Primary and secondary drivers, and change ideas

Secondary driver: Use of reliable tools and shared language to identify frailty and those at risk of frailty

Change ideas

• Frailty screening at interactions with key services
• Standardised use of reliable tools such as Clinical Frailty Scale and Think Frailty
• Population screening for frailty using eFI
• Electronic recording of frailty (e.g. frailty coding)

Secondary driver: Timely delivery of Comprehensive Geriatric Assessment

Change ideas

• Timely CGA across all settings
• Use of integrated multidisciplinary and multi- agency team huddles
• Adopt 7 steps to appropriate polypharmacy reviews
• Development of systems to record and share the assessment of frailty

Secondary driver: Proactive reassessment and responsive multidisciplinary and multi-agency intervention

Change ideas

• Services designed to enable self-referral as circumstances change
• Use of multidisciplinary and multi-agency team meetings in primary care
• Reliable process for sharing information between health, social care, third and independent sector

Resources to support the delivery of these change ideas

Secondary driver: Resources, services and community assets which support prevention and empower people to self-manage

Change ideas

• Access to community based activity to improve physical and mental health e.g. walking and befriending
• Community link worker to signpost and navigate access to community support
• Timely access to screening and lifestyle modification groups e.g. nutrition and smoking cessation
• Access to housing advice and support

Secondary driver: Proactive person-centred care planning, management and end of life care

Change ideas

• Ensuring individuals have a recently updated Key Information Summary
• Anticipatory Care Planning included in person centered care planning and review at transitions of care
• Teams use a recognised tool to support people to set and achieve personal goals
• Process for shared decision making with individual, family, carers and MDT, including at the end of life

Secondary driver: Timely and equitable access to clearly defined care pathways

Change ideas

• Pathways to enable direct admission to frailty specific clinical areas from the community
• Development of pathways which prevent hospital admission
• Development of pathways which promote hospital discharge within 48 hours
• Creation and promotion of local map of services and community assets

Secondary driver: Effective care coordination to improve experience of care

Change ideas

• Single access point to health and social care services for people living with frailty
• Process to support transitions between teams and services
• Use of integrated multidisciplinary and multi-agency team huddles
• Process to share information between teams and services

Secondary driver: Health and social care services are responsive to changes in an individual’s level of frailty

Change ideas

• Use of reliable tools to recognise deterioration in health to prompt holistic assessment
• Services designed to enable self-referral as circumstances change
• Development of workforce and work patterns to enable responsive support
• Process in place for regular case reviews

Resources to support the delivery of these change ideas

Secondary driver: Strategic leadership which supports integrated working

Change ideas

• Leadership walk-rounds at team, locality and strategic levels
• Strategic frailty leadership network
• Mechanism to encourage staff feedback
• Development of a shared vision

Secondary driver: Integrated multidisciplinary and multi-agency working

Change ideas

• Processes to enable teams to work together and build trusting relationships
• Use tool to assess readiness for integration
• Integrated huddles across health, social care, third and independent sectors
• Process to share information between teams and services

Secondary driver: Co-producing services with people families and carers

Change ideas

• Involvement of people with lived experience, families and carers in service improvement
• Use of recognised frameworks to support lived experience engagement
• Use of feedback to inform service improvement

Secondary driver: Compassionate leadership to promote psychological safety and staff wellbeing

Change ideas

• Celebrating success
• Structured debrief opportunities and 1:1 time
• Clear link to local wellbeing strategies
• Learning and development opportunities for health and social care staff

Secondary driver: System for learning

Change ideas

• Opportunities to share learning locally and nationally
• Sharing learning through HIS Frailty Learning System
• Quality improvement education for teams
• Frailty specific education for MDT and wider team

Resources to support the delivery of these change ideas