frailty and , warrant being scaled up alongside further development of the eFI. The outputs of this improvement programme will be disseminated across partner organisations within the region and nationally.

How to Get Involved and Join the Healthy Ageing Collaborative

If you are a GP, Clinician or an older person who is interested in knowing more about the eFI and/or the Healthy Ageing Collaborative, please contact Sarah.De-Biase. If you are already using the eFI to inform services for people with frailty but the work is not yet represented on the eFI Engagement Map, please get in touch to share what you are doing with others.

NHS England have established a Kahootz Future Collaboration platform forum: 'Supporting Older People living with Frailty in Primary Care' which the Healthy Ageing Collaborative team are supporting. The platform has been sent up in response to requests from primary care clinicians and commissioners and it is hoped the forum will be used to not only share and develop resources and templates but as a space to share views, collaborate on work and discuss issues relevant or useful to supporting people with frailty in primary care. If you would like to join the Kahootz platform, please email Sarah De Biase or Megan Humphreys to request membership.

‘Please join the CHC and/or Healthy Ageing Collaborative Twitter conversation at #ageingwellnhs #datasaveslives #eFI @CHCNorth @SarahDeBiase


 

Box 1: List of 36 deficits contained in the eFI

  • Activity limitation
  • Anaemia & haematinic deficiency
  • Arthritis
  • Atrial fibrillation
  • Cerebrovascular disease
  • Chronic kidney disease
  • Diabetes
  • Dizziness
  • Dyspnoea
  • Falls
  • Foot problems
  • Fragility fracture
  • Hearing impairment
  • Heart failure
  • Heart valve disease
  • Housebound
  • Hypertension
  • Hypotension/syncope
  • Ischaemic heart disease
  • Memory & cognitive problems
  • Mobility and transfer problems
  • Osteoporosis
  • Parkinsonism & tremor
  • Peptic ulcer
  • Peripheral vascular disease
  • Polypharmacy
  • Requirement for care
  • Respiratory disease
  • Skin ulcer
  • Sleep disturbance
  • Social vulnerability
  • Thyroid disease
  • Urinary incontinence
  • Urinary system disease
  • Visual impairment
  • Weight loss & anorexia

Summary of reliable reserach evidence

Our evidence syntheses publications Recognising and managing frailty in primary care and Improving outcomes for residents of care homes

Impact Case Studies

Electronic Frailty Index (eFI) Tool

Healthy Ageing Collaborative


The Health Foundation, an independent health care charity, is funding two teams working with the Healthy Ageing Collaborative to be part of its £1.5 million innovation programme, Innovating for Improvement. The fifth round of the Innovating for Improvement programme is supporting 22 health care projects in the UK with the aim of improving health care delivery and/or the way people manage their own health care by testing and developing innovative ideas and approaches and putting them into practice.

The two funded projects are:

Self-management support intervention for older people with frailty
Lead organisation: Trust Primary Care Limited, Bradford

This project aims to test whether a self-management support intervention (SMS) helps older people living with mild frailty to self-manage their health and wellbeing, and rely less on health care resources. Volunteers will work in partnership with primary care to investigate the barriers and enablers to implementing an SMS intervention with this patient group.

Systematic, evidence-based medication reviews for older people with frailty
Lead organisation: Harrogate and Rural Districts Clinical Commissioning Group

This project aims to test whether a self-management support intervention (SMS) helps older people living with mild frailty to self-manage their health and wellbeing, and rely less on health care resources. Volunteers will work in partnership with primary care to investigate the barriers and enablers to implementing an SMS intervention with this patient group.

This project aims to reduce inappropriate prescribing, medication errors and health care utilisation for older people with frailty. This will be achieved by bringing together primary care teams to undertake collaborative patient safety and quality improvement training, and supporting them to develop their own interventions based around established protocols for deprescribing.

Over the course of the programme the teams will develop their innovative ideas and approach, put it into practice and gather evidence about how the innovation improves the quality of health care for people at risk of or living with frailty.


Electronic Frailty Index wins prestigious healthcare IT innovation award

The Yorkshire & Humber Academic Health Science Network’s (AHSN) Improvement Academy is delighted to announce that the electronic frailty index (eFI) has won the Healthcare IT Product Innovation category at the EHI Live 2016 Awards.

The eFI was developed in a collaborative partnership between the University of Leeds, TPP, the University of Bradford, the University of Birmingham and Bradford Teaching Hospitals NHS Foundation Trust. The work was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Yorkshire and Humber (NIHR CLAHRC YH).


Click below to see a map of eFI Engagement:



eFI Webinar

Development and validation of an electronic frailty index using routine primary care electronic health record data (Clegg A, et al. Age Ageing. 2016)

Evidence Briefing - Improving outcomes for residents of care homes

Effectiveness Matters: Recognising and Managing Frailty in Primary Care

WHO (2012). Good health adds life to years: Global brief for World Health Day 2012

Bates, C, Clegg, A. Connolly, J, Crossfiled, S, Parry, J, Young J (2014) First National Frailty Workshop:White Paper. Unpublished

NHS England (2014) Safe compassionate care for frail older people using an integrated care pathway

Frailty: Language and Perceptions A report prepared by BritainThinks on behalf of Age UK and the British Geriatrics Society

Managing frailty as a long-term condition (Harrison et al. 2015)

Pilot Use of SystmOne STOPP Toolkit (East Parade surgery)

eFI Guidance SystmOne Notes for All Partners

STOPP SystmOne How to Guide

Multimorbidity: clinical assessment and management guidelines

Running the SystmOne Practice Population eFI Report

Connected Bradford Briefing Note

Safer Prescribing in Frailty Project

Testing the feasibility of the Supporting Self-Care Intervention

Twitter: #ageingwellnhs or #eFI


Mrs Andrew’s story – what went wrong - Video from Prof David Oliver as to what can go wrong when an older person with frailty is admitted to hospital instead of an appropriate CGA and timely discharge to community services

Frailty Fulcrum - Useful video to help communicate frailty to older people and their family/carers, both in terms of its link with ageing and impact on quality of life.


Please see the link here to a regular newsletter for professionals interested in older people’s care. Provided by North East London Foundation Trust and UCLPartners.

It is recommended that you subscribe to the newsletter using the link at the bottom of the newsletter – this will give you direct access to future editions.

The author/editors who welcome contributions for the newsletter– short text but with links for further information. The person to contact is: Laura Stuart-Neil at Laura.Stuart-neil@uclpartners.com.


Sarah De-Biase

Sarah.De-Biase@yhahsn.nhs.uk

01274 383407

@SarahDeBiase