Baseline mobility

Frailty nurse specialist practitioner Laura Maitra says: ‘One of the aims of EI is to keep people with frailty out of hospital altogether. That is because when people come home from hospital their baseline mobility has reduced.

‘I’ve seen people on my caseload come home and they’ve lost muscle in their thigh and backside area, and are weaker when moving from sitting to standing. That means they’re at a higher falls risk and then need readmission to hospital. It can be a cycle,’ says Ms Maitra, who works for Gateshead Inner West Primary Care Network.

The reason for this physical deconditioning following hospital admission is explained in the Age UK report Fixing the Foundations. It says hospital patients are in bed for long periods and move around less, leading to muscle weakness.

Ms Maitra is part of a frailty team attached to five GP practices, from which health professionals will refer patients to her if they spot potential signs of frailty.

‘It could be one of the GPs or practice nurses,’ she says. ‘They will notice a patient appearing more frail, maybe they’re not as tidy looking or as mobile. As part of EI, I will complete a comprehensive geriatric assessment with that patient.

‘That includes reviewing medications, falls history and looking at getting necessary equipment into their home to prevent falls. I’d be going through fortification and diet, strength and balance exercises.

‘Simple things we do as EI make a huge difference. For example, if someone can’t get to the toilet due to pain, the correct pain medication enables them to get there. That can resolve incontinence, and they are strengthening their muscles by walking to the toilet. All that prevents the frailty from becoming more severe. And all that comes from a simple change in medication.’

Ms Maitra says EI – which can sometimes be in the form of relatively simple solutions to practical problems – can also free up hospital capacity.

‘There was one patient with repeat hospital admissions due to falls,’ she says. ‘We did a home visit, and saw her rug was in the wrong place. It was that simple to free up a hospital bed space from EI.’

There are several tools for assessing frailty syndromes. The comprehensive geriatric assessment (CGA) is the gold standard for accurate diagnosis and tailored interventions, and is often used by frailty teams for initial assessments.

People with frailty can be assessed at home instead of hospital

Picture credit: Superstock

Frailty categories

The Rockwood clinical frailty scale is more regularly used when clinicians see patients, according to Ms Maitra. It assesses the degree to which a person is living with frailty and places them into a category. Used over time, it can highlight deterioration or improvements.

An electronic frailty index (eFI) is available to GP surgeries to help identify patients aged 65 and over who may be living with frailty. An eFI score is calculated from their health record data and puts them into a frailty category – fit, mild, moderate or severe.

Around 35% of older people live with frailty, including 15% in which it is moderate or severe, says Age UK. In the case of mild frailty, anticipatory care strategies can be used instead of EI.

Ms Maitra says: ‘If their eFI and Rockwood score is lower, we use anticipatory care. We make the changes before a fall occurs or we first see signs of weakness. We may change their medications or offer them weekly strength and balance classes.’

Clinical and care speciality adviser for frailty, older people and dementia Zena Aldridge says nearly all nurses will come across frailty.

‘Acute staff will be dealing with acute problems, but they need to identify frailty and flag it to primary or community care,’ says Dr Aldridge, who works at NHS Norfolk and Waveney Integrated Care Board.

‘Then patients can be cared for by the correct services.’

Community work

EI approaches have been implemented across settings, says Dr Aldridge. One-stop frailty clinics are attached to some emergency departments.

Ms Maitra says specialist nurses triage people presenting with frailty, rather than general emergency nurses who may be more likely to admit these people when they do not require it.

Dr Aldridge says frailty multidisciplinary teams are also working in community settings such as care centres and rehabilitation units. This can decrease wait times for patients who would otherwise attend hospital. ‘We have to deliver services differently and spend money better. Shifting money into community EI work is one way to do that.

‘If we bolster this area, we stop people going into acute care at all, and acute is where it gets expensive.’

She adds that commissioning targets need to change. ‘Commissioners ask service providers how many patients they have seen that month. They don’t ask what difference you made to the patient.

‘Community nursing has become task-oriented. Nurses think: “I need to do Doris’s leg wound quickly because I have 25 others to do.” They don’t have time to think: “Why does Doris’s wound keep breaking down?” If they had the capacity to look into that, it could prevent Doris being admitted to hospital later.’

Effective commissioning

Ensuring that frailty services are organised and commissioned effectively will become crucial as the number of older people rises, says Dr Aldridge.

‘We also need to use technology,’ she says. ‘Our trust has Silverline, a specialist helpline that enables multidisciplinary teams to work across settings. Paramedics and nurses in the community can use it to call a hospital specialist if they’re not sure about admitting someone with frailty to hospital.

‘That’s a form of EI, because the patient might end up staying at home and you’re just taking bloods for review, depending on the advice. It stops people with frailty getting into an ambulance when it’s not needed.’

Frailty matron Rachel Bucknell says shared digital systems are crucial for effective multidisciplinary team working when using EI approaches. This was also mentioned in the Joining the Dots report.

‘We have access to Sunrise EPR, which enables access to a hospital’s clinical platform,’ says Ms Bucknell, who works at Aspen Medical Practice in Gloucester. ‘I can sit there and do a virtual ward round.’

Using Sunrise EPR, Ms Bucknell can see inpatient results and notes of people from her frailty caseload if they are admitted to hospital. This includes bloods, scans, and consultant and discharge plans. It allows her to see how patients have presented in hospital and to question inconsistencies in what she knows of them.

‘I checked one man’s hospital notes and he had told staff he had a wife, lived in a house with stairs and managed to wash himself,’ she says. ‘He lived in a bungalow, was bereaved and struggled to manage. I phoned the ward and said the discharge plan was inaccurate and they made changes. That saved lots of discharge delays. But I couldn’t have done it without access to hospital notes.’

Shared digital systems that join up services, such as Sunrise EPR, have enabled Ms Bucknell to contribute to hospital multidisciplinary team meetings for people on her caseload.

‘It’s often made the difference between lots of discharge delays and none, and it means there is no delay in follow-up after discharge. That reduces the chance of that person bouncing back into hospital.’

Workforce retention

Nurses Lucy Lewis and Mandy Waldon, both consultant practitioners specialising in frailty, say workforce retention and budgets are barriers to more EI in the community. They work in the NHS at Home service of Wiltshire Health and Care, which provides EI in people’s homes for up to 14 days, as an alternative to hospital.

Ms Waldon says: ‘We are 48% fully recruited to all posts in our service. We can’t increase this because there aren’t the staff available to fill posts.’

Ms Lewis has also seen the detrimental impact of separate health and social care budgets. This is also raised in the Joining the Dots report, which recommends that health and social care should be integrated.

Ms Lewis says: ‘A woman left hospital with a package of care for only morning and evening. Separately, she had a diuretic for heart failure due at lunchtime.

‘She hadn’t been taking it because with her package of care no one was supporting her at lunchtime. As a result she had fluid buildup, breathing difficulties and oedema in the legs. Social services said they couldn’t do the lunchtime call because it was a health need, not a social need.

‘Urgent care at home services, which are funded by the health budget, said they couldn’t manage medication for a long-term condition. Meanwhile, there is this woman in the middle who needs to take her medication or she will be another hospital admission.’

Find out more

Age UK (2023) Fixing the Foundations: Why it’s Time to Rethink How We Support Older People with Health Problems to Stay Well at Home.

Age UK (2023) tinyurl.com/AUK-understanding-frailty

British Geriatrics Society (2023) Joining the Dots: A Blueprint for Preventing and Managing Frailty in Older People.

NHS England (2023) Frailty Resources.