Principle 3: Establish systems and processes for frail people

Frailty is one of the most challenging consequences of population ageing. Frailty develops as a consequence of age-related decline in multiple body systems, which results in vulnerability to sudden health status changes triggered by minor stress or events, such as an infection or a fall at home.

Between a quarter and half of older people are estimated to be frail. However, frailty is a gradual state and many younger people can also be considered to be in the early stages of frailty.

As healthcare professionals, it is our role to support people living with frailty to maintain their health for as long as possible. We know that frail older people tend to have a longer length of stay, which can lead to complications and worse health outcomes, with an increase in their long-term care needs. So, for their wellbeing, we need to minimise this as much as possible.

We need to ensure that frail older people are discharged immediately once their acute care is complete, with the right level of support to continue their recovery and rehabilitation in their own home.

Ensuring that there is a comprehensive geriatric assessment in place is fundamental to this. This assessment could be carried out as an in-patient or on arrival at hospital and followed up at home.

Key steps to successfully establishing a frailty pathway include:

  • Ensuring there is a rapid response service in place to support frail older people to avoid unnecessary hospital admissions
  • Identifying and measuring frailty from the moment the patient enters the ‘front door’, using an evidence-based assessment tool (e.g. by using the Rockwood Clinical Frailty Score)
  • Having a multidisciplinary team that is competent to deliver a holistic assessment and management of older people (through a Comprehensive Geriatric Assessment) early in the patient pathway
  • Engaging with a single assessment process and patient record which is completed by the whole team
  • Involving patients and their families (and carers) in their care – they should routinely be asked what matters to them, and their responses clearly documented

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