1. Improving care and support for people with frailty
Rachel Reid
Implementation Facilitator– North
27nd April 2018
This resource has been developed for people working in CCGs, primary care, community services, local authorities and across STPs/Integrated Care Systems in either a commissioning or provider role.
The aim of the resource is to provide advice on how NICE guidelines and quality standards can be used to support improvements in the identification and risk reduction of people with, or at risk of developing, frailty.
When writing this presentation, the following definition of frailty was referred to:
“A long-term condition characterised by lost biological reserves across multiple systems and vulnerability to decompensation after a stressor event” (Prof Martin Vernon, National Clinical Director Older People, NHS England)
© NICE All rights reserved.
Subject to Notice of rights

2. Overview What does NICE say about frailty?
Using NICE Quality Standards to improve care
Practical support and finding what you need
Any questions
The slides provide a brief overview of key NICE resources related to the topic of frailty. Todays session has a focus on a problem solving approach to improving H&WB of older people living with frailty and risk reduction for people with, or at risk of developing, frailty, there is a more detailed description of NICE quality standards and how they can be used to drive and measure quality improvement.
In addition to producing guidance and quality standards, NICE also publishes and makes available a wide range of practical resources to support the implementation of NICE guidance and use of NICE quality standards. This presentation will give a brief overview of these resources and highlight some key ones relating to frailty.
Finally, a brief tour of how to navigate the website will ensure that you can find what you are looking for quickly and easily.

3. Martin Vernon, NCD Older People (Feb 2017)
This slide has been included with kind permission of Martin Vernon, NCD Older People (Feb 2017) and is based on the British Geriatric Society Fit for Frailty model. It was used as a point of reference when collating the key resources included within this presentation. The model highlights the importance of recognising that someone is frail; undertaking a holistic (multidisciplinary) review; developing an individual, tailored care and support plan including further risk assessment and intervention (e.g. falls risk assessment).
These steps are covered in more detail in the following 2 NICE guidelines:
Multimorbidity: clinical assessment and management [NG56] Published date: September
Older people with social care needs and multiple long-term conditions [NG22] Published date: November
Martin Vernon, NCD Older People (Feb 2017)

4. What are NICE guidance and quality standards?
Evidence
Guidance
Quality
Standards
A set of systematically developed recommendations to guide decisions for a particular area of care or health issue
Research studies - experimental and observational, quantitative and qualitative, process evaluations, descriptions of experience, case studies
A NICE quality standard is a concise set of statements designed to drive and measure priority quality improvements.
Most people who are aware of NICE will be familiar with NICE guidelines. NICE guidelines make evidence-based recommendations on a wide range of topics, from preventing and managing specific conditions to planning broader services and interventions to improve the health of communities.
They describe what is effective (what will result in the best outcomes) and what is cost effective (best value for money). They are developed to guide decisions made about health and care (for practitioners, providers, commissioners, service planners and users) and aim to promote integrated care where appropriate.
For more information:
NICE guidelines are developed by independent committees and are based on a wide range of evidence sources. These examples show the breadth of evidence that will be considered depending on the topic question and the types of evidence available. The guideline committee also has the option of inviting additional topic experts to provide advice in the absence of published evidence, and the option to call for evidence (i.e. ask stakeholders if they are aware of anything).
NICE consults on the scope and the draft of each guideline. To register as a stakeholder so that your organisation can comment on guideline scopes and draft guidelines go to:
NICE Quality Standards
Quality standards set out the priority areas for quality improvement in health and social care. They cover areas where there is variation in care. Each standard gives you:
a set of statements to help you improve quality and information on how to measure progress.
For more information:

5. Typically around 4-6 statements
Define priority areas for quality improvement: areas where there is variation
Based on best available evidence such as NICE guidance and other evidence sources accredited by NICE
This is what a quality standard looks like. There are typically 4 – 6 quality statements, each describing a priority area for quality improvement. They are based on NICE guidance and other NICE-accredited sources.  This quality standard lists 5 areas which are key to the quality of social care for older people with multiple long-term conditions. You will note that statements 4 and 5 highlight the importance of integrated health and social care plans focused on a person’s personal priorities which are reviewed annually. This is consistent with the BGS frailty model presented on slide 3.
The 5 statements included within this quality standard are based on a number of national evidence sources (next slide).

6. Evidence sources
Older people with social care needs and multiple long-term conditions (2015) NICE guideline NG22
Department of Health (2014) Better care for people with 2 or more long term conditions
Department of Health (2014) Care Act 2014
Department of Health (2014) Care and support statutory guidance
Department of Health (2014) Carers strategy: the second national action plan 2014–2016
NHS England (2014) Safe, compassionate care for frail older people using an integrated care pathway: practical guidance for commissioners, providers and nursing, medical and allied health professional leaders
Department of Health (2013) Integrated care: our shared commitment
For ease of reference, the evidence sources underpinning the NICE quality standard on social care for people with multiple long-term conditions are listed and hyperlinked here.
It is important that the quality standard is considered alongside other evidence and current policy documents.
This quality standard has been developed in the context of important legal changes affecting people with social care needs. The Care Act 2014 established new provisions as well as updating existing ones, bringing together relevant policy and guidance that may have a significant impact on this group.
The quality standard is expected to contribute to improvements in the following outcomes:
social care-related quality of life
health-related quality of life
involvement in decision-making
safety of people using services
hospital admissions
residential care admissions
older people being supported to live where they wish
service user and carer satisfaction.

7. You can use NICE quality standards to help identify gaps in service quality and provision, and opportunities for high impact improvements, by mapping against NICE quality standards
In addition to detailing the areas where quality improvement effort will have the highest impact, the quality standards include evidence based metrics to measure progress of local improvement activities, in order to ensure that outcomes have improved and local activities have had the anticipated impact. The metrics can also be a useful source of KPIs (key performance indicators) or performance metrics for inclusion in system wide performance dashboards.
You can access this additional information by clicking on each statement. (Next slide).

8. As well as a rationale and quality measures, you can also find detailed definitions of terms within the statements and direct links to the underpinning evidence.
The definitions of terms used in the quality statement can be particularly helpful when reviewing local approaches. They often provide a useful checklist as in this example (next slide).

9. The definition of a health and social care plan outlines in detail what should be covered by the process. This detail comes directly from the underpinning guidelines which are evidence based recommendations describing what is safe, effective and value for money.
If you are reviewing your process or developing a care plan these are the key things to include – use to review local planning process

10. Key quality standards: Frailty - interventions
Multimorbidity
Social care for older people with multiple long-term conditions
Falls in older people 
Pressure ulcers
Delirium (includes risk assessment and prevention)
Sepsis
Dementia: support in health and social care
Medicines optimisation 
Nutrition support in adults
Transition between inpatient hospital settings and community or care home settings for adults with social care needs (see quality statement 2 on comprehensive geriatric assessment)
 End of life care for adults
This slide lists and provides hyperlinks to the key quality standards that can help support improvements in care and support for people with frailty.

11. This slide has been included with kind permission of Martin Vernon, NCD Older People.
The evidence suggests that there are a number of opportunities for helping people to reduce their risk of becoming frail/more frail. The interventions included in the box on the right, should be targeted to people most at risk of becoming increasingly frail. There are a number of NICE guidelines that contain recommendations to support improvements in these areas. How to find and navigate these guidelines will be covered shortly within this presentation. The next slide includes a list of, and hyperlinks to, the key NICE quality standards that relate to the topics.

12. Key quality standards: Frailty - prevention
Mental wellbeing and independence for older people (addresses mood, physical activity and social isolation)
Mental wellbeing of older people in care homes (physical and mental wellbeing, sensory impairment and sense of identity)
Dementia: independence and wellbeing (includes home safety, physical activity, physical, social and emotional wellbeing)
Preventing excess winter deaths and illness associated with cold homes
Foot care
Alcohol use disorders: diagnosis and management
Smoking: supporting people to stop and Smoking: harm reduction
Falls in older people
Nutrition support in adults
Medicines optimisation and Managing medicines in care homes (addresses polypharmacy)
These links will take you to the key quality standards that could help with improving local approaches to reducing individuals’ risk of frailty.

13. For more info on how to use quality standards…
This new web page describes how to use NICE quality standards to improve quality.
It describes how to use them to identify gaps and areas for improvement, to measure quality of care currently being provided, understand how to improve care, and demonstrate where it is good.
There is also a section for commissioners describing how to use NICE quality standards.
Throughout these pages there are links to resources and also examples of how other people have used NICE quality standards to improve care.

14. Finding what you need
The next section of this presentation provides a tour of the NICE website and some tips on how to find what you are looking for quickly and easily.

15. This is the homepage of the NICE website. The website address is www
This is the homepage of the NICE website. The website address is
You can use the search bar on the homepage to find what NICE has said about a topic.
However, you might find it easier to browse a whole topic by area such as population (e.g. older people) or setting (e.g. care homes).

17. This is the topic landing page for population groups: older people.
Key NICE pathways, guidelines, quality standards and other key guidance and advice (for example interventional procedure guidance) are listed by title.
Guidelines and quality standards that are currently in development are also listed should you wish to see a draft version or get involved as a stakeholder (by commenting on drafts, for example ).
You can skip to the type of NICE product that you are looking for by using the menu on the right hand side (highlighted in red). Or you can scroll down the page to browse everything listed (next slide).

18. Once you have found the guideline you are looking for, you will find that the layout of the ‘guideline landing pages’ all follow the same layout. The guideline title and date of publication/last update is detailed at the top of the page and a menu on the left enables you to skip to sections of the guideline. You can also skip to sets of recommendations from the overview page, for example recommendations on how to assess frailty.
The guideline landing page also includes links to related quality standards and interactive flowcharts (next slide).

19. NICE Pathways contain everything NICE says on a topic in an interactive flowchart. This is the high-level overview of the multimorbidity pathway. You can easily drill down to the information that you are looking for by clicking on the boxes in the flowchart. For example, clicking on the box “Delivering an approach to care that takes account of multimorbidity” will take you to a more detailed interactive flowchart – the icon at the bottom of the box indicates this (next slide).
For more information or to view the pathways:

20. This is the flowchart for “delivering an approach to care that takes account of multimorbidity”. You will notice that it is still relatively high-level. However, by clicking on a box within the flowchart, a summary of the relevant recommendations appears on the right. This includes hyperlinks to the actual guideline should you want more information.
The blue circles containing a white tick (highlighted in red) indicate that there is a related quality standard statement. This is also included in the information on the right hand side, by scrolling down the reading pane (next slide).

21. In addition to publishing evidence based guidelines and quality standards, NICE also produces and makes available (through shared learning and endorsement collections) a range of practical tools and resources to help you implement NICE guidance and use NICE quality standards.
Going back to the guideline landing page for Multimorbidity: clinical assessment and management, you will see that the page has been designed to look like file tabs. By clicking on the ‘tools and resources’ tab, you can access the practical tools and resources that can help you implement the guideline recommendations. (Next slide)

22. You will see that there are a range of practical tools and resources available here. You will usually find a ‘baseline assessment tool’ (or a ‘quality standard service improvement template’) to help you assess the extent to which current services and approaches are in line with NICE guideline recommendations.
You will also find a resource impact statement providing an overview of the economic evaluation that supported the NICE guideline in its assessment of ‘cost effectiveness’. Focuses on the recommendations that are considered to have the greatest resource impact, or that will generate savings. The statement outlines the total resource impact and highlights (and quantifies) benefits of treatment/prevention. These are useful resources to support local discussions about cost effectiveness (or return on investment) of services and programmes.
The shared learning information (highlighted in red) contains links to practice examples detailing how people have used the guideline locally (next slide).

23. Frailty: (some) shared learning examples
Integrated Care Clinical Pharmacist for Frail Older People: Case Management and Enhanced Rapid Response
Peer Support Meetings for Pharmacists Undertaking Medication Reviews for Older People in Care Homes and Domiciliary Settings
Medicines Optimisation for Older People in Care Homes and the Intermediate Care Setting: Developing and Reproducing new Models of Care
Neighbourhood Integrated Medicines Optimisation Team: Improving medicines use at home
Patient Led Clinical Medicines Reviews
The Alive! approach to providing meaningful activities for older people living in care, particularly those living with dementia
Improving the mental and social wellbeing of the elderly in residential care – a case study from Mellifont Abbey Residential Care Home
Patient information leaflets about preventing falls in hospital and the use of bedrails
Multifactorial interventions can reduce harm from falls in Acute Hospital settings
Care Home Support Team (CHST) - Reducing Falls
Community based Falls Prevention in Older People
Moving on, The Lunch Club experience
The role of Private domiciliary care for dementia care
Derby Dementia Support Service
The shared learning collection contains over 500 case studies showing how our guidance and standards have been used to improve the quality of health and social care services around the UK. This slide lists the key ones relating to improving care and support for people with or at risk of developing frailty (aligned to the models previously discussed in the presentation). They have all been hyperlinked for ease of reference.
For more information or to browse the collection:

24. You will also find tailored resources that have been produced specifically to support implementation of some of the recommendations in a guideline. These are often produced by another organisation and then endorsed by NICE. This example, a falls risk assessment tool kit, has been produced by Keel University in collaboration with Walsall CCG. All NICE endorsed resources are available for you to use free of charge.
NICE endorsed resources are complementary information not produced by NICE. For more information or to view a list of the resources:

25. If you still can’t find what you are looking for, it may be that NICE hasn’t produced a guideline on the topic. However, NICE evidence search provides access to selected and authoritative evidence in health, social care and public health. As part of the service, NICE also provides access to information content purchased on behalf of the NHS. This includes access to a range of bibliographic databases such as MEDLINE and professional journals.
You can access NICE evidence search by clicking on ‘Evidence services’ at the top of any page on the NICE website, then click on ‘Evidence search’. You will see that you can also use this route to access BNF and BNFC online in addition to CKS (Clinical Knowledge Summaries).
Evidence search features a search bar where you can search for individual words, specific phrases or, as in the example on the next slide, connected terms (next slide)

27. NICE Field Team and Technical Advisers
NORTH
Annie Coppel
Associate Director
Angela Parkin
Regional Technical Adviser
(and Northern Ireland)
Rachel Reid
Implementation Facilitator
NORTHERN IRELAND
Lesley Edgar Implementation Facilitator
MIDLANDS & EAST
Deborah O’Callaghan Associate Director
Gill Eddy
Regional Technical Adviser
(and Wales)
Joanne McCormack
Implementation Facilitator
Michelle Liddy
Regional Technical Adviser
LONDON
Jane Moore Implementation Consultant
SOUTH
Chris Connell
Associate Director
Zoe Girdis
Regional Technical Adviser
(and Channel Islands)
Jade Fortune
Implementation Facilitator (South East)
Vacancy
Implementation Facilitator (South West)
© NICE All rights reserved.
Subject to Notice of rights