Living and dying well with frailty collaborative: guidance and change package


August 2019 to March 2020 Healthcare Improvement Scotland programme

The Living and Dying Well with Frailty collaborative ran from August 2019 to March 2020. Its aim was to support health and social care partnerships (HSCPs) improve how they identify and enable people aged 65 and over to live, and die, well with frailty in the community.

As part of this programme we produced two resources that supported HSCPs and GPs:

We developed these with HSCPs and GPs to improve:

  • early identification of frailty
  • anticipatory care planning
  • shared decision-making

This can help people living with frailty get the support they need, at the right time, in the right place.

The resources focus on four drivers for change:

  1. Using the eFrailty Index through SPIRE to identify people aged 65 and over living with frailty.
  2. Engaging in anticipatory care planning conversations, recording the information in the Key Information Summary (KIS).
  3. Working within a multi-disciplinary team to consider the holistic needs of the person.
  4. Using quality improvement methods to structure the work. This included using data to learn how changes are being implemented and the impact they make.

For further information contact