Frailty

What are our priorities and what do we want to achieve?

The Lincolnshire Older People’s Strategy was agreed early in 2024, co-produced with colleagues from across the health and care system, as well as patient and public representatives. It is based upon clinical evidence and best practice. Its key focus is prevention, proactive identification, treatment and management of frailty, with a view to improving patient outcomes and experience, reducing overall deterioration, improving coordination of care and to reduce unplanned acute activity.

To make delivery of the strategy manageable we designed a delivery model of 5 pillars (prevention, neighbourhood, a single point of access, integrated care and workforce) with specific areas of focus but also connected around a population not the intervention. Governance and programme arrangements have been put in place to support this approach.

What are we doing? Examples of our work

Our early successes have included:

• Launch of Ageing Well Campaign to encourage connecting people to their local community network.
  
  
• Five Early Adopters Primary Care Networks (PCN) have engaged in delivery the strategy with initiatives including:
  • Community events targeting specific cohorts to raise awareness and engage people in prevention opportunities.
  • Clinical review of patients following risk stratification using eFI (electronic frailty index).
  • Use of population health management data to identify cohorts of patients for proactive offer of strength based assessments leading to interventions such as Comprehensive Geriatric Assessment and Personalised Care and Support Planning and review.
  • Through the Enhanced Health in Care Homes (EHCH) framework, multi-disciplinary team (MDT) working has been introduced and telehealth developments in care homes have progressed.
  • A Comprehensive Geriatric Assessment template, co-designed by colleagues from primary care and Trusts, is currently in use supported by locally developed training.
    
    
• The introduction of a nationally agreed tiered training package from the British Geriatrics Society Training.
  
  
• Frailty same day access centres are operational at both Lincoln County and Pilgrim Hospitals; 20 virtual ward beds are supported by daily MDTs and an intake of 10 new advanced care practitioners (ACP) trainees.
  
  
• Introduction of a population health dashboard which captures both process and outcome measures across the frailty spectrum, and which drills down to PCN level.
  
  
• Scoping of a Frailty Proof of concept in a PCN, that once tested and proven can be rolled out across all PCNs in the Lincolnshire system.

Lessons learnt

We have learnt lessons in our first year of implementing the five year strategy notably that Lincolnshire has a huge wealth of activities to keep older people mentally and physically well. However, older people are not always aware they are there or how to access them, or even if they are suitable for them.

Working in partnership

By working in partnership with partners and stakeholders we need to further foster, develop and build the capability and capacity of community-based assets with a view to reducing dependency on health-based interventions. Additionally, there are further opportunities to target people from specific population groups, including those where there are known health inequalities, who have traditionally been less engaged, supporting them to proactively self-care and engage proactively with services.

Our frailty work has seen a refresh in connections with Enhanced and Better Care in Care Homes programmes alongside our falls programme of work which has seen the implementation of telehealth supporting Multi-Disciplinary Team (MDT) working, building community of practice forums with staff, stakeholder and partners to improve education and knowledge as well as supporting improved connections and workforce integration.