An evaluation of the Luton Framework for Frailty: an integrated care programme for older People with different frailty levels

Abstract

Background: Frailty is an age-associated condition in which a person loses reserves due to accumulation of multiple deficits making an individual vulnerable to minor stress and it leads to adverse outcomes such as falls, fractures, emergency hospital admission, institutionalisation and mortality. Frailty is posing a burden to the NHS and to social care in the UK. The NHS in England has made identifying and managing those people with moderate or severe frailty at the general practice level mandatory as part of the GMS 2017/18 contract. The Luton Clinical Commissioning Group (Luton CCG) has used these policy recommendations to develop the Luton Framework for Frailty (LFF). The LFF is an integrated care programme, which is offered to older people aged ≥65 years who are residents of Luton. Initially, an older person is assessed for frailty using the eFI and clinical judgement at their general practice, an individual is categorised according to their frailty level into one of the four categories of fit, mild, moderate and severe frailty, with services offered according to frailty level. It has been nearly three years since this policy has been introduced and the LFF has been implemented. However, no comprehensive evaluation has been conducted yet. The present study was commissioned to gain a deeper understanding of the LFF and the factors that affect the implementation of an integrated care programme and its impact on the outcomes for older people with different frailty levels (OPDFL).Methods: This study has used a mixed-methods approach. A systematic review was conducted to assess the effectiveness of integrated care interventions on OPDFL. A qualitative study was conducted with service providers including commissioners, programme managers, general practitioners and geriatricians to process map the care pathways for OPDFL in Luton and to: firstly, explore their perceptions regarding the barriers and facilitators to the implementation of LFF, secondly describe the LFF according to the six domains of the chronic care model and explore its strengths and limitations and thirdly, explore their perceptions of the impact COVID-19 had on the implementation of LFF. Finally, a quantitative study was conducted to analyse the routinely collected patient data to assess the impact of LFF on the outcomes such as falls reported to the general practice, emergency hospital visits and deaths for OPDFL.Results: The findings of the review show there is a lack of studies that have assessed the effectiveness of integrated care interventions for older people stratified by their frailty levels. Thus, there are more studies needed which stratify older people by their frailty levels because they have different needs and design integrated care interventions accordingly. Various limitations have been identified in the LFF when described according to the six domains of the CCM such as the focus of the services have traditionally been on those at the acute end and there are less resources provided for those identified as fit, there is a need for promoting self-management among OPDFL, more frailty-specific training for health and care professionals across the system, need for a common health information system across the primary and secondary care services and creating awareness about the integrated care interventions and care pathways across the system. The barriers and facilitators identified were across four themes, firstly formal policy and governance, secondly, shared values and goals, thirdly collaborative work and lastly, implementation. Furthermore, it was found that COVID-19 had negatively impacted all the preventative work started through LFF which was halted during the pandemic. The quantitative study showed that the routinely collected data are of questionable quality due to the huge numbers of missing values. There is huge variation in the services provided to OPDFL, while some practices provide services to a higher number of individuals, others provide services to a very low number. The number of falls reported to the general practice was very few throughout the forty-one months period reported in this study, emergency hospital admissions were higher while the number of deaths reported had errors. Finally, while the services provided increased in the first few months of LFF, they then reduced again.Contributions to Knowledge: This is the first comprehensive evaluation of the implementation of the national policy of identifying and managing older people with frailty at a local level. Evidence generated by this study provides guidance to commissioners, service providers and policymakers for areas of improvement and implementation of a system-wide integrated care intervention for OPDFL and the limitations identified in this study can guide future research.

Date of Award	Jul 2023
Original language	English
Awarding Institution	University of Bedfordshire
Supervisor	David Hewson (Supervisor) & Gurch Randhawa (Second supervisor)