39PROACTIVE IDENTIFICATION, ASSESSMENT AND TREATMENT OF MODERATELY FRAIL PATIENTS IN NORTH ISLINGTON

Abstract

Topic: Frailty affects 10% of people over 65 and 25-50% of those over 85 (Clegg et al, Lancet, 2013, 381 868, 752-762). Frailty should be identified with a view to improving outcomes and avoiding unnecessary harm (www.bgs.org.UK, accessed 15/06/18). The proactive identification of patients with moderate frailty will allow earlier intervention and improved access to care in patients that may otherwise be missed. Intervention: Nine local GP practices came together to form a population of c70000, around which a Care and Health Integrated Network (CHIN) was created. Through this, the north Islington frailty team, in partnership with the GP practices, created a register of moderately frail patients based on the electronic frailty index (eFI) and the Rockwood clinical frailty scale. The team proactively screens patients for frailty and identifies unmet needs, particularly around medication management, falls prevention and social isolation. If appropriate, a home based Comprehensive Geriatric Assessment (CGA) is undertaken and the team can give immediate interventions and make direct onward referrals. The team is multi-disciplinary consisting of a physiotherapist, pharmacist, Age UK navigator, GPwSI in elderly care, and consultant geriatrician. Improvement: A total of 460 patients were identified as moderately frail. The team have telephone screened 22% (102) of these patients, finding a 58% accuracy rate in moderate frailty diagnosis using the above method. Of those screened, 48% had unmet needs, which required a CGA. 78% of these had had a fall and required falls assessment, 80% had a medication review due to polypharmacy or compliance issues, and 75% had a review for social needs. Discussion: The eFI and Rockwood frailty score can be used in combination to help identify patients with frailty. This methodology enables moderately frail patients with unmet needs to be accurately identified, ensuring timely preventative intervention. The creation of a single frailty register and proactive identification of moderately frail patients across GP practices is a novel approach and demonstrates how primary care, secondary care and the third sector can work collaboratively to benefit patients. It is difficult to evaluate a proactive approach. As this project develops we will evaluate further outcomes, including unplanned admissions, improved access to services and cost savings for the NHS.