Living Well with Frailty
IMPROVEMENT RESOURCE
August 2015
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Why Focus on Frailty?
Frailty is a complex syndrome of increased vulnerability and reduced functional
reserve influenced by the ageing process, chronic conditions, life course events, social
and psychological factors.
The presence of one or more of the common frailty syndromes should raise
suspicions that the individual is frail. In that case an apparently simple presentation
may mask a more serious underlying condition. The five common syndromes are:
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Falls
Immobility
Delirium
Incontinence
Susceptibility to side effects of medication
People who are frail often experience poor outcomes after a seemingly minor illness,
a change in circumstances, medication or a move to an unfamiliar care setting. Frailty
is associated with a higher risk of sudden physical, cognitive and functional decline
and an increased risk of falls, immobility, disability, institutionalisation and death. It
carries high personal and system costs.
But frailty and adverse outcomes are not an inevitable consequence of ageing. We
all have a role to play in preventing or delaying the onset of frailty and functional
decline through integrated and coordinated support for prevention, assessment,
treatment, rehabilitation and care in all settings and including end of life care.
The report by Deloitte’s Centre for Health Solutions discusses the increasing
numbers of frail older people and suggests that improvements are needed on three
fronts: physical and mental healthcare, social care and place of care.
http://www2.deloitte.com/uk/en/pages/life-sciences-and-healthcare/articles/bettercare-for-frail-older-people.html
The European Innovation Partnership on Active and Healthy Ageing (EIP-AHA) is a
response to the major societal challenges of an ageing population, a reducing
workforce, the increase in long term health conditions and the need to redesign our
health and care systems to deliver sustainable services. The goal by 2020 is to have
improved healthy life-years for European citizens by two years.
Pen pictures.pdf
Frailty is one of the six EIP- AHA Action Groups. Scotland was one of the top three
reference site regions in Europe (with Northern Netherlands and Andalucía) in
recognition of our innovative work on Reshaping Care for Older People, falls and
telecare. https://webgate.ec.europa.eu/eipaha/library
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Our Magnificent Seven
Seven partnerships in Scotland are working together in a discovery programme to
improve the care and support pathway to help older people to live well with frailty.
A good pathway will be one that is:
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Simple to navigate for older people and their carers, and for staff from all
sectors.
Fit for all who are frail, and in every locality
Affordable and sustainable given funding and workforce challenges.
The Flash Report has key contacts for the seven
partnerships and lists the initial pledges made at the
workshop on 1st June 2015.
This programme will build on fantastic work already taking
place to support older people living with frailty in Argyll and
Bute, Fife, Glasgow City, North and South Lanarkshire,
Borders and Midlothian.
Reshaping Care Building on Progress
Across Scotland much progress has been made in Reshaping Care for Older
People (RCOP). Many examples of innovation and good practice can be found in the
report
http://www.jitscotland.org.uk/resource/reshaping-care-for-older-peoplechange-fund-building-on-progress-june-2015/
A modified RCOP pathway has the key elements of a Frailty pathway
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Multiple Conditions: Living Well in Localities
Many Conditions One Life is an Action Plan to improve the quality of support and
services for people who live with multiple conditions in Scotland. It builds on the
changes we are making through the introduction of Self-Directed Support and the
integration of health and social care to support people to live well at home or in their
local community and to have a positive experience of health and social care. Actions
include anticipatory care planning, care management and technology enabled care and
support.
Presentations that illustrate of these actions in practice can be accessed at
http://www.jitscotland.org.uk/news/multi-morbidity-event-glasgow/
Our Advice Note has links to other useful resources and websites in Scotland.
The WHO global strategy for people-centred and integrated health services has many
international examples
http://www.who.int/servicedeliverysafety/areas/people-centred-care/en/
Active and Healthy Ageing
JIT and the Scottish Government worked closely with partners from health, social care,
housing, Third Sector, Care Inspectorate and the Scottish Older People’s Assembly
(SOPA) to develop an Active and Healthy Ageing action plan for Scotland 201416. The plan is a call to action to support people to live well as they move into and
through later life. There are specific actions for national organisations, health, care
and housing partnerships, community planning partners, the third and independent
sectors, and older people and communities.
The four themes are based on what older people told us is important to them:
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I want to have fun and enjoy myself
I wish to remain connected to my friends
I wish to be able to contribute to society for as long as I want
Don’t talk about me without me, and respect my beliefs and values
http://www.jitscotland.org.uk/resource/active-healthy-ageing/
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A Stitch In Time?
A Stitch in Time? used practical action learning to explain what the third sector does,
the contribution to RCOP and developed evaluation methods and relevant evidence.
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Working groups created a logic model and indicator bank.
Focussed work with specific issues such as community transport
Third sector interfaces mapping exercises. Click to access the mapping
exercises for Midlothian, East Lothian and Edinburgh.
Developing evaluation methods such as story telling. Find out more!
Work with funders to improve reporting formats and enhancing evidence
evidence reviews and commissioned research about the third sector
contribution in specific areas such as eating well, community transport, mental
health and well-being, volunteering and social connectedness.
Publication of several publications and resources
The third sector contribution to health and social care - Learning from A Stitch
in Time? materials: A guide for commissioners
The next phase is Threading the Needle : Using third sector evidence to
commission outcomes Threading the Needle
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More examples of Third sector support for frail older people to live well at home can
be found in this series of case studies
http://www.jitscotland.org.uk/resource/third-sector-support-for-discharge/
Meal Makers
Meal Makers is a free, local neighbourhood food-sharing project that connects people
who love cooking and want to be active in the community (Cooks), with older
neighbours (Diners) who would appreciate home cooked food delivered to them every
now and then. Meal Makers tackle social isolation and the growing problem of
malnutrition by helping older adults who no longer find it easy to cook for themselves to
enjoy freshly home cooked food. They also help strengthen connections within
communities by providing a flexible way for people to volunteer their time and skills
locally in a way which suits them.
More information is available at: https://www.mealmakers.org.uk/
Adapting for Change Demonstration Sites
The overall aim is to develop and test key aspects of the approach recommended by
the Adaptations Working Group to inform a revision of the national policy framework for
housing adaptations, and to provide learning to improve practice. The objectives are:
 Test approaches in relation to key issues around current services and supports
 Identify approaches, consistent with recommended principles, which deliver better
outcomes
 Capture the learning on a continuing basis over the test period and share this
across Scotland
 Inform the review and revision of the national policy and funding framework for
housing adaptations
There are 5 Demonstration Sites: Aberdeen, Borders, Falkirk, Fife and Lochaber
Adaptions Network
 To share learning across Scotland from demonstration sites, other initiatives in
Scotland & elsewhere
 Focus on practice improvement, in line with AWG recommendations
 Part of a developing wider Housing Learning Network
For more information contact: [email protected]
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National Falls Programme
Up and About Pathways for the Prevention and Management of Falls and Fragility Fractures
presents, in one document, an overview of the various aspects of fall and fragility fracture
prevention and management and attempts to demonstrate how they link to provide
comprehensive, co-ordinated and person-centred care.
The national falls programme aims to reduce the personal and economic cost of falls in Scotland
by supporting health and social care partnerships to implement local integrated, falls prevention
and management pathways for older people.
Working with partners from all sectors, a range of resources have been produced to help
partnerships improve the care and support of people who fall or are at risk of falling.
Website: http://fallspathway.nhshealthquality.org
Community of Practice http://www.fallscommunity.scot.nhs.uk
Working Together to Prevent Falls for Health and Wellbeing
The Flash Report from the April 15 collaborative learning event can be found here.
Making the right call for a fall
This resource provides practical guidance and case study examples to help health and social
care professionals, planners and managers improve the experience and outcomes for older
people who present to the Scottish Ambulance Service following a fall or with a flare up of their
long term conditions on a background of general frailty.
Managing Falls and Fractures in Care Homes for Older People is a good practice self-assessment
resource to help staff assess how well falls prevention and management and the prevention of
fractures is being addressed in their service and how to make improvements. The resource includes
an introduction to falls and fractures in care homes, self-assessment guidance and a range of tools
which can be downloaded and used in a care home to help improve or change practice.
The National Managing Falls & Fractures in Care Homes for Older People Project is a scheme
aiming to reduce the number of falls in participating care homes by 50% by the end of 2015.
A newsletter on the project called 'Up and About in Care Homes' highlights improvements being
made through the project. Issues published to date can be accessed on the Knowledge Network's
Falls and Bone Health Community website
Further information from Ann Murray, National Falls Lead at: [email protected]
Edith Macintosh AHP Consultant at [email protected]
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‘Focus on Dementia: Changing Minds, Improving Lives in Scotland’ is a partnership
between Scottish Government, Joint Improvement Team, Alzheimer Scotland, and the
Quality & Efficiency Support Team (QuEST), where the opinion of people with
dementia and their carers is fundamental to the work we do. Other key partners such
as NES, SSSC, HIS and Housing partners contribute significantly and academic input
is secured when required.
The programme was established to support the implementation of Scotland's National
Dementia Strategy 2013-2016 and aims to build resilience for people with dementia
and their families, avoiding crises including unnecessary admission to hospital and
institutional care settings. Where hospital admission is unavoidable, it aims to ensure
care experience is safe, co-ordinated, dignified and person centred, ensuring
seamless transition across care settings. The programme will:
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Support the delivery of the Post-Diagnostic HEAT target
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Test the Alzheimer Scotland '8 Pillars Model of Community Support in 5 test
site areas, evaluating the impact of different geographic areas, demographics
and approaches to services on the delivery of the model.
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Support improvement in care of individuals with dementia in acute hospitals.
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Support partnerships to use data to drive improvement.
For further information, please visit:
http://www.qihub.scot.nhs.uk/quality-and-efficiency/focus-on-dementia.aspx
Power of Attorney in Scotland – the Future is in your hands
A social media campaign aims to get the public to “Start the Conversation” with loved ones
so that their wishes can be respected if they should find themselves in a situation where
they no longer have the capacity to make welfare or financial decisions for themselves. It
includes a television campaign featuring celebrities, and parallel Twitter and Facebook
campaigns. www.mypowerofattorney.org.uk
Good Life Good Death Good Grief provides a range of ideas and resources to
promote more openness about death, dying and bereavement in Scotland
http://www.goodlifedeathgrief.org.uk/content/online resources/
Caring for people in the last days and hours of life ( SG 2014)
http://www.gov.scot/Topics/Health/Quality-Improvement-Performance/peolc
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Fit for Frailty:
The Fit for Frailty guides were developed by the British Geriatrics Society, Royal College of
General Practitioners and AGE UK.
Fit for Frailty Part 1 provides advice and guidance for all levels of health and social care
professionals working in community and outpatient settings and who may encounter older
people living with frailty.
Part 2 is aimed at GPs, geriatricians, health and social care service managers and
Commissioners who are planning services.
Toolkit for General Practice
This was developed by New Devon CCG, NHS Kernow and the NHS England Devon,
Cornwall and Isles of Scilly Local Area Team in response to requests for a common approach
to case finding, assessment, care planning and case management of frail older people.
It includes appendices describing
Rockwood Clinical Frailty Scale
Four metre walk test – average speed longer than 5 seconds to walk 4 metres is an
indication of frailty.
PRISMA7 questions - score of three or more indicates frailty.
1. Are you more than 85 years?
2. Male?
3. In general do you have any health problems that require you to limit your
activities?
4. Do you need someone to help you on a regular basis?
5. In general do you have any health problems that require you to stay at home?
6. In case of need can you count on someone close to you?
7. Do you regularly use a stick, walker or wheelchair to get about?
Information on READ codes for recording frailty
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“Maximising Recovery, Promoting Independence” An Intermediate Care Framework
for Scotland describes intermediate care as a continuum of integrated community services
for assessment, treatment, rehabilitation and support for older people and adults with long
term conditions at times of transition in their health and support needs.
These services offer alternatives to emergency inpatient care, support timely discharge
from hospital, promote recovery and return to independence, and prevent premature
admission to long-term residential care.
Intermediate care can be provided in:
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Individuals’ own homes, sheltered and very sheltered housing complexes
Designated beds in local authority or independent provider care homes
Designated beds in community hospitals
The Intermediate Care: Community of Practice has resources, examples of good practice
and evaluations and digital stories about
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Reablement
Intermediate care at home,
Hospital at Home
Step up and step down beds
Day Hospitals and Frailty clinics
Discharge Hubs
For further information, please contact Marie Curran: [email protected]
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Older People in Acute Care
The ‘Improving Care for Older People in Acute Care’ programme complements the scrutiny programme
underway across hospitals in Scotland.
A High Level Driver Diagram presents the three primary areas of focus :
-Care Co-ordination
-Cognitive Impairment
-Leadership and Culture
By ensuring appropriate assessment of care when older people are admitted to hospital, we will
support people to get the right help they need in the right setting and avoid delayed discharge. The
programme has helped hospital teams to Think Frailty to identify and provide the right support for the
most vulnerable individuals.
Think Frailty Community of Practice Contact : Penny [email protected]
More information can be found in the Improvement programme impact report and in the report
Improving the identification and management of frailty: Case Study Report
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The Acute Frailty Network (AFN) – Improving services for frail older people aims to
support the widespread adoption and improvement of acute frailty services in England.
The report of the Commission on Hospital Care for Frail Older People challenges
hospitals to gear up to provide the very best care for their most frequent users, involving
geriatricians from the start of the admission together with the other appropriate specialists.
Alongside the report is a series of case studies showing good practice from around the
country. Also available at hsj.co.uk is further evidence that led to the commissioners’
conclusions and a full bibliography.
http://www.hsj.co.uk/comment/frail-older-people/commission-on-hospital-care-for-frailolder-people-main-report/5076859.article
Care Homes
Care... about physical activity is a resource that offers support for everyone in a care
home to get involved and become physically active in different ways and not just
through formal exercise sessions. This will help national and local organisations to
promote physical activity in care homes. It is designed to stimulate simple solutions
and practical approaches to enable all residents to choose to be active every day.
The Care Inspectorate developed the resource in partnership with the British Heart
Foundation National Centre for Physical Activity and Health at Loughborough
University.
Make Every Moment Count is a resource designed to improve the quality of life of
older people receiving care services. The guide highlights how making the most of
every moment can make a real difference to a person's quality of life in simple but
very meaningful ways. By providing key messages on how to better understand an
individual’s needs, values and lifestyle, the guide can help people working in care
services to deliver an enhanced experience for Scotland’s older people.
The Care Inspectorate developed the resource in partnership with The Scottish
Government, NHS Scotland, Alzheimer Scotland, the care sector, Scottish Care, the
College of Occupational Therapists and The Chartered Society of Physiotherapy
Scotland.
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My Home Life is a UK-wide initiative to promote quality of life for those living, dying,
visiting and working in care homes for older people through relationship-centred and
evidence based practice. In Scotland the programme is led by University of West of
Scotland (UWS) in partnership with Scottish Care and Age Scotland.
The approach is a social movement bringing together organisations that reflect the
interests of care home providers, commissioners, regulators, care home residents
and relatives and those interested in education, research and practice
development. It uses an appreciative inquiry (AI) approach that focuses on what
works well and identifies strategies for doing more of what works well. It is an
exciting philosophy for development in that its starting point is that in every
organisation something works well. Thus, rather than focussing on what is not
working well, the approach sets out to establish strengths which re-energises and reengages people to challenge the status quo and take forward plans for improvement.
There are
now 12 programmes running with over 120 care home managers participating.
(www.myhomelifescotland.org.uk)
Queen’s Nursing Institute
The Delivering Dignity programme was launched in 2012 to demonstrate how
innovative research can protect and enhance the dignity of older people, and
improve their healthcare experience. Six projects were selected for funding, and
each drew to a close during 2014. ‘Telling the Story‘, Impacts of the Delivering
Dignity Programme in Scotland is the final impact report of each project in a clear
and accessible format.
Our Voice
As we remove the barriers to health and care pathways and aim for seamless services
for people by integrating health and social care, the timing for developing a framework
for hearing the service user and public voice could not be better. This is about a
commitment, across health and social care services, and with policy makers, to ensure
that people using services are active partners at the centre of how those services are
designed and delivered, and how their success is measured.
‘Our Voice’ is a framework being developed to help ensure services are designed and
produced with the communities they serve, build on peoples’ strengths and support the
health and wellbeing of the whole person and their family.
Find out more at The Health Council
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Contact: [email protected] or Or Email:
[email protected]
IRISS (Institute for Research and Innovation in Social Services)
IRISS is a small third sector organisation that works with the social services workforce
across Scotland to enable positive outcomes for individuals who access support. Our
focus is on embedding research, creativity and innovation.
We have a distinctive three part approach: we inform, we facilitate and translate, and we
co-create to enable culture change in the design, delivery and experience of social
services.
Sign up to our mailing list: http://www.iriss.org.uk/mailing-list
Indicator of Relative Need (ioRN)
Having good information is important for the often complex decisions taken by NHS &
social care staff. The ioRN offers the best kind of person-centred information – useful
to front-line staff and to managers alike. The ioRN is a tool that summarises the level
of people’s needs for care and support. It is available to ‘go live’ now in your
organisation as part of your integrated suite of essential resources.
Whether you are unfamiliar with the ioRN, or would simply like to know why and how it
has been redesigned, please contact [email protected]
Meaningful and measurable was a Collaborative Action Research project that
brought together academics, practice partners and national organisations with a
shared interest in adopting a focus on personal outcomes in health, social care and
other services. It explored the tension between:
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Meaning: the need for detailed, contextualised information on individual experience
to inform individual planning and service improvement.
Measurement: the need to aggregate information on personal outcomes to inform
decision making at organisational and national levels.
Reports are available at https://meaningfulandmeasurable.wordpress.com/projectoutputs/
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Personal Outcomes
Personal Outcomes are at the heart of the principles and intent of integration and are
now embedded in Scottish Law and in the Suite of Indicators agreed to demonstrate
progress in improving these outcomes.
JIT can provide:
• practical advice about using a Personal Outcomes Approach in a locality
• engagement with members of the Personal Outcomes Partnership about their work
to facilitate staff development and strategic approaches in local partnerships
• understand how the wider People Powered Health & Wellbeing Programme can
help to support a co-production approach at locality level
• access to the new Evidence Summary on “How can local health and social care
partnerships generate and interpret system-level evidence about how their services
improve personal outcomes?”
More information at http://www.jitscotland.org.uk/action-area/personal-outcomes/
Integration of Health and Social Care al Care
Integration of health and social care is one of Scotland's major programmes of reform.
At its heart, it is about ensuring that those who use services get the right care and
support whatever their needs, at any point in their care journey.
http://www.gov.scot/Topics/Health/Policy/Adult-Health-SocialCare-Integration
Scottish Government HSCI Communications Toolkit
http://www.gov.scot/Resource/0047/00475356.pdf
Scottish Government H&SC Integration Blog
BLOG
http://blogs.scotland.gov.uk/health-and-social-care-integration/
Quality Improvement Hub
The NHSScotland Quality Improvement Hub is a national collaboration among special
health boards, the Joint Improvement Team and Scottish Government Health.
Explore the website to access tools, techniques and examples of practice at:
www.qihub.scot.nhs.uk/
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The Joint Improvement Team (JIT) is a uniquely positioned strategic improvement
partnership between the Scottish Government, NHSScotland, COSLA (Convention of
Scottish Local Authorities) and the Third, Independent and Housing Sectors.
Explore the website for improvement tools and examples of practice:
http://www.jitscotland.org.uk/
Links to other useful resources
Anticipatory Care Planning
Care Planning in General Practice for people with LTC
Delayed Discharge Actions– http://www.jitscotland.org.uk/actionareas/delayed-discharge/ and the Home First resource
http://www.jitscotland.org.uk/resource/home-first-ten-actions-transformdischarge/
Emotional Support Matters and the Living Better Report
Health Literacy Action Plan for Scotland: Making it Easy.
Key Information Summary
Living Well with Long Term Conditions: Report
Palliative and End of Life Care Zone at NHS Inform
http://www.nhsinform.co.uk/palliativecare/ and
http://www.nhsinform.co.uk/bereavement/
www.healthcareimprovementscotland.org/our_work/personcentred_care/palliative_care.aspx
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NHS Education Scotland Palliative Care in Practice
http://www.palliativecareinpractice.nes.scot.nhs.uk/
Polypharmacy Reviews – updated guidance
Self Management Works – the Health Foundaiton2013
SPARRA: Risk Prediction Tool
Technology enabled care and support – case studies and resources:
Scottish Centre for Telehealth and Telecare
Living it up
ALISS
JIT Scotland
Scottish Telehealthcare Community of Practice
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