Case Study 1: NHS West Lincolnshire CCG – Using eFI to identify patients for unplanned admissions

In a nutshell: Older people should be assessed for the presence of frailty during all encounters with health and social care personnel (including reception and clerical staff). The  NHS England Enhanced Service  suggests the use of risk-stratification tools or other methods to case find and populate the register of at-risk patients. However, current methods of risk stratification has the potential to miss 25% of frail older patients as it relies on numbers of admissions and so may not always highlight high-risk patients. NHS West Lincs CCG are using the eFI to identify the patients with frailty for their ES to ensure people with frailty are included in the top 2% of patients at risk of unplanned hospital admissions.


Until recently the CCG have used the Devon Tool to risk stratify patients and identify the top 2% of patients most at risk of unplanned admissions. However, the perception amongst GPs was that patients with frailty were being identified too late when crises and hospitalisation had already occurred, preventing the opportunity for proactive intervention. As well as being able to target the top 2% using the eFI, the tool also allows them to identify patients with moderate frailty for which proactive care is most likely to benefit.

Compared to the Devon Tool, the wider dimension and sheer volume of read codes and markers of frailty that create an eFI score is giving GPs confidence that the eFI will accurately populate their unplanned admissions register. The eFI is currently being shared with a selection of GPs across the CCG to obtain feedback on the tool. The plan over the next 8-10 weeks is to adopt the eFI across primary care to inform the unplanned admissions DES.

The overall aim of the programme is:

Outcomes being used to measure impact:

Once this programme demonstrates relevant outcomes, the results from this will be used to improve pathways that exist. This will include using the eFI to inform referrals to the local Neighbourhood Teams and to the Community Geriatrician for CGA.

Contact: Carol Cottingham Head of Delivery Urgent Care & Long Term Conditions Lincolnshire West Clinical Commissioning Group

Email: Carol.Cottingham@LincolnshireWestCCG.nhs.uk