Frailty interventions

Canterbury Cluster Manager
Kim - 8752 4954 | 

Sutherland Cluster Manager
Jason - 9330 9974 | 

Frailty increases dependence, hospital admissions, and accelerates the need to enter an aged care facility, with frail patients having 2-3 times the healthcare utilisation and associated costs of their non-frail counterparts. Information gained from a well-administered comprehensive geriatric assessment allows clinicians to implement a person-centred care plan, which can reduce functional decline, support independence and improve quality of life.

The Staying Well at Home project has commissioned a suite of quality improvement (QI) activities to address this emerging field of medicine. The first of these activities were two continuing professional development (CPD) events hosted in the Sutherland and Canterbury areas in November to raise awareness of the role of the over 75 health assessment in identifying early signs of decline and informing a tailored care plan. Local geriatricians co-presented at both events, which attracted a range of health professionals, representing the team care approach that is necessary to manage frailty issues. To access the recording of the Frailty CPD please follow this link:

Add links to 3 x frailty articles final drafts when finalised.

Other QI activities offered to general practices on the topic of frailty include:

Clinical Audit Self-assessment 75+ Health Check (RACGP accredited Cat 1. 40 points with an additional 10-point QI component)

CESPHN has developed ‘self-assessment’ audit to help GPs and the practice team identify whether there is room for improvement in their general practice’s 75-year health check. GPs will receive 40 category 1 RACGP points for completing a self-assessment audit that will involve:

  1. Mapping the patient journey - Identifying 10 community-dwelling patients aged 75 years and over with an unplanned hospital admission or ED presentation in the last 12 months.
  2. Reviewing circumstances - Reviewing the circumstances pre/post the admission or ED presentation, and identifying what could have been done differently to avoid the admission or ED attendance.
  3. Reviewing management - Reviewing the care that your practice team provided to this patient (such as the assessments that were performed, and recommendations for any issues that were identified).
  4. Reflection - Reflecting on any opportunities to enhance the care of older patients.

The RACGP accredited ‘self-assessment’ audit is a great team-building activity, as it can be done with a group of GPs and nurses discussing improvements in the “process of care” in your practice. All the information and materials you require to complete the activity are in the following documents:

Assistance to identify ‘At-Risk’ older patients in your practice

Central and Eastern Sydney PHN can assist you to:

  1. Extract information from your clinical software to identify ‘at risk’ community-dwelling patients aged 75 years and older that were seen in last 6 months, take 8+ medications, and diagnosed with one or more of the following diagnoses (dementia, heart failure, COPD, stroke, CKD or depression).
  2. Generate a de-identified report that describes key characteristics of patients aged 75 years and older such as:
  • Percentage who had a 75+ health assessment in the past 12 months;
  • Percentage who take 8+ medications;
  • Percentage who had a Home Medicine Review in the past 12 months;
  • Percentage who had their Body Mass Index checked in the past 6 months.

For further information please contact Kim Sherman or Jason Phillips on 1300 986 991.

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