Primary and secondary drivers, and change ideas

Click on each Primary Driver below to see secondary drivers and change ideas:

Early identification and assessment of frailty

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

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

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

Leadership and culture to support integrated working

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