Electronic Frailty Index: Identifying People With Mild Frailty And Developing A 3rd Sector Led Response
Midlothian Health and Social Care Partnership
Frailty is an increasing challenge for Midlothian Health and Social Care Partnership (HSCP). Services could be unable to meet growing demand and struggle in the medium to long term if the health and social care system does not change. But there are substantial challenges in identifying people with frailty, particularly mild or moderate (the rising-risk population).
Previously, age and hospital activity was used to identify frailty, which meant our understanding of this population’s needs and services used, was poor.
The Improvement Fund grant from the ihub allowed us to proactively identify this population through GP read codes using the electronic Frailty Index (eFI).
This project aimed to improve person-centred care for people living with (mild) frailty, by:
- developing a robust process using eFI
- shifting from being reactive to pro-active
- building relationships between third sector and primary care
- developing referral pathways into community-based support (for example MERRIT, Eat Well Age Well)
- understanding the needs of this population to help future planning of services
The use of eFI confirmed that over 8000 people are living with frailty across Midlothian, double the number previously thought, with the majority (around 6000) coded as ‘mild’.
eFI also revealed that half of the frail population are aged under 75 (with a strong link to deprivation for the younger frail).
For the mild cohort, there are unmet carer needs, unmet nutrition needs, basic home adaptations required, people not accessing benefits they are entitled to (e.g. attendance allowance, Blue Badge) and a need to link with groups and activities to reduce social isolation and maintain independence
This is important learning for how we forward plan, in terms of growing numbers and challenging our assumptions about age.
- What was the approach?
Midlothian Health and Social Care Partnership’s (HSCP) strong relationship with British Red Cross (BRC) provided an opportunity to use eFI to identify those who would benefit from the Neighbourhood Links Service’s advice, information and practical support.
Neighbourhood Links offers a comprehensive assessment, covering practical, emotional and social issues and connects people to HSCP services, other statutory agencies, and third sector support. It also allows signposting for future services, e.g. government grants for improving home heating, attendance allowance referrals, Blue Badges, and Dial a Ride.
By employing a dedicated worker who could build relationships with the practices, we wanted to see a shift from crisis response and inconsistent awareness of services, to a pro-active systematic approach that made it easy for primary care to link people to person-centred support and support them to make choices.
Using eFI, practices identified patients from the mild frailty cohort on a monthly basis and a phased approach was used to send letters out to patients. The pace was increased over the first 3 months while we gauged the uptake rate, wanting to avoid a waiting list developing. A process was also instigated to ensure people phoning BRC were directed into the right service.
Following contact, a home visit was offered by the Project Worker and family members were also encouraged to attend. Follow up visits or phone calls were carried out by the Project Worker as required. Once a case was closed, an evaluation form was sent to the individual. To date, 74 have been sent out and 39 returned.
Meetings between BRC, the HSCP and each of the three practices set out the parameters of the project and how the Project Worker would keep in touch, raise concerns and inform each practice about the work being undertaken with their patients.
A steering group was established with representation from primary care, health and social care and third sector organisations. The steering group has helped direct the project and was useful in overcoming operational issues, as well as highlighting new areas of work, e.g. falls pathway with MERRIT, agreeing on a core data set for primary care, developing a test of change regarding simple home adaptations.
In addition to the Project Worker, line management was provided by BRC’s Service Manager, with support from the Assistant Strategic Programme Manager from the HSCP. The Practice Managers acted as the key contacts within primary care and were instrumental in actioning changes to processes to help with the smooth running of the project.
Third sector services have worked together to develop referral pathways to avoid duplication and make it easier for primary care, as well as set up new pathways with health and social care, which all improve the patient experience.
- What was the impact?
“Thank you for everything, now I feel my house is fire safe also staying alone I know if I need help there is someone there the push of a button (Midcare Alarm). The Co-ordinator made me feel she really wanted to help do everything she could for me and I am very grateful.”
As of the end of April, 149 people have contacted BRC, with 93 accessing the service. This equates to around 1 in 10 people with mild frailty.
We now know that:
- There are over 8000 people living with frailty, most of them mild (around 6000)
- There are unmet carer needs, unmet nutrition needs, basic home adaptations required, people not accessing benefits they are entitled to, and a need to link with groups and activities to reduce social isolation and maintain independence
- We can reach people before crisis
- The Project Worker role has been instrumental in developing excellent relationships with primary care colleagues
- Data sharing between the statutory sector and third sector is a priority that needs resolving
- We can support good quality data for primary care
This project supports people to stay in their home, remain independent for longer, and enables them to link back into their community. The main benefits are:
Prevention: Almost 55% of people said they had mobility issues. The same number had fallen in the last 6 months. Of those who had fallen 32 people (34%) needed simple home adaptations such as installing grab rails and banisters and 11 people (almost 12%) had their walking aids checked to ensure they were fit for purpose. Both of these approaches are important interventions to reduce falls risks.
“It has made me aware of services I hadn’t heard of. I now have handrails; attendance allowance and I am due to get my heating upgraded. Thank you.”
23% have accessed groups via BRC’s Local Area Co-ordinators service to overcome loneliness and isolation. 30% have benefitted from a Blue Badge and 33% from Dial A Ride, making it easier for people to get out and about.
Carers Needs: 1 in 3 were unidentified carers and went onto access services at VOCAL (Voices of Carers Across the Lothians).
Future planning: Important conversations about DNACPR, Power of Attorney and Emergency Care Plans. All of these can be shared on social work and GP systems, which help support more effective joint working. For the individual, they say it gives them ‘peace of mind’.
Finances: DWP referrals for Attendance Allowance equates to over £2016.75 a week raised for 21 people. The total of £104,871 a year extra income is being spent in Midlothian and helps make life easier. There have also been successful applications made for new boiler and central heating installations as well as council tax rebates and while we are not able to quantify costs associated with these outcomes, they are important to note.
Services: The GP practices also benefited, along with the other organisations represented on the steering group who got to know each other and work together more effectively. For BRC, there is a better/broader understanding of services needed to meet needs and as a result, greater job satisfaction. Partnership working helped enormously in overcoming operational issues as well as identifying how pathways could be improved for patients and simplified for referrers.
- What was the learning?
Key learning points:
- Building relationships with the GP practice team, in particular the Practice Manager is key. Time spent face to face to build constructive ones is time well spent. This has led to wider engagement opportunities with GP practices across Midlothian.
- Recognising the barriers to access and identifying potential solutions as a team was an effective way to overcome difficulties as well as create a sense of project ownership. The follow-up phone calls offered a personal connection and made a difference to the uptake rates.
- Having the right people on the steering group is crucial, especially if services are going to receive referrals as a result of the project.
- Constantly reflecting and having the ability to adapt the approach/service quickly to meet the patient’s needs.
- Data sharing remains a barrier
Letters from the GP Practice alone were not enough for people to opt into the service.
Follow up phone calls and BRC having a presence at the Flu clinics significantly improved uptake. As a result, in agreement with the GP practices, follow up phone calls now form part of the routine process and this has resulted in a much improved uptake.
The uptake rate improved as the process was refined to incorporate a simpler letter and a new leaflet.
It is also worth noting that receiving a letter ‘out of the blue’ prompted some patients to contact their GP practice thinking it was ‘a scam’ and illustrates well that contacting people not in crisis is a different approach and brings challenges.
Sharing the Learning
We have shared learning at a range of HSCP events (Professional Forum, Primary Care Collaborative, GP Reps, Voluntary Sector Summit), British Red Cross Scotland and UK wide events, International Quality Conference delegates as part of NHS Lothian’s Experience Day.
We also had a poster accepted and were shortlisted as a finalist in the ‘person-centred’ category at the NHS Scotland Conference 2019.
- What are the next steps?
Funding for a further 12 months has been secured to enable the work to continue with the original three practices. In addition, parallel work (part of Midlothian’s wider frailty programme) has involved BRC and this will be strengthened over the coming year. Moving forward we want to explore how we overcome the data sharing issues and look at closer working relationships between primary care and third sector organisations.
Our focus will be on:
- Looking at the impact on GP contacts
- Test of change to allow BRC to directly assess and order adaptations
- Eat Well Age Well and Glasgow University research into Nutrition in older people.
The approach could be adopted Midlothian-wide and the method (identification, proactive contact) applied to other health and care settings, if you gave a service that has the time and capacity to engage with the cohort.