Better care for older people from a GP perspective (Part 2 of 3 Part series)


Who is at risk of physical frailty in my practice?

Wellness, reablement and restorative approaches are emerging as powerful ways to help older people improve their function, independence and quality of life. Early identification of people who are pre-frail or frail and who could benefit from these approaches is an important preventive activity in contemporary general practice. Using a FRAIL screen in the 75+ health assessment is recommended to identify this group, but which people really need the health assessment? Finding this group using the software extraction tools can really make a difference!

The five simple questions for the FRAIL screen from Professor John Morley (questions require a yes/no response).

Fatigue-are you feeling tired or fatigued? (yes-score 1)
Resistance- can you walk a flight of stairs? (overcoming the resistance of body weight against gravity) (no-score 1)
Ambulation- can you walk around the block? (no-score 1)
Illnesses- 5 or more chronic conditions? (yes-score 1)
Loss of weight of 5 per cent or more over past 6 months? (yes-score 1)

Scoring: If the older person scores 2, they are pre-frail, 3+ indicates they are frail and would benefit with immediate referral to community based restorative care program.

For example, you can use the extraction tool to identify patients that meet the following search criteria:

  • active patients of the practice seen in the last 6 months
  • community dwelling people aged 75 years or older
  • prescribed 8 or more medications
  • with one or more of the following diagnoses (dementia, heart failure, COPD, stroke, CKD, and/or depression)

The search could also include Medicare item numbers with this group if the clinical and billing software is compatible. This shows which of the “at risk of frailty” group have NOT had a health assessment (item 707), care plan (721), Team Care arrangement (723), care plan/TCA review (732) or a Home Medication Review (900) in the previous 12 months.

This helps us understand how to distinguish who really needs the extra care and supports to remain well using the comprehensive geriatric assessment. This is a review of medical, functional, psychological and social needs. In General Practice, it helps to have a good template which provides a suite of objective assessment tools allowing optimal decision making to occur. The common problems associated with frailty include:

  • Falls
  • Cognitive impairment
  • Continence
  • Mobility
  • Weight loss/poor nutrition
  • Polypharmacy
  • Physical inactivity
  • Low mood
  • Visual problems
  • Social isolation

What do you do about Frailty?

When patients presented with any of the conditions listed above, some GPs made unhelpful comments such as “there’s nothing much to be done, it’s because you are getting older”. However, it is important for GPs and Practice Nurses to be familiar with new evidence-based frailty screening tools for older people, and to offer patients evidence-based responses to frailty including:

  • Referrals to restorative care exercise (muscle building) programs,
  • Dietary supplementation (Vitamin D, sustagen and other high protein drinks)
  • Social and cognitive stimulation and support

Restorative care programs are offered in a variety of places by local Hospital and Community Health Services, Public and private Hospital Day rehab programs, and community Allied health and Not-for-profit providers. These interventions are proven to slow the rate of functional decline, and frequently reverse decline if people are detected at the early frail stage.

The 75+ Health Assessment can be used to generate a personalised shared care and support plan outlining treatment goals to optimise medical conditions, management plans to optimise wellness and plans for urgent care. This should always include discussions around Advance Directives and potentially an end of life care plan.

It is suggested a health assessment item (707), care plan (721) and Team care arrangements (723) be performed together by the same nurse or GP to avoid duplication and to provide maximum value to the patient and to the practice. Although complex older patients need a 3- monthly review of care plan and TCA (item 732), this is very frequently under-utilised for our older patients.

Is there room for improvement in your practices’ 75+ Health Assessment?

CESPHN has developed a pdf Clinical Audit “Self-assessment 75+ Health check” (161 KB) to help GPs and the practice team identify whether there is room for improvement in their general practice’s 75+ Health Assessment. This QI activity attracts 40 category 1 points from the RACGP. Designed by Dr Chris Bollen, this is a great team-building exercise, as it can be done with a group of GPs and nurses discussing improvements in the “process of care” in your practice.

This QI activity attracts 40 category 1 points from the RACGP and it involves:

  1. Identifying 10 community dwelling patients aged 75 years or older from your general practice who have been admitted to hospital or attended a hospital ED in the last 12 months.
  2. Reviewing the circumstances pre/post the admission or ED attendance and reflecting on what could have been done differently to avoid the admission or ED attendance. Sometimes this is not immediately obvious, so it is worthwhile considering if there were factors in the preceding 6 months which could have impacted the outcome.
  3. Checking if a 75+ Health Assessment had been performed in the previous 2 years, and if this assessment included:
  • The goals of the older person
  • Cognition screening
  • Nutrition screening
  • Mood assessment
  • Fitness to drive (if applicable)
  • Comprehensive social history (communicated in all referral letters and care plans)
  • Mobility function assessment, including a record of the mobility deficits that were observed
  • The number of times body weight was recorded for the person in the previous 18 months, and if there was a trend of unplanned weight loss, what action had occurred?
  • An annual Kidney Health Check comprising Creatinine, eGFR, Blood pressure and urinary Albumin/Creatinine Ratio (ACR) and checking for any renally-cleared medications
  • The number of medicines taken by the older person and a request for a Home Medicine Review
  • Documented legal documents to support the older person’s choices in the event they lose capacity (e.g. Advance Directives).

This QI activity is great for team-building as it can be done with a group of GPs and nurses discussing improvements in the “process of care” in your practice.

What assistance can the Staying Well at Home team provide?

The Staying Well at Home team can assist your practice with this QI activity by demonstrating how to identify at-risk patients with extraction tools, please contact the ‘Staying Well at Home’ team. Kim Sherman or Jason Phillips