Note – July 2017: The CDRC System has been updated to satisfy the requirements of the new frailty section of the GMS contract. The full CDRC Frailty Management System goes much further than required in the GMS contract
Frailty is an increasingly recognised syndrome that signifies increased risk of adverse outcomes such as unplanned hospital admission, institutionalisation and death. There is good evidence that intervention can improve the outcomes for these patients.
Please note that some frail patients are not elderly so the term frail, rather than frail elderly, is used throughout. Also note that many frail patients are not housebound.
The module comprises three main elements:
- Identification of frail patients and maintenance of a ‘disease register’ of frail patients.
- Regular assessment of these frail patients (at least annually)
- Creation a care plan for frail patients.
The CDRC module have been designed to try and integrate this frail service with many of the overlapping services that we provide e.g. avoiding unplanned admissions, dementia care, palliative care, dementia screening, nutritional screening etc. Hopefully this will improve the efficiency of the system and create a more streamlined approach for patients.
The module is largely based on the British Geriatric Society’s Fit for Frailty Document.
Patient Identification
The module proposes a multi-track approach to identifying frail patients. The three main components are:
- Local knowledge – i.e., clinicians pool their knowledge of frail patients
- Identification following presentation with a ‘frailty syndrome’ e.g. delirium, falls.
- Identification using the electronic frailty index (eFI).
The eFI is a tool that counts the number of ‘deficits’ that a patient has, based on Read coded information. It has been validation in an enormous UK cohort. The eFI gives a value of 0-1. Values above 0.75 are, by and large, incompatible with life. Values above 0.36 suggest significant frailty. The eFI correlates strongly with outcomes such as hospitalisation, institutionalisation and death. The small proportion of patients with a high eFI who are not frail are at high risk of hospital admission and may still be candidates for the avoiding unplanned admission scheme.
The CDRC module calculates an eFI for every patient on the list and highlights potentially frail patients with a stickman to the right of the CDRC GMS icon on the top right of the screen.
The eFI threshold is currently set at a 13/36 (0.36) threshold and will identify about 1.5% of your non-institutionalised population. This threshold can be altered to change the sensitivity and specificity of frailty detection.
NB A high eFI does not confirm a diagnosis of frailty – See Confirming Frailty
A list of patients who might be frail can be found in CDRC > Reports > *Eligible for frailty screen (‘severe’ eFI 13/36 cutoff) based on eFI cutoff alone.
There is also a list based on a more sensitive search strategy that also considers age over 90, patients in care homes or sheltered accommodation and patients in the palliative care list as well as those with an eFI in the severe range. Initial work suggests this will identify 90-95% of frail patients whilst still having a workable false positive rate.
Confirming Frailty
Once a potentially frail patient has been identified a clinician needs to confirm that the patient is frail. For many patients, this will be very obvious e.g., the majority of nursing home patients. In this case, the clinician just needs to add the ‘frailty’ code. Clicking on the stickman will take you to the Frailty DCS template that allows you to do this.
YOU CANNOT USE eFI TO CONFIRM FRAILTY
Template
The Frailty DCS template also provides diagnostic tools to help you confirm frailty.
PRISMA 7
The PRISMA 7 score is a question based tool that asks five questions and combines them with age and sex details to give a score. Values of >=3 suggest frailty.
TUGT
The Timed up and go test (TUGT) measures the time taken for the patient to rise from sitting, walk 3 metres, turn, walk back to the chair and sit again. A time greater than 10 seconds suggest frailty.
Clinical discretion is needed when interpreting these tests as some patients with an isolated problem e.g. knee arthritis might give a false positive.
If a patient is clearly not frail there is a button to click to indicate this
Once the frailty screening is complete, the stickman will disappear for 5 years if the patient is not frail.
Categorising Frailty
Although it is largely unhelpful in primary care, the new GMS contract requires the severity of frailty to be categorised into mild, moderate or severe. It recommends the Clinical Frailty Score to make this assessment.
The radio buttons at the bottom of the template allow you to record the frailty diagnosis either to go in the problem list, summary list or just as a Read code, depending on your practice preference.
Assessing Frail Patients
Once a patient has been diagnosed with frailty they will have the stickman icon to the left of the CDRC GMS icon
These patients should have, at least, an annual review. The key areas that the BGS has identified as being of relevance are:
- Dementia
- Depression
- Nutrition
- Polypharmacy
- Falls risk
- Continence
- Vision and hearing
- Mobility and inactivity
- Alcohol and smoking
- Social isolation and loneliness
The CDRC Frailty Assessment comprises three main parts:
- The core data entry that most clinicians will be familiar with – e.g., height, weight, BP, lifestyle
- A specific template covering some of the areas above
- A care planning template that covers the generic information that is needed for almost all care plans – e.g., patient wishes, relatives and carers, professionals involved etc.
Template
The Frailty DCS Template’s home page is designed to prevent duplication by displaying what has already been done.
The home page of the Frailty DCS template shows:
- Link to the core data, the care planning template and a link to a detailed printout for home visits.
- Details of the patients frailty diagnosis, severity classification, last frailty assessment and care planning
- Current SCR sharing preferences with ability to reset the preferences (and a link to more detailed information)
- Link to guidance for categorising and coding frailty (which is, unfortunately, required by the new GMS contract)
- Link to the national frailty PIL
An EHCP is the preferred care plan for the scheme but other care plans are acceptable.
The next page, Frailty, shows the specific areas to be covered. Crucially, the right hand panels show what has already been done. So for example , if the patient has dementia it is clearly unnecessary to perform further testing. This patient has been referred to the falls team recently so further fall assessment is not needed.
The specific tests are designed to fit into or complement work that we already do.
- Falls – this uses the FRAT score that many clinicians will already be familiar with
.and is quick and easy to calculate. It also forms the basis of the referral criteria for the falls team where referral should be considered for those at high risk.
- Dementia screen – this is identical to the Dementia screening DES. For those that screen positive with the initial ‘memory problems’ question, a 6 Cognitive Item Test is administered. Patients who screen positive might require further assessment and/or referral to the mental health team.
- A polypharmacy review will involve an experienced clinician assessing the medication. However, the STOPP tool is an additional aid that can identify some potential medication issues. This is described elsewhere.
- Nutritional status is assessed with the MUST tool. Clicking the MUST button launches a MUST calculator which guides you through the MUST calculation. Patients should then be managed according to the local nutrition pathway.
- Depression screening is performed with Whooley’s two questions. Patients who screen positive may need further assessment.
Finally, mobility and continence are assessed using the Barthel index. Possible interventions might include referral for assessment from physiotherapy, occupational therapy, district nursing or the community continence service.
Resources
The resources page of the template provides links to the BGS Fit for Frailty Guidance and information about local resources such as Frail Elderly Rapid Assessment Clinics and the Frail Elderly Consultant Advice Line.
Summary Care Record
The GMS contract requires consideration of seeking consent for sharing additional information via the Summary Care Record for moderately and severely frail patients.
If a frail patient’s record is opened and:
- They are not sharing additional information
- They have not set their preference in the last 3 years
The following prompt will be displayed:
Clicking the Change SCR Preference button will open the Frailty template template, from where you can change the SCR preference. More details can be found in the Summary Care Record section.
Reporting
Reporting and Data Quality
The reports below, found in the CDRC > Frailty folder, will with monitoring performance and data quality. They are specifically built for the North Durham frailty scheme. The reports include:
- Those frail patients who have had a frail assessment and EHCP/care plan or declined a care plan
- Patients who have had a frail assessment but haven’t been coded as frail
- Frail patients who have had an EHCP/care plan or frail assessment but not both
