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WELCOME
Wednesday 15 April 2015 Webinar
Introducing a Toolkit to support the management of Frailty in Primary Care
Introducing a Toolkit to support the
Management of Frailty in Primary Care
Wednesday 15 April 2015
12.30pm – 1.30pm
Helen LyndonNurse Consultant Older People, Clinical Lead Frailty, NHS England
&
Beverley MatthewsLTC Programme Lead, NHS Improving Quality
Beverley Matthews
LTC Programme LeadNHS Improving Quality
LTC Year of Care Commissioning Programme:
• 5 Early Implementer sites
• 35 Fast Followers
• Whole Population Datasets
• Implementation Guide
• Simulation Modelling
• Specialist Support Team
LTC Person Centred CareImprovement Programme:
• 40 Early Implementer sites
• 4 regional learning networks
• Snapshot Survey
• Simulation Modelling
• Specialist Support Team
Long Term Conditions Learning Community
• LTC Dashboard
• Case Studies
• Lunch and Learn Series
• The Bulletin
• Specialist Support Team
@NHSIQ @bev_j_matthews #LTCimprovement #LTCyearofcare
LTC Lunch & Learn Series ….coming soon…
Date Webinar Hosted by Bev Matthews &
17 April 201512.30 – 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 201512:00 – 13:00
Information Sharing for Care Coordination Adam Hatherly, HSCIC&
Christine Wike, NHSIQ
1 May 201512:30 – 13:30
Information as a Therapy Mark DumanMRPharmS DirectorMonmouth Partners
6 May 201512:30 – 13:30
Prevention & Effective Interventions inFrailty
Helen LyndonNurse Consultant Older People, Clinical
Lead Frailty, NHS England
27 May 201512:30 – 13:30
Primary Care Workforce for the 21 Century Webinar
Sharon LeePrimary Care Workforce Facilitator
South Kent Coast CCG
9 June 201512 noon – 1pm
Health 1000 Rob MeakerBarking, Havering & Redbridge
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
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
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
www.england.nhs.uk
Frailty – a complex syndrome of
increased vulnerability
11
Life course
determinants:
BiologicalGenetic
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 promotionDelay onset
FRAILTY
Delay/prevent adverse outcomes
Rodriguez-Mañas L, Fried LP. Frailty in the clinical scenario. Lancet. 2014 Nov 6
Reversibility
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
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
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”
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
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