Working with multidisciplinary teams in the community to deliver reliable approaches to supporting individuals with frailty
In addition to our work on Anticipatory Care Plans, the ihub is also supporting Integration Authorities to identify and better support individuals who are frail. The evidence highlights that proactively identifying people in the community who are frail and then ensuring they have appropriate support to maintain their independence is key to reducing unnecessary hospital admissions.
In 2016–2017, our Living Well in Communities team supported the introduction of the eFrailty Index (eFI), developed by NHS England, into the Scottish context. This tool applies algorithms to existing GP data to produce a list of all individuals on the practice list who are either mildly frail, moderately frail or severely frail. However, knowing who falls into which category is meaningless if we don’t then do something with that data.
The following case study highlights how we are now working with services to develop tools and approaches to support them to use the information gathered to make more informed decisions about how to better support individuals to live well with frailty.
Midlock GP Practice
Midlock GP Practice has been working with the ihub to test the eFI in a Scottish context. The testing has involved working with a GP and other members of South Glasgow City Health and Social Care Partnership, including community nursing, social work, the rehabilitation team, carers’ support, housing, commissioning, older people’s mental health services and the voluntary sector.
Following stratification of their population using the eFI, the Midlock team then considered what interventions would be appropriate for individuals with different levels of frailty.
As part of this, a multidisciplinary team started to use the ihub falls and frailty tool to guide their frailty case reviews. The tool promotes an assets-based approach and holistic assessment across agencies, and provides useful prompts that help staff by signposting to partner agencies that could assist in care provision. Incorporating the tool in the case reviews led them to identify five key interventions which should be implemented for every individual identified as frail:
- frailty identification and coding on the GP system
- Anticipatory Care Plans uploaded to KIS
- ensure a key worker is allocated
- provide carer support and assessment, and
- conduct a falls and frailty conversation.
These interventions had previously not been happening for every person, every time.
All of the team have made commitments to support the work. Community nurses are engaging more in ACP conversations, and the voluntary sector feel valued and are now a core part of the multidisciplinary team, whereas previously they had been on the periphery. The team have changed the way that they work and are now able to more proactively target those most in need of support.
“It challenges me to think differently about the people I treat.”
“Working together has made us communicate with one another more regularly and avoid duplication of assessment.” – Midlock GP Practice team