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.

This includes the consideration of specific elements of the individual’s condition and guidance for how professionals can work together to improve the coordination of the care delivered.  

This section also includes links to guidance on anticipatory care planning which you can use to involve people in discussions about their wishes and future care needs. Encouraging individuals to think ahead is important to help ensure that in the event of a change in their health or care needs the right thing is done at the right time with the right outcome.


Tools and Resources

  • Evidence summary of community based interventions: 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.
  • Frailty and falls assessment and intervention tool: 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.
  • Multi Disciplinary Team (MDT) Guidance: Guidance notes on multidisciplinary team meetings to discuss those identified with frailty.
  • Anticipatory Care Planning (ACP): A person-centred approach to help people to plan for their future. The ACP toolkit pulls together guidance and resources on all aspects of ACP to support health and social care professionals throughout the care planning process.
  • Deteriorating Patients: Older people, living with Frailty, can experience a sudden deterioration in their physiological condition during a stay in hospital. You can find more information, tools and resources on the Deteriorating Patient web pages.  
  • Falls: Older people living with Frailty are more likely to experience a fall during a stay in hospital. You can find more information, tools and resources on the Falls web pages
  • 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. You can find more information, tools and resources on the Focus on Dementia web pages.
  • 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. This document is a summary of the systematic review-level evidence that is available on the approaches to care coordination in palliative care and end of life care.
  • Delirium: Older people, living with frailty, are more likely to experience an episode(s) of an acute condition known as Delirium during a stay in hospital.
    • Delirium tooklit: This toolkit provides easy access to the tools and resources developed to support delirium identification and treatment. 
    • Delirium leaflet: 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. 
    • Delirium poster: The Healthcare Improvement Scotland Delirium infographic poster is a quick and visual way to understand Delirium identification, management and risk reduction.
  • Improving planned care pathways toolkit: This toolkit has been developed, using learning from across Scotland, to support NHS boards in taking a quality improvement (QI) approach to sustainably reduce waiting times.
  • Hospital at Home - Guiding principles for service development: This publication brings together and reviews the published evidence on the effectiveness and safety of hospital at home initiatives for older people with frailty and shared learning from existing services across Scotland.
  • Neighbourhood Care: Neighbourhood Care is a holistic model of care in the community, which was adapted from the Buurtzorg model in the Netherlands. You can learn more about how the model has been applied in Scotland on our Learning from neighbourhood care web page.
  • 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 ihub Frailty Improvement and Implementation Programme.


Examples and case studies

  • Experience of living with frailty: In this video, Mr Lucas discusses his experience of living with frailty, and the care that he receives that helps him to live independently at home.