1. Frailty: Delivering the New GMS Contract & Next Steps
Andy Clegg
Senior Lecturer & Consultant Geriatrician
University of Leeds & Bradford Royal Infirmary
@drandyclegg

2. Evidence for community-based interventions
Outcome
Comprehensive geriatric assessment of older people
14% reduction in nursing home admission
Comprehensive geriatric assessment of ‘frail’ older people
10% reduction in hospital admissions
Community-based post discharge care
13% reduction in nursing home admission
10% reduction in hospital admission
Group-based education (supported self-management)
40% more likely to be living at home
Falls prevention
8% reduction in falls
Exercise interventions
Improved function
Reducing inappropriate polypharmacy
Reduced falls/hospitalisations
Caveats
Beswick Lancet 2008, Clegg RCG 2012, Theou J Aging Research 2011

3. Considering the caveats
Clinical and public health decisions are almost always made with imperfect data
There will always be an argument for more research and for better data, but waiting for more data is often an implicit decision not to act or to act on the basis of past practice rather than best available evidence
The goal must be actionable data that are sufficient for clinical and public health action that have been derived openly and objectively and that enable us to say, “Here’s what we recommend and why.”
Frieden NEJM 2017

4. How should we take action?

5. Apply established models of LTC management
Organisational, system-level approach to caring for people with LTCs in a primary care/community setting
Components of the approach are highly relevant for frailty

6. Applying the chronic care model in frailty
Identify relevant subpopulations of people with frailty for proactive care
Mobilise community resources to meet needs of people with frailty
Empower and prepare people with frailty to self-manage their condition(s)
Embed proactive planned interactions which incorporate individual goals
Embed evidence-based guidelines into practice & integrate specialist expertise

8. eFI development and validation
Development cohort 250,000
Internal validation cohort 250,000
External validation cohort 500,000
Clegg Age Ageing 2016 (open access)

10. Outcomes Clegg Age Ageing 2016 (open access) Outcome Mild frailty
(HR, 95% CI)
Moderate frailty
Severe frailty
1 yr care home admission
2.00 (1.68 to 2.39)
2.70 (2.41 to 3.04)
5.94 (4.61 to 7.64)
3 yr care home admission
1.52 (1.37 to 1.69)
3.42 (2.84 to 4.12)
5 yr care home admission
1.56 (1.43 to 1.70)
2.34 (2.10 to 2.61)
3.00 (2.42 to 3.70)
1 yr hospitalisation
1.85 (1.81 to 1.88)
2.96 (2.90 to 3.02)
4.62 (4.50 to 4.74)
3 yr hospitalisation
1.71 (1.69 to 1.73)
2.54 (2.51 to 2.58)
3.64 (3.57 to 3.70)
5 yr hospitalisation
1.63 (1.61 to 1.64)
2.43 (2.40 to 2.46)
3.59 (3.54 to 3.65)
1 yr mortality
1.91 (1.78 to 2.04)
3.39 (3.15 to 3.65)
5.23 (4.73 to 5.79)
3 yr mortality
1.74 (1.68 to 1.81)
3.02 (2.90 to 3.14)
4.56 (4.29 to 4.84)
5 yr mortality
1.66 (1.62 to 1.71)
2.73 (2.64 to 2.81)
3.88 (3.68 to 4.09)
Clegg Age Ageing 2016 (open access)

11. Frailty trajectories and care pathways
Fit (50%)
Mild frailty (35%)
Moderate frailty (12%)
Severe frailty (3%)
Supported self-management
Care & Support Planning
Proportion alive
Comprehensive Geriatric Assessment
Time
5 yrs

12. National implementation & dissemination

13. 2017/18 GMS Contract

14. NHSE Six Step Guidance Identification e.g. using eFI
Clinical confirmation (e.g. CSHA Clinical Frailty Scale)
Coding of frailty diagnosis
Consent for summary care record
Falls assessment & medication review
Clinical judgment for other relevant interventions

15. Falls assessment in primary care: BGS/AGS guidance

16. Full evaluation Falls history Gait, balance, mobility, muscle weakness
Visual impairment
Cognitive impairment
Urinary incontinence
Home hazards
Cardiovascular examination (e.g. dysrhythmia/AS) & medication review

17. Evidence base: individualised, multifactorial intervention
Strength & balance training
Home hazard assessment & intervention
Vision assessment & referral
Medication review with modification/withdrawal

18. Commissioning falls prevention services

19. Options for designing falls prevention services
Specialist falls service, involving a single point of access for referrals, multifactorial interventions, and strength & balance exercises
Services that include a component of falls prevention e.g. frailty services/pathways
Embedding prevention in ‘non-specialist’ services, either contractually or via locally agreed ways of working
Case finding
Developing workforce competencies
Incorporating strength & balance training into physical activity services

20. GMS contract: other interventions

21. Six essential characteristics of a service for frailty
Effective recognition, diagnosis and referral for frailty
Use of tools to assist case finding
Trained staff with appropriate expertise
A person-centred approach, moving away from disease-focused to holistic, goal orientated care
Practice underpinned by comprehensive geriatric assessment & personalised care planning
Integration across services/settings

22. Next steps: Personalised Care Planning
Personalised care planning to improve quality of life for older people with frailty Clegg A, Young J, Bower P, Cundill B, Farrin A, Foster M, Foy R, Hartley S, Hawkins R, Holmes J, Hulme C, Humphrey S, Lawton R, Pendleton N, West R, Bates C, Nazroo J NIHR PGfAR £2.7M (October 2017 to February 2023)

23. Personalised Care Planning for Older People with Frailty
Aim To establish whether PCP for older people with frailty improves quality of life (SF36) and reduces health and social care resource use at 12 months Work Package 1 Refining the target population by exploring QoL & health/social care resource use in frailty, using the eFI (ResearchOne; CARE 75+; ELSA) Work Package 2 Optimising the Age UK integrated care service to deliver PCP for older people with frailty Work Package 3 Feasibility study (cluster RCT, 8 general practices, 400 participants) - Yorkshire Work Package 4 Definitive cluster RCT, 40 general practices, 2,000 participants – Yorkshire & Greater Manchester

24. Research Outputs
Identification of the target population for PCP in frailty, using the eFI as a well-validated and widely available tool
A suitably optimised PCP intervention, including a common framework for routine NHS delivery
Definitive evidence on the effectiveness and cost-effectiveness of PCP for older people with frailty
Information for policy-makers and commissioners on wider NHS implementation

25. Summary
There is an existing evidence base for community interventions to improve outcomes for older people with frailty
Considering frailty as a long-term condition enables development of a community-based model of care, based on the existing evidence base
The eFI identifies subpopulations of older people at increased risk of adverse outcomes
The eFI, supported by clinical judgment, can help in the identification of older people with frailty as part of the 2017/18 GMS contract
National guidance on designing & commissioning falls prevention pathways and frailty services
Next steps include optimising and evaluating personalised care planning for older people with frailty in a major research programme

26. Thank you