Frailty is a common syndrome that occurs from a combination of de-conditioning and acute illness on a background of existing functional decline that is often under recognised.

Frailty can affect up to 25% people aged 70 and over this equated to approximately 26,000 people residing in Northern Sydney.

People with frailty have 2 to 3 times the health care utilisation of their non-frail counterparts and experience higher morbidity, mortality as well as lower quality of life.

Frailty can increase functional  decline, increase the risk of falls, contribute to longer length of hospital stay and increased chance of institutionalisation.

Many of the causes of frailty can be managed and, in some cases reversed to create better health outcomes and quality of life. It is  therefore important to identify older people who are living with frailty.

Not all older people are frail and not all people living with frailty are old. However, it is important to identify frailty early in order to combat the condition and it effects. Current health guidelines suggest that people over the age of 70 should be screened routinely.

The use of a validated screening tool will ensure accuracy, reliably and consistency of identification of frailty. In Northern Sydney we recommend the use of the  “The FRAIL Scale” to identify a level of frailty.

The Frail Scale

A score of 1 to 2 indicates pre-frailty and a score of 3 or more indicates frailty.

Frailty is more common in females and the risk of frailty increases with age.

Early intervention can allow people to stay active and healthy longer, keeping them in their homes and out of hospital.

Correctly managing frailty can significantly improve a persons function and quality of life. It can also provide a better chance of recovery from acute illness as it reduces susceptibility to  negative health outcomes.

Once you have assessed a persons level of frailty a (pre-frail or frail,) it is important to develop a management plan that addresses the corresponding sections of the frail scale.

This targeted approach can include:

• Referral to appropriate allied health professional such as a physiotherapist or dietitian
• Exercise classes
• Reviewing medications
• Managing weight loss

The decision support tool below provides more detail and some guidance for best course of action.

Frailty Management and Decision Support

Things to consider when implementing the Frail scale

The Best Practice and Medical Director templates

The Best Practice and Medical Director templates (.rtf files) can be imported to your software. These templates should not be opened and viewed before importing them. You will need to right click, copy and save or drag the .rtf file onto your desktop. Refer to the instructions below.

Frail Scale Templates for Medical Director

• Directions on how to upload templates Read Instructions.
• Frail Scale for Medical Director (MD). To download, please Right Click and save link (clicking directly on this link will load the BP file into your web browser instead).
• 75+ assessment that includes Frail scale (MD). To download, please Right Click and save link (clicking directly on this link will load the BP file into your web browser instead).

Frail Scale Templates for Best Practice

• Directions on how to upload templates Read Instructions.
• Frail Scale for Best Practice (BP). To download, please Right Click and save link (clicking directly on this link will load the BP file into your web browser instead).
• 75+ assessment that includes Frail scale (BP). To download, please Right Click and save link (clicking directly on this link will load the BP file into your web browser instead).

Other Resources

• FRAIL Scale Topbar App: quick reference guide
• FRAIL Scale App: video demo
• Online Positive Aging Tool Click Here
• Suggested Management tool to accompany Frail Scale Click Here
• HealthPathways – Frailty Pathway Click Here
• Northern Sydney Frailty Initiative – Healthy Ageing and Frailty clinician brochure Open Brochure
• When Seniors Say No brochure Open Brochure
• Basic Steps (falls prevention program) resources order form Open form
• Steeping On referral form Open Form
• Medication review for people living with frailty | Agency for Clinical Innovation (nsw.gov.au)

Evidence to Support Frail Scale: 

• Asia Pacific Clinical Practice Guidelines for the Management of frailty Read Guidelines
• Nutritional Interventions in Sarcopenia Read Article
• Effects of physical exercise interventions in frail older adults Read Article
• The Effectiveness of Exercise Interventions for the Management of Frailty: A Systematic Review Read Article
• Interventions for Treating Sarcopenia: A Systematic Review and Meta-Analysis of Randomized Controlled Studies Read Article
• Inappropriateness of Medication Prescriptions to Elderly Patients in the Primary Care Setting Read Article
• Beliefs and attitudes of older adults and carers about deprescribing of medications Read Article

Please find the following links and searches to help you find the most appropriate service for your patients.

For detailed clinical referral , assessment and management information related to the Northern Sydney region please visit Sydney North HealthPathways site. Click on the logo below – note: log in details are required and if you do not already have these please email healthpathways@snhn.org.au and they will be sent directly to you.

Geriatrician:

To refer to a Geriatrician for a comprehensive geriatric assessment please use the following:

• You can search for a Geriatrician via postcode on Healthshare Open Search
• NSLHD Geriatrician referral
  • Hornsby Ku-Ring-Gai Hospital – Ph: (02) 9477 9514  / Fax:  (02) 9477 5684
  • Royal North Shore Hospital Campus – Ph: (02) 9462 9333 / Fax: (02) 9906 4301
  • Brookvale Community Centre – Ph: (02) 9998 6120 / Fax: (02) 9979 7876
  • Mona Vale Community Centre – Ph (02) 9998 6120 / Fax: (02) 9979 7876

Geriatrician Outreach to Primary Care

Geriatrician Outreach to Primary Care aims to increase Geriatrician input into GP-led patient planning and care in the community while building relationships and facilitating two-way learning opportunities.​

It seeks to work collaboratively with GPs to manage complex patients and prevent conditions that may be at potential risk of deterioration.

• Geriatrician Outreach to Primary Care: model and contact information

Search for Allied Health Professionals in Sydney North

Please use this search tool for Allied Health providers in Northern Sydney listed with an interest in frailty as registered in the Primary Health Network, this includes pharmacists that can assist with polypharmacy review.

Exercise

Frailty prevention exercise program options in NSW can be searched using the Active and Healthy website: Click Here

ViviFrail – MATERIALS FOR PROFESSIONALS RESPONSIBLE FOR THE PRESCRIPTION OF A PROGRAM OF PHYSICAL EXERCISE: Click here

Progressive resistance training for frailty (nsw.gov.au)

For patients requiring individual exercise prescription, a physiotherapist or exercise physiologist can assess gait and balance, design an individually-tailored program, provide one-on-one progressive exercises and recommend correct use of assistive devices.

• Australian Physiotherapy Association: Find a physiotherapist (treatment: gerontology or musculoskeletal) Open Search
• Exercise & Sports Science Australia: Find an exercise physiologist (specialty: older adult) Open Search
• NSLHD outpatient Physiotherapy referral information can been seen here Click Here

For patients requiring dietary advice

• Search via Dietitians Australia Open search
• NSLHD outpatient Dietitian referrals (accepts GP referral) Open Form

For referral to home safety assessment and occupation therapy:

• Search via Occupational Health Australia Open Search
• NSLHD outpatients
  • Hornsby Ku-ring-gai Hospital Outpatients – Ph: (02) 9477 9493
  • Northern Beaches Health Service –  Ph: (02) 9998 6100
  • Royal North Shore Hospital – Ph: (02) 9462 9666
  • Ryde Hospital – Ph: (02) 9858 7888

Sydney Home Nursing Safe and Steady Program

Care coordination links to assist in conducting 75+ health assessments with patients, Regal Home Health – Ph: (02) 9264 4555 Click Here

My Aged Care portal Click Here

Geriatrician outreach to primary care

Geriatrician Outreach to Primary Care aims to increase Geriatrician input into GP-led patient planning and care in the community while building relationships and facilitating two-way learning opportunities.​

It seeks to work collaboratively with GPs to manage complex patients and prevent that may be at potential risk of deterioration.

Patients can complete their own online positive aging screening Click Here

Eating well booklet Open Booklet

Healthy eating to stay strong and independent Open Brochure

Living Well brochure Open Brochure

Staying active booklet Open Booklet

Staying active website Click Here

Health coaching website (self referred NSW free health coach) Click Here

Stepping On brochure (falls prevention program) Open Brochure

My Aged Care brochure Open Brochure

Meals on wheels contact numbers:

• Crows Nest –  Ph: (02) 9437 7517
• Hornsby Ku-Ring Gai – Ph: (02) 9144 2044
• Hunters Hill Ryde – Ph: (02) 9817 0101
• Lane Cove –  Ph: (02) 9427 6425
• Mosman –  Ph: (02) 9978 4130
• Willoughby  – Ph: (02) 9777 7830
• Manly –  Ph: (02) 9976 1469
• Northern Beaches –  Ph: (02) 9970 8399

NSLHD Health Contact Centre  – Ph: 1300 732 503 (Mon-Fri: 7.30 am to 6.30pm)

NSLHD Carer support information website Click Here

 

Welcome to the Upside of Ageing

LiveUp is a free national healthy ageing platform designed to help you reimagine, reset, and reconnect with living your life to its fullest. You’ll find personalised suggestions, including tailored activities, assistive products, social connections and more, all in your local area or online. Head to live.org.au and take control of your healthy ageing journey.

• Here are simple exercise videos to improve strength and balance that patients can do at home.

Sit to Stand

Side Leg Raises

• Patients should include at least 10gm of protein with every meal – here are some examples

Stepping up a step

Knee Raises

Past events – 18/09/2019

Sydney North Health Network (SNHN) in partnership with the North Sydney Local Health District are working together as part of the ‘Integrating Care for Older People in Northern Sydney’ program to deliver services and system improvements.

As part of this body of work workshops were held for conusumer and provider workshops to better understand the experience of patients who experience frailty. During the two full day workshops the reality, challenges and opportunities for improvement for service delivery across the Northern Sydney region were discussed and mapped.

Details:

Workshop 1 – Patient Journey Workshop – current state

Date: Monday 18th November 2019

Time: 9.30am – 4.30pm

Location: SNHN, located at Level 5, Tower 2, 475 Victoria Avenue, Chatswood NSW 2067.

Details:

Workshop 2 – Patient Journey Workshop – future state

Date: Friday 29th November 2019

Time: 9.30am – 4.30pm

Location: SNHN, located at Level 5, Tower 2, 475 Victoria Avenue, Chatswood NSW 2067.

__________

Past Education events – 10th & 11th December 2018

The Northern Sydney Frailty Initiative held two education event in December 2018.

The education event aimed to assist health professionals further understand the impact of frailty on patients and how early identification and targeted intervention can reduce frailty, avoid inappropriate hospital admissions, keep people well and at home for longer and reduce need for RACF and hospital admissions. It also demonstrated the use of the frail scale scaler and supporting management plans to address the reversible contributing factors of frailty in your day to day practice.

Presenters for the sessions included:

• Professor Susan Kurrle

Professor of Health Care of Older People, Director, NHMRC Partnerships Centre on Cognitive Decline, Geriatrician Hornsby Ku-ring-gai Hospital

• Dr Christopher Bollen – MBBS MBA FRACGP FACHSM MAICD

Dr Bollen has been practicing as a GP since 1990. He has a special interest in older people, and is a RACGP representative on Centre for Research Excellence in Frailty (Adelaide)

• Jane Bollen RN

Jane works at Allenby Gardens Family Practice in Adelaide running a nurse led (team based care) “Healthy Ageing Clinic

You can read a copy of the presentation here Read Presentation

Frailty Articles 2018

An article has been written by Dr Chris Bollen for the Norther Sydney Frailty Initiative. It is article 1 of a 3 part series based on the concepts of frailty and better care for older people from a GP perspective.

You can read “Healthy Ageing in General Practice” Part 1 written by Dr Chris Bollen MBBS MBA FRACGP FACHSM MAICD here: Read Article

Background
The Northern Sydney Frailty Initiative commenced in 2018 as a partnership between SNHN and NSLHD to co-design and deliver an integrated model of care that addresses the reversible contributing factors of frailty for the ageing population of Northern Sydney, across the full patient journey. The project was delivered in both the inpatient setting and in Primary care.

The overarching aim is to optimise the wellness of older people who are frail in the Northern Sydney region, through screening for frailty and implementing appropriate management plans.

The Primary Care arm of the Initiative was approached in two phases. Phase one occurring throughout 2018 -2019 that focused on building health professional knowledge, capacity, and the understanding of how to appropriately screen for frailty and the options for implementing, preventive and reablement management plans to deliver good patient outcomes.

Phase two of the project of the project will gain a deeper understanding of the screening process and identify service gaps to assist in developing a co-commissioning strategy.

Phase 2 Aims / Objective

The overarching aims of the next phase of the initiative are:

• Assess capacity and skills in primary care to manage frailty appropriately.
• Develop and test approaches and workflows to identifying (screening for) and managing frailty in the elderly population in general practice.
• Identify and develop pathways to appropriate care in the community.
• Inform future care models and strategies to support and enhance the care of frail older persons.

 

What we aim to learn from the pilot:

• Barriers and enablers to screening and management in general practice.
• Continue to identify Allied Health and other service networks required to support management in community and where there are gaps.
• Usage of rapid access pathways to geriatrician specialist support

 

Approach

Project will be collaborative, integrated and codesigned.

Design:

• Practices involved will be sought through an expression of interest and targeted through the GPs identified from the Geriatric Outreach program
• 10-20 practices will be engaged, with a minimum of one GP per site for a period of 6-9 months
• Each practice will be work-flowed to understand the best way to trial the screening process (GP at visit, PN at 75+ age assessment etc) and what data and reporting is possible and plausible (draft data sheet)
• Ongoing collaboration and feedback will be sought from participants at a one to one level and at structured workgroups
• Practices will provide monthly reporting and feedback
• Ongoing agile project evaluation and reports will be provided to advisory groups and management as well as an end of project report.

Implementation:

• Practice will have the app and reporting documents set up to assist them with tracking their patients.
• Practice will screen eligible patients over 75, (est 25-30% frail) and report on the management referral and interventions commenced for the patient.
• Patients will be tracked to ensure management interventions are completed/attended and feedback/reports are received from referees.
• Practices will be provided frailty education and project support from the SNHN, including linkages to Health Navigators, HealthPathways and the Geriatrician Outreach Program.
• Practices will receive an incentive payment to assist with screening and collection of data, regarding the management of patients, including care coordination and navigation outcomes.
• Where gaps are identified, SNHN may co-design a mechanism to commission access to allied health or other agreed services
• Ongoing reflection, adaptation and learning feedback through project update calls and reports every month.

 

FRAIL Scale Topbar App

The FRAIL Scale Topbar App allows a clinician to fill in a frailty risk screen quickly and easily, even while a patient is present.

The scale is based on the Northern Sydney Frailty Initiative FRAIL Scale and is an Australian adaptation of the Fried frailty index.

• FRAIL Scale Topbar App: quick reference guide
• FRAIL Scale App: video demo