Frailty trajectories: understanding tipping points across care settings (DEM 12)

Type of Research

Mixed methods study

 Context

  • Older adults are heavy users of health and social services, but not all use all types of services. Heavy utilisation is concentrated in the frailest and those nearing the end of their life.1,2
  • Frailty is a distinct health state of vulnerability characterised by increased risks of adverse outcomes or sudden/disproportionate deterioration in physical, cognitive or mental health triggered by an apparently minor event. Older people living with frailty can be low users of services until a trigger event, then may never recover to their previous level of health.3
  • Around 10% of people ≥65 are estimated frail and 25-50% of those ≥85, with findings suggesting levels of frailty are higher in recent cohorts, and in the poorest wealth groups.4,5
  • In that context, decision makers are equally concerned with increased demand by frail older people as with quality and safety across the continuum of health and social care services.

Optimising journeys through care for frail older people living in the community is at the heart of this project. It addresses regional and national decision makers priorities, including the Five Year Forward’s6 view prevention aims and call for integration and ever-improving quality and effectiveness of care.

Frailty trajectories & linked data

  • Frailty is now seen as a practical, unifying concept in the care of older people. Failure to detect frailty in clinical practice may expose patients to interventions from which they might not benefit and be harmed.
  • In the UK dedicated frailty care pathways and frailty registers are being set up. In fact, the use of objective frailty metrics can serve as a common language across care settings to enable discussions of personalised care approaches. It can also be used to reflect the complexity of need by allowing the identification of clinically meaningful sub-groups and help us identify how trajectories in the health and social care systems can be optimised to improve quality and performance across care settings.
  • Integration of care across settings is a current priority around which multiple service initiatives are developing, but the care data integration needed to optimise this goal is not yet a reality. This project will put CLAHRC researchers and their service partners in a strong position to maximise opportunities for service impact from analysis of the large-scale linkage of routine data already being collected.

The research

The project aimed to 1) describe care trajectories to capture the process of frailty in later life and 2) test the effects of known predictors of transitions, adverse events or harm, and 3) describe configurations of service utilisation and costs. This will inform preventive and management practices as well as commissioning in the context of integrated care to improve quality of care and avert harms.

Our key hypotheses were:

  • Despite high complexity and individuality, care approaches to frail older people can be characterised by a number of trajectories within and across settings;
  • Acute care events, demographics, socioeconomic and psychosocial variables are all important variables in identifying trajectories;
  • Trajectories and clinical tipping points help understand care quality and harm risk;
  • Transitions at the interface of care settings constitute critical cost, quality drivers and tipping points where preventive strategies can be deployed;
  • There is a strong relationship between frailty profiles, care trajectories and costs; the magnitude and direction of which differ at the end of life.

The project relied on analysis of linked administrative datasets and robust statistical tools to identify trajectories of service utilisation across settings for various levels of frailty. The meaning of these trajectories for clinicians, healthcare professionals, commissioners and members of the public were derived using qualitative methods, such as individual interviews and focus groups. The qualitative aspect of the project was undertaken by Community Matron Maria Martin, with support from colleagues at the Cambridge Institute of Public Health, as part of the CLAHRC Research Fellowship programme. Findings were also informed by regional and national integrated care initiatives/projects to help use understand how enabling organisational factors influence expenditures.

Research partners

A range of stakeholders were involved in the project in a truly co-production partnership, including:

  • Partnership working with the EAHSN Patient Safety Collaborative, Addenbrooke’s Hospital and Cambridge Clinical Informatics (for the Cambridge University Hospital NHS Foundation), Cambridgeshire County Council (for public health and social care data), CPFT, East of England Ambulance Trust, and the CCG (for primary care data) will enable access to thousands anonymised records of real-time routinely collected data on frail older people living at home in the community – within state-of-art ethics and governance frameworks.
  • Public involvement is being sought via collaborations with organisations across the region, starting with our Public Involvement in Research into Ageing and Dementia (PIRAD) and the EoE Citizens’ Senate (hosted by the Strategic Clinical Network and Senate EoE). We are now establishing a user group to inform all phases of the project, with scientific advisory group representation. Other groups being approached include INSPIRE, the Older People’s Partnership Board (supported by Cambridgeshire Alliance for Independent Living), COPE (Cambridgeshire Older People’s Enterprise) and Age Concern.

For an overview of the role and impact of PPI in the Project, please see this poster  

Key Findings

The qualitative element of the study exploring views of frailty amongst community care staff has found that:

  • there was a general consensus that frailty is an umbrella term that encompasses interacting physical, mental health and psychological, social, environmental, and economic factors.
  • different specialities emphasised the role of certain areas of the frailty umbrella in their narratives of the description and assessment of frailty in older adults living in the community.
  • nurses had a more medical focus, therapy focused specialities discussed functional abilities and mobility more, and psychiatric nurses and social workers placed more emphasis on mental health and social factors respectively.
  • the assessment and management of frailty requires a holistic approach facilitated by interdisciplinary working.
  • Former CLAHRC fellow Maria Martin is implementing her project on how different professional groups within the community team perceive frailty, which aims to improve the care of older people with frailty and overcome the problems highlighted. With support from the ARC Implementation leads, a ‘Community of Practice’ is being established to reshape education/training in frailty across relevant health-care disciplines in a community trust.

BITE sized summary

Publications

  • Coker JF, Martin ME, Simpson RM, Lafortune L. Frailty: an in-depth qualitative study exploring the views of community care staff. BMC Geriatrics. 2019 Feb 19;19(1):47. doi: 10.1186/s12877-019-1069-3 (Link)

References

  1. Alemayehu B, Warner KE. 2004 Health Services Research 39(3): 627-42.
  2. Payne G et al. 2007. Milbank Quarterly 85(2): 213-57.
  3. Fried LG et al. 2004. Journals of gerontology. 59(3): 255-63.
  4. Clegg A, et al. 2013. Lancet 381(9868): 752-62.
  5. Marshall A et al. 2015. J Epi Comm Health 69(4): 316-21.
  6. NHS Five year forward view, October 2014.

For more information about the project, please contact the Project Lead: Dr Louise Lafortune at ll394@medschl.cam.ac.uk

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