Frailty care planning and coordination
Frailty is a complex condition associated with the development of multiple long-term conditions.
The following resources are designed to support you to consider how best to deliver care to people living with frailty.
Tools and Resources
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This document provides evidence for interventions in frailty that are community based, focused on the prevention of harms or poor outcomes, and supported by relatively high-level evidence. |
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This tool is designed for use within health, social care and third sector to support assessment and identification of interventions to meet an individual’s needs. Also available for individuals to download and print in poster format and as a booklet. |
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Guidance notes on multidisciplinary team meetings to discuss those identified with frailty. |
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A person-centred approach to help people to plan for their future. The FCP toolkit pulls together guidance and resources on all aspects of FCP to support health and social care professionals throughout the care planning process. |
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Older people, living with frailty, can experience a sudden deterioration in their physiological condition during a stay in hospital. |
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Older people living with frailty are more likely to experience a fall during a stay in hospital. |
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A Healthcare Improvement Scotland team who support improvement in hospital settings and specialist dementia units, diagnosis and post-diagnostic support, care co-ordination in the community and palliative and end of life care. |
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This toolkit provides easy access to the tools and resources developed to support delirium identification and treatment. |
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This leaflet was developed to help people, families and carers who have first-hand experience of an episode of delirium and need access to information about this distressing but treatable condition. |
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The Healthcare Improvement Scotland delirium infographic poster is a quick and visual way to understand Delirium identification, management and risk reduction. |
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Polypharmacy guidance toolkit by the Scottish Government Effective Prescribing and Therapeutics Division |
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| Improving care and support for people living with frailty in Scotland (May 2022) | This publication from the 90 Day Learning Cycle presents findings which have established seven key components of an integrated frailty system across health social care and the independent and third sector, and sets out next steps for the Focus on Frailty Programme. |
| Ageing and frailty standards (November 2024) |
Healthcare Improvement Scotland have developed standards for ageing and frailty in Scotland. The standards draw on current evidence from:
They cover older people who may experience frailty as they age and apply in all settings. |