Identification and management of patients with frailty

The 2017 GMS contract requires GP practices, from 1 July 2017, to use an appropriate tool (e.g. Electronic Frailty Index - eFI) to help identify patients aged 65 and over who are living with moderate and severe frailty.

For those patients identified as living with severe frailty the practice should deliver a clinical review providing:
  • An annual medication review
  • Where clinically appropriate discuss whether the patient has fallen in the last 12 months and provide any other clinically relevant interventions.
  • Where a patient does not already have an enriched Summary Care Record (SCR) the practice will promote this, seeking informed patient consent to activate the enriched SCR.

​Practices are expected to code clinical interventions for this group appropriately. Data will be collected automatically by NHS England who will use this to understand the nature of the interventions made and the prevalence of frailty by degree among practice populations and nationally. This data will not be used for performance management purposes
QMasters' solution to easily identify and manage patients with frailty
Clinicians are expected to use the eFi score, alongside clinical judgement, to record a diagnosis of moderate or severe frailty in appropriate patients. The eFi score alone should not be used to make this diagnosis. This score is based on a multiple factors within a clinical record and will change as the clinical record changes.
Our QToolset Frailty suite makes the identification and management of frailty easy.
  1. It allows automatic addition of an eFi score code to all patients over 65 years old so GP practices can plan how they will review patients who may have severe frailty. The eFi score can be updated whenever a GP practice chooses to do so.
    ​Please click here to learn more about adding the eFi score to all patients over 65.
  2. Comprehensive reports allow easy review of those patients diagnosed with severe frailty who have outstanding actions.
  3. It includes a single, simple, smart template to carry out a full frailty assessment with full instructions for clinicians about what is required.
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QMasters' frailty searches
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    I am a QToolset subscriber

    These tools form part of our QToolset. Subscribers will receive them as part of their next update. They can also be downloaded from our website using the button below if you wish to install them immediately (please contact us for a password if you don't already have it). We require your contact details so we can advise you of updates to these tools as they are released.

    I am NOT a QToolset subscriber

    These tools form part of our QToolset, a suite of tools to help GP practices maximise income, save time, and improve clinical safety. There is more information about our QToolset here.

    ​If your GP practice is not a QToolset subscriber you can receive these tools free of charge by completing the form below. We will install them for you and also produce a free Data Validation Summary Report that will identify the value of any coding errors in your practice population that are affecting your reported prevalence of chronic disease.