A recent study written by Newcastle University and published in The Lancet asks if late-life dependency is increasing. The study reports that older people are living longer with substantial care needs. Most will live in the community and need collaborative health and social care.
How can GPs make sure they know about every frail person? This is the fundamental first step to putting appropriate care plans in place.
Make use of existing data
Electronic records at GP practices contain detailed information about each patient's medical history. In isolation, knowing that a patient has a certain disease will not show a direct link to them being frail. Yet looking at the full patient's record allows us to estimate how frail they are. Typical considerations include:
- atrial fibrillation
- chronic kidney disease
- heart failure
Computers are good at running repetitive tasks such as calculating an Electronic Frailty Index (EFI) for every patient. Vision has an EFI calculator that considers 36 separate indicators to create these indices. It also has reports that highlight the frail patients GPs might not already be aware of. These reports include:
- Patients estimated to be moderately or severely frail but without a recorded frailty score
- Patients whose frailty is getting worse
- Frail patients who are overdue for a medication review
It is difficult for GPs to remain aware of their frail patients. By nature it is a transient cohort. These reports help GPs to identify all their frail patients at any time.
Frailty and the GMS contract
GP practices in England must identify and manage their moderately and severely frail patients aged over 65. The Vision EFI calculator and reports help practice staff to manage the care for these patients as well as identify them.
We've published a guide to help GP practices meet the requirements of the GMS contract titled '3 steps to managing patients with severe frailty'.
Population level management
Groups of GP practices from federations right up to STPs can identify and manage their frail patients at population level using Outcomes Manager. Download our ebook to find out how to get started with population level healthcare management.