Frailty resources

View a range of tools and resources you can use to help improve outcomes for people living with frailty, along with case studies from health and social care teams.

Frailty case studies

We have produced four case studies to support teams to implement improvements to health and care services accessed by people living with frailty:

Queen Elizabeth University Hospital in Greater Glasgow and Clyde on their experience with the Frailty at the Front Door collaborative and the further tests of change they did following that.
Charlie Chung of Fife Health and Social Care Partnership looking at their community health and wellbeing hubs.
NHS Lanarkshire describe their approach to primary care multi-disciplinary team meetings and how they have collaborated with third sector on a preventative approach to supporting people living with frailty.
Dr Stephen Carty of Edinburgh Health and Social Care Partnership, highlights how Leith Mount Surgery, a GP practice in Edinburgh, improved the quality of care for people living with frailty by introducing a proactive approach to frailty coding, identification and management.

Through screening and identifying people living with frailty we can improve their outcomes by ensuring the right services and care are delivered at the right time." Dr Lucy McCracken, National Clinical Lead for Older People

What is frailty?

Frailty is the manifestation of ageing that is associated with poor outcomes, including increased risk of disability, hospital admission, institutional care or death. The impact on a person’s quality of life is considerable, as well as an increased use of primary care and unplanned secondary care services.

If frailty is identified at an early stage and individuals are targeted with evidence-based interventions that can manage frailty, or reverse it, this can improve people’s quality of life and wellbeing. Optimal outcomes are more likely achieved when community health and social care services and hospital systems are fully aligned, well-coordinated and care and support are attuned to the specific needs of people living with frailty.

Who are these resources for?

The resources on our pages can be used by health and care professionals, teams and organisations to consider how best to identify and support their frailty population.

Frailty identification

Tools and resources to improve how people with frailty are identified; whether in a community or hospital setting.

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Frailty care planning and coordination

Tools and resources designed to support you to consider how best to deliver care to people living with frailty.

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How can the ihub support you?

The ihub delivers improvement programmes which contribute to improving outcomes for people living with frailty. Follow the below links for more information, tools and resources related to these programmes.

Current programmes
- Frailty Improvement Programme: Supporting health boards and Health and Social Care Partnerships provide an integrated frailty service.
- Hospital at Home: Hospital at Home is a short-term, targeted intervention that provides a level of acute hospital care in an individual’s own home that is equivalent to that provided within a hospital.
- Anticipatory Care Planning (ACP): A person-centred approach to help people to plan for their future.
- Falls: Older people living with Frailty are more likely to experience a fall during a stay in hospital.
- Focus on Dementia: A team within the ihub supporting 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.
- Deteriorating Patients: Older people, living with Frailty, can experience a sudden deterioration in their physiological condition during a stay in hospital.
- Access QI: Working with NHS boards to use quality improvement to sustainably and affordably improve waiting times.
Hibernated programmes
- Frailty at the Front Door Collaborative: The collaborative aimed to improve the process of identification and care coordination for people living with frailty who present to unscheduled care.
- Living and Dying Well with Frailty Collaborative: The collaborative supported Health and Social Care Partnerships to improve how they identify and enable people aged 65 and over to live and die well with frailty in the community.
Past programmes
- Palliative and End of Life Care: Palliative care and end of life care involves providing good care to people with life limiting conditions, or whose health is in irreversible decline.
Quality Improvement
Using quality improvement methods to test and implement new ways of working is important for ensuring that you learn from your tests of change and understand the impact that the changes have on:
- people living with frailty,
- the health and social care professionals who deliver care, and
- the organisations that plan and coordinate services.
The following generic quality improvement resources can be used in conjunction with the frailty specific guidance to help structure your ideas and test new ways of working.
- Quality Management System: The ihub’s Quality Management Portfolio is a new portfolio of work offering high-level interventions to support boards and partnerships enhance their quality infrastructure.
- Quality Improvement Zone: The QI Zone provides information and resources to support people with experience at all levels of quality improvement to develop their knowledge.

Any tools or resources that have helped you?

We welcome any suggestions you have for new resources and feedback to improve existing resources. If you have tools or resources that have helped you to make improvements locally or you want to provide feedback, please get in touch by emailing us at his.frailty@nhs.scot.