Resources to support change ideas

Focus on frailty

Tool and resources to support the understanding and delivery of the change ideas are listed below in the sections for the relevant drivers:

Primary driver: Early identification and assessment of frailty

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

Resource Source What is it and what is it for?
Evidence and guidelines:
Development and validation of an electronic frailty index using routine primary care electronic health record data Clegg, A, Bates C, Young J, Ryan R, Nichols L, Teale EA, et al. Age and Ageing. 2016;45(3):353-360 Article describing the development of an electronic frailty index using data from a UK primary care database 
A global clinical measure of fitness and frailty in elderly people Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. Canadian Medical Association Journals. 2005;173(5):489-495 Article describing the development and application of a 7-point Clinical Frailty scale to 2305 elderly patients
Tools and resources:
Clinical frailty scale Dalhousie University Judgement-based clinical tool to screen for frailty and to broadly stratify degrees of fitness and frailty
THINK frailty tool Healthcare Improvement Scotland Tool supporting screening for frailty as an adjunct to clinical judgment. Can be used to screen all people over 75 and people resident in care homes over 65.
eFI in NHS Forth Valley Healthcare Improvement Scotland Paul Baughan, GP and palliative care clinical lead, talks about the electronic frailty index
University Hospital Monklands case study Healthcare Improvement Scotland Case study of a Frailty at the Front Door improvement project in NHS Lanarkshire 
LifeCurve™ Improving independence (and reducing costs) at scale presentation Newcastle University Presentation on improving independence (and reducing costs) at scale 
Electronic Frailty Index (eFI) Healthcare Improvement Scotland Tool for identifying people as they progress through different levels of frailty, based on routine interactions with their GP

Secondary driver: Timely delivery of Comprehensive Geriatric Assessment in acute and community care settings

Resource Source What is it and what is it for?
Evidence and guidelines:
Silver Book II British Geriatrics Society Guidance and best practice on recognising and treating non-specific presentations in urgent care of older people
CGA in primary care settings British Geriatrics Society Toolkit providing an introduction to Comprehensive Geriatric Assessment (CGA) in primary care settings
Comprehensive geriatric assessment for older adults
admitted to hospital		 Ellis G, Gardner M, Tsiachristas A, Langhorne P, Burke O, Harwood RH, et al. Cochrane Database of Syst. Rev. 2017; 9 Cochrane systematic review on the effectiveness of comprehensive geriatric assessment(CGA) in improving care in older people admitted to hospital 
The relationship between frailty and polypharmacy in older people: a systematic review.  Gutierrez-Valencia M, Izquierdo M, Cesari M, Casas-Herrero A, Inzitari M, Martinez-Velilla N. Br. J. of Clin. Pharm. 2018; 84:1432-1444 Systematic review of quantitative studies of the impact that frailty and polypharmacy have on each other
Health outcomes and implementation barriers and facilitators of comprehensive geriatric assessment in community settings: a systematic integrative review Sum G, Nicholas SO, Nai ZL, Ding YY, Tan WS. BMC Geriatrics. 2022;22(1):379. Systematic review of the quantitative evidence on comprehensive geriatric assessment in community-dwelling adults  
Tools and resources:
7 steps to appropriate polypharmacy NHS Scotland  Practical, step-by-step guide for managing polypharmacy 
Modern ward rounds Royal College of Physicians Report from UK healthcare professional leaders setting out best practice for modern ward rounds 

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

Resource Source What is it and what is it for?
Evidence and guidelines:
Multidisciplinary team meeting (MDT) Guidance Healthcare Improvement Scotland Guidance notes on multidisciplinary team meetings to discuss those identified with frailty in the community 
Community-based care pilot project Healthwatch Liverpool Report of a 100-day pilot project focused on providing community-based care for frail older people
Framework for countries to achieve an integrated continuum of long-term care World Health Organisation Framework to guide countries in assessing system-level components to implement sustainable and equitable long-term care actions
Delaying and reversing frailty: a systematic review of primary care interventions Travers J, Romero-Ortuno R, Bailey J, Cooney MT. British Journal of General Practice. 2019;69(678):e61-e9. Systematic review of the evidence to assess the comparative effectiveness and ease of implementation of frailty interventions in primary care
Tools and resources:
Fife Health and Social Care Partnership: The community health and wellbeing hub model in Fife case study Healthcare Improvement Scotland Case study of community health and wellbeing hubs (Hubs) developed and tested in Fife
Delivering integrated care: the role of the multidisciplinary team Social Care Institute For Excellence Logic model describing good integrated care; includes a visual depiction of how a fully integrated health and care system might be structured and function, and the outcomes and benefits it should deliver for service users and carers

Primary driver: People living with frailty, carers and family members access person-centred health and social care services

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

Resource Source What is it and what is it for?
Evidence and guidelines:
Integrated care models for managing and preventing frailty: A Systematic review for the European Joint Action on Frailty Prevention (ADVANTAGE JA) Hendry A, Vanhecke E, Carriazo AM, López-Samaniego L, Espinosa JM, Sezgin D, et al. Transl Med UniSa. 2019;19:5-10 Systematic review of the evidence on models of care for frailty to identify those designed to prevent and tackle frailty in the community and at the interface between primary and secondary care
Behavioural risk factors in mid-life associated with successful ageing, disability, dementia and frailty in later life: A rapid systematic review  Lafortune L, Martin S, Kelly S, Kuhn I, Remes O, Cowan A, et al. PLoS ONE. 2016; 11(2): e0144405 Systematic review of the evidence on behavioural risk factors in mid-life that are associated with successful ageing and the primary prevention or delay of disability, dementia, frailty and non-communicable chronic conditions
Tools and resources:
Healthier for longer: How healthcare professionals can support older people. British Geriatrics Society & Greenbrook S. Report exploring how messages of prevention and healthy ageing apply to a population group that may already be ill and frail, and to the healthcare professionals who care for them
Community led models: innovation in health and social care report Healthcare Improvement Scotland Report sharing learning from innovative approaches to community-led health and social care provision, focusing on the Scottish experience
People led care portfolio Healthcare Improvement Scotland HIS's combined portfolio of work on:Collaborative Communities, Person-centred Design and Improvement, Unpaid Carers Improvement Programme and Human Learning Systems  
Age UK care co-ordinator roles The King’s Fund Article describing a pilot of Age UK staff coordinating disparate health and care services for vulnerable older people
Frailty matters University of the West of Scotland & Health and Social Care Alliance Joint project to understand and support the role of community nurses in leading personalised care for older people with frailty

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

Resource Source What is it and what is it for?
Evidence and guidelines:
Decision aids that really promote shared decision making: The pace quickens. Agoristsas T, Heen AF, Brandt L, Alonso-Coello P, Kristiansen A, Akl EA, et al. BMJ, 2015; 350:g7624 Article analysing the the limitations of current decision aids, and how they can be improved to help effective shared decision making
Shared decision making in realistic medicine: What works Scottish Government Synthesis of recent evidence on the current use of shared decision-making in Scotland, and international evidence of what works in encouraging greater use of shared decision-making in clinical consultations
A systematic review to identify and assess the effectiveness of alternatives for people over the age of 65 who are at risk of potentially avoidable hospital admission Huntley AL, Chalder M, Shaw ARG, Hollingworth W, Metcalfe C, Benger JR, et al. BMJ Open. 2017;7(7):e016236. Systematic review of the evidence on what alternatives to acute care  there are for older patients and are they safe, effective and cost-effective
Tools and resources:
REDMAP framework BDr K Boyd, Reader in Palliative Care, The University of Edinburgh 6-step guide to Future Care Planning conversations with people who are living with a serious illness, health conditions or disabilities that will get worse at some stage, or older people who are becoming frailer
Always events® NHS England Quality improvement methodology and toolkit to enable understanding of what matters to people who use services, families and carers and to co-produce improvement in the experience of care
Future care planning  Healthcare Improvement Scotland Guidance and resources on all aspects of future care planning to support health and social care professionals throughout the care planning process
Principles of Structured Response to Deterioration Healthcare Improvement Scotland Standard set of questions to support a clinician responding to a deteriorating patient. Includes a flowchart visual guide
Supportive and Palliative Care Indicators Tool (SPICTTM) University of Edinburgh Tool to help identify people with deteriorating health due to a serious illness, one or more health conditions (multimorbidity) or frailty in older age 

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

Resource Source What is it and what is it for?
Evidence and guidelines:
Early discharge hospital at home Gonçalves-Bradley DC, Iliffe S, Doll HA, Broad J, Gladman J, Langhorne P, et al. Cochrane Database of Syst. Rev. 2017(6). Systematic review of the evidence on health outcomes and economic benefit of early discharge hospital at home services as an alternative to inpatient care 
The (cost-)effectiveness of preventive, integrated care for community-dwelling frail older people: A systematic review Looman WM, Huijsman R, Fabbricotti IN. Health Soc Care Community. 2019;27(1):1-30. Systematic review of the evidence on effectiveness and cost‐effectiveness of preventive, integrated care for community‐dwelling frail older people
Tools and resources:
Improving planned care pathways toolkit Healthcare Improvement Scotland Quality improvement tools and resources to sustainably and affordably reduce waiting times
Hospital at home toolkit Healthcare Improvement Scotland Range of tools and resources to support areas to implement and expand Hospital at Home services
NHS GGC: Augmenting front door frailty in Queen Elizabeth University Hospital case study Healthcare Improvement Scotland Case study of the QUEH Frailty Team working with the the ihub at HIS to carry out tests of change 
NHS Tayside improvement team workplan 2021-2022 Healthcare Improvement Scotland Report for the NHS Tayside Medical Director on the Improvement Team's  achievements, structure, resourcing, approach and intentions relating to Quality Improvement activities in the year 2021- 2022
The frailty at the front door collaborative impact report Healthcare Improvement Scotland Evaluation of the impact of phase one of the Frailty at the Front Door collaborative December 2017 - May 2019. Describes lessons learned and summarises next steps 

Secondary driver: Effective care coordination to improve experience of care

Resource Source What is it and what is it for?
Evidence and guidelines:
The SIGN discharge document Scottish Intercollegiate Guideline Network (SIGN)  Template for a single discharge document that can be used as the immediate discharge document for patients on the day of discharge, and as the final discharge summary/letter for more complex cases. Note: this document is over the SIGN review period and withdrawn
Transition between inpatient hospital settings and community or care home settings for adults with social care needs National Institute for Health and Care Excellence (NICE) Guideline covering the transition between inpatient hospital settings and community or care homes for adults with social care needs. It aims to improve people's experience of admission to, and discharge from, hospital by better coordination of health and social care services
Effectiveness of integrating primary healthcare in aftercare for older patients after discharge from tertiary hospitals – a systematic review and meta-analysis Ran L, JaiweiG, Jibin L, Wang G, Hesketh T,  Age and Ageing. 2022; 51(6) Systematic review of the evidence on integrating primary healthcare into post-hospital discharge care. Includes data analysis of readmission rates and length of hospital stay  
Tools and resources:
Care co-ordination Healthcare Improvement Scotland Change package to support community dementia services to improve the quality of PDS and integrated care co-ordination for people living with dementia and carers in Scotland
Improving planned care pathways toolkit Healthcare Improvement Scotland Quality improvement tools and resources to sustainably and affordably reduce waiting times
Frailty and falls assessment and intervention tool Healthcare Improvement Scotland Tool for use in health, social care and third sector to support assessment and identification of interventions to meet an individual’s needs. Designed to enhance the local assessment and intervention process and documentation

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

Resource Source What is it and what is it for?
Evidence and guidelines:
Report of round table on healthy ageing in Scotland International Foundation for Integrated Care Report from an inter-agency think tank’ to discuss Scotland’s readiness for the WHO Decade of action on healthy ageing: ten years of concerted, catalytic and collaborative action to improve the lives of older people, their families, and the communities they live in 
Living well in communities with frailty: Interventions evidence summary Healthcare Improvement Scotland High level overview of the evidence on community based frailty interventions, to support commissioning
Transitions and trajectories in frailty states over time: a systematic review of the European Joint Action ADVANTAGE O'Caoimh R, Galluzzo L, Rodriguez-Laso A, Van der Heyden J, Ranhoff AH, Carcaillon-Bentata L, et al. Annali Dell'Istituto Superiore di Sanita. 2018;54(3):246- 52. Systematic review of the evidence on trajectories or transitions between different stages of frailty
Tools and resources:
Midlothian Health and Social Care Partnership: An HSCP approach to using data to improve the care of people with frailty Healthcare Improvement Scotland Case study of a Midlothian GP cluster and HSCP using the eFI to identify and improve the quality of care of those most at risk from frailty
Frailty and the electronic frailty index Healthcare Improvement Scotland Guide to frailty and the electronic frailty index

Primary driver: Leadership and culture to support integrated working

Secondary driver: Strategic leadership which supports integrated working

Resource Source What is it and what is it for?
Evidence and guidelines:
Integrated care Models for managing and preventing frailty: A systematic review for the European Joint Action on Frailty Prevention (ADVANTAGE JA)  Hendry A, Vanhecke E, Carriazo AM, López-Samaniego L, Espinosa JM, Sezgin D, et al. Transl Med UniSa. 2019;19:5-10  Systematic review of the evidence on models of care for frailty to identify those designed to prevent and tackle frailty in the community and at the interface between primary and secondary care
Safety culture and workforce well-being associations with positive leadership walkrounds Sexton JB, Adair KC, Profit J, Bae J, Rehder KJ, Gosselin T, et al.  The Joint Commission Journal on Quality and Patient Safety. 2021. 47(7):403-411 Article describing a study to determine the association between Positive Leadership WalkRounds (PosWR), an organizational practice in which leaders conduct rounds and ask staff about what is going well, and HCW well-being and organizational safety culture
Making our health and care systems fit for an ageing population The Kings Fund Report setting out a framework and tools to help local service leaders improve the care they provide for older people across nine key components
Integrated care for older populations and its implementation facilitators and barriers: A rapid scoping review Threapleton DE, Chung RY, Wong SYS, Wong E, Chau P, Woo J, et al. Int J Qual Health Care. 2017;29(3):327-34 Review of the evidence on integrated care approaches in older/frail populations, identifying eight important components
Tools and resources:
Leadership walk-rounds and safety conversations Healthcare Improvement Scotland Improvement tools to connect senior staff with frontline staff via a structured conversation to build a culture of safety within an organisation. They can also help identify barriers to caring for patients as safely as possible
Patient safety leadership walk-rounds Institute for Healthcare Improvement Improvement tool providing key elements for successful implementation of WalkRounds™ and sample formats and questions to ask staff
Strategic planning: good practice framework Healthcare Improvement Scotland Presentation on the Good Practice Framework Designed to enable practical and constructive local conversations on strategic planning

Secondary driver: Integrated multidisciplinary and multi-agency working

Resource Source What is it and what is it for?
Evidence and guidelines:
Integrated care for older people with frailty The British Geriatric Society Report providing case studies showing what an integrated health and social care system looks like in practice and the positive impact it can have, with the aim of sharing best practice in a range of settings
Impact of multidisciplinary team huddles on patient safety: a systematic review and proposed taxonomy Franklin BJ, Gandhi TK, Bates DW, Huancahuari N, Morris CA, Pearson M, Bass MB, Goralnick E. BMJ Quality & Safety. 2020;29:1-2. Systematic review of the evidence relating to scheduled, multidisciplinary, hospital-based safety huddles and their impact
Multidisciplinary interventions for reducing the avoidable displacement from home of frail older people: a systematic review. Sempe L, Billings J, Lloyd-Sherlock P.  BMJ Open. 2019;9(11):e030687. Systematic review of the evidence relating to interventions addressing avoidable displacement from home for older people 
Tools and resources:
SCIROCCO self assessment tool Scaling Integrated Care in Context Online self-assessment tool to assess a region’s readiness for integrated care
Fife Health and Social Care Partnership: The community health and wellbeing hub model in Fife case study Healthcare Improvement Scotland Case study of community health and wellbeing hubs (Hubs) developed and tested in Fife.
Multidisciplinary team meeting (MDT) Guidance Healthcare Improvement Scotland Guidance notes on multidisciplinary team meetings to discuss those identified with frailty in the community

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

Resource Source What is it and what is it for?
Evidence and guidelines:
Enabling public, patient and practitioner involvement in co- designing frailty pathways in the acute care setting O’Donnell D, Ní Shé E, McCarthy, Thornton S, Doran T, Smith F, et al.  BMC Health Services Research. 2019. 19:797 Article describing quality improvement initiatives which resulted from a co-design process aiming to improve service delivery in the acute setting for frail older people
Service user, carer and provider perspectives on integrated care for older people with frailty, and factors perceived to facilitate and hinder implementation: A systematic review and narrative synthesis Sadler E, Potterton V, Anderson R, Khadjesari Z, Sheehan K, Butt F, et al. PLoS One. 2019;14(5):e0216488. Systematic review of the evidence on service user, carer and provider perspectives on integrated care for OPF (older people with frailty), and factors perceived to facilitate and hinder implementation
Tools and resources:
Community led models: innovation in health and social care Healthcare Improvement Scotland Report sharing learning from innovative approaches to community-led health and social care provision
Care Experience Improvement Model (CEIM) Healthcare Improvement Scotland Framework that supports health and social care teams to make improvements directly related to feedback in a person-centred way
Experienced based co-design Healthcare Improvement Scotland Improvement programme that supports health and social care staff and those using a service to come together and share experiences of what matters about receiving and delivering that service
Person-centred design and improvement programme Healthcare Improvement Scotland Improvement programme that supports people working in health and social care to take a person-centred approach to improving the services they deliver and the quality of experience and outcomes for people in Scotland

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

Resource Source What is it and what is it for?
Evidence and guidelines:
The importance of psychological safety  Edmonson, A Video (see link at bottom of page)  defining psychological safety 
Three ways to create psychological safety Edmonson, A Video describing three key actions to foster a psychologically safe work environment
A systematic review of factors that enable psychological safety in healthcare teams O’Donovan R, McAuliffe E. Int. J for Qual. In Health
Care. 2020. (4):240-250		 Systematic review of the evidence on enablers of psychological safety specific to healthcare settings 
Tools and resources:
IHI framework for improving joy in work Institute for Healthcare Improvement Framework with nine components for ensuring a joyful, engaged workforce; key change ideas; and measurement and assessment tools
National wellbeing hub Scottish Government Website with wellbeing resources, aimed at health and social services staff in Scotland 
National trauma training programme NHS Education for Scotland Website with evidence-based training, tools and guidance to support trauma-informed and responsive systems, organisations and workforces in Scotland
Ready to lead: Lesson 7 – celebrating success NHS Education for Scotland and ihub Resource supporting successful quality improvement leadership 
Values based reflective practice NHS Education for Scotland Learning resource describing the VBRP® model which helps staff deliver safe, effective and person-centred care by promoting regular inter-disciplinary group reflection
Psychological safety toolkit Psychological Safety Toolkit to support understanding of what psychological safety is, how to measure it in teams, build and maintain it, and reflect back in order to foster continuous improvement

Secondary driver: System for learning

Resource Source What is it and what is it for?
Evidence and guidelines:
Human learning systems: A practical guide for the curious Centre for Public Impact, Healthcare Improvement Scotland, Iriss Guide to support people in the health and social care system in Scotland to undertake their own experiments in Learning System based change
Knowledge into action – supporting the implementation of evidence into practice in Scotland Davies S, Herbert P, Wales A, Ritchie K, Wilson S, Dobie L. Health Information and Libraries Journal. 2017. 34(1)74-85 Article describing the knowledge into action model for NHS Scotland which provides a framework for librarians and health care staff to support getting evidence into practice
Educational programmes for frail older people, their families, carers and healthcare professionals: A systematic review Viggars RJ, Finney A, Panayiotou B. Wien Klin Wochenschr. 2022;134(5-6):227-36. Systematic review of the evidence on educational programmes on frailty for older individuals, their families, carers and health professionals 
Tools and resources:
Frailty hub: Education and training British Geriatric Society eLearning and other training materials on frailty 
HIS frailty learning system MS Teams channel Healthcare Improvement Scotland Microsoft Teams channel for those working on HIS frailty learning system programmes
Learning systems Healthcare Improvement Scotland Web resource describing learning systems, how to establish, and core components
Learning from Excellence website Learning from Excellence Website with resources and ideas to promote peer–reported excellence in healthcare
TURAS Learn Quality Improvement Zone NHS Education for Scotland eLearning with a number of Quality Improvement modules