Case Study 3: NHS Airedale Wharfedale & Craven CCG – A tiered Elderly Care Service

In a nutshellImproved care for older people with frailty will necessitate more robust primary care-based systems capable of routinely identifying people living with different severity grades of frailty and applying a graduated response of supported self-management; case management that is well integrated with community, mental, social and voluntary sectors; and anticipatory end of life care. Ilkley Moor & Grassington Medical Practices in NHS AWC CCG are using the eFI to implement a tiered frailty service which addresses the whole pathway across primary care, community care including social care and secondary care as these are likely to be the most successful.


Ilkley Moor Medical Practice & Grassington Medical Centre, part of NHS Airedale, Wharfedale and Craven (AWC) CCG are implementing a tiered Elderly Care Service for patients identified as having mild, moderate and severe frailty based on the electronic Frailty Index (eFI). The project includes partnership working with the Local Authority and Airedale NHS Foundation Trust. The project aims to target 400+ patients across Ilkley & Grassington.

The team was initially designed to consist of GPs, a Community Matron, a Consultant Geriatrician, a Health and Social Care Coordinator and administrative support. The Health & Social Care Coordinator role has been removed from the model due to lack of Council resource. Discussions are underway with a local Voluntary Sector Organisation (VSO) regarding coordination support. The model will be piloted as a GP/Geriatrician/Community Matron led Elderly Care Service. This pilot will run for a year, with an evaluation planned at 6 month intervals.

Case finding for the service involved using a combination of clinical judgement, concentration/proximity of patients (i.e. targeting larger cohorts within care home settings to maximise impact) and the CCG risk stratification tool (Combined Predicative Model) - selecting the top 3-5% of patients from each practice report. The eFI was used to describe the frailty profile of patients within this 3-5% case list and patients were categorised according to a mild, moderate or severe frailty diagnosis.

Patients with moderate and severe frailty will have GP led care with protected sessions for care planning, home visits and pre-defined criteria for escalation and step down treatment. It is anticipated that the case load will be split based on clinical judgement, knowledge of patient and severity of frailty All patients on the case list will receive information about community links until further VSO support becoming available. Ilkley Moor and/or Grassington Medical Practice will test and implement a supported self-management intervention using the NHS England & Age UK Practical Guide to Healthy Ageing with support from Yorkshire and Humber Improvement Academy. Other practices will be involved in testing the supported self-management intervention, including: Saltaire Medical Practice, NHS Bradford Districts CCG, Wentworth Street Surgery, NHS Greater Huddersfield CCG and Creswell Medical Centre, NHS Hardwick CCG.

Consultant input will initially involve a monthly MDT case-based discussion with GPs to review admissions and re-admissions, with advice on care planning for more complex patients. As the project evolves, the Consultant Geriatrician may offer patient consultations within care home settings in addition to offering specialist support for GPs, care home staff and carers/relatives

The overall aim of the programme is:

Outcomes being used to measure impact:

A similar new model of care for patients > 65 years old is being piloted in West London CCG. The CCG are using the eFI to stratify the population relative to their severity grade of frailty and they will offer health and social care support to patients with mild frailty; case management to those with moderate frailty, and specialist care to those with severe frailty.  The case identification and severity grading of frailty using the eFI will be complemented by GP-led clinical decision making. This will allow patients to be reclassified if their care and support needs better suit a different tier within the service and allow the GP’s knowledge of their patient to strengthen the approach used to stratify the population. The CCG’s initial plan is to test the model across small group of practices to build confidence in the eFI. This will lead to agreement on the eFI range/cut-off the CCG will use to identify the frail population the service with target, in line with available resources.

Contact: Mark Evans, Business Manager, Ilkley Moor Medical Practice, AWC CCG; Nuong Trieu, Data Analyst, West London CCG Whole Systems Integrated Care

Email: Mark.Evans@bradford.nhs.uk; nuong.trieu@Attain.co.uk