1 st National Frailty Workshop

Transcription

1 1 st National Frailty Workshop White Paper Dr Chris Bates 1,2, Dr Andy Clegg 2,3, Dr John Connolly 1, Samantha Crossfield 1,2, Dr John Parry 1, Prof John Young 2,3,4 1. TPP, 2. University of Leeds, Institute of Health Sciences, 3. Bradford Teaching Hospitals NHS Foundation Trust, 4. NHS England, National Clinical Director for Integration and Frail & Elderly Care Contents Introduction... 2 Workshop... 2 Frailty... 2 A House of Care approach... 2 Living with Frailty... 3 Development of the Electronic Frailty Index... 3 Next Steps with the Electronic Frailty Index... 7 Index Validation... 7 Calibration... 8 Implementation... 8 Opportunities for the Frailty Index... 9 Primary Care... 9 Secondary Care... 9 Tertiary Care... 9 Elderly Care Homes... 9 Carers Challenges Conclusion References Please note: Any research data shown in this document is fictitious.

2 Introduction The ageing population is driving a shift in the focus of healthcare toward the main challenges associated with older age, particularly the clinical condition of frailty (Clegg et al., 2013). Frailty is a diminishment in the ability to maintain homeostasis in a changing environment. Around 10% of people over 65 have frailty, rising to between 25% and 50% among those aged over 85. People with frailty have increased risk of disability in older age, hospitalisation and care home admission. Frailty interacts with all aspects of a person s health and therefore requires an integrated approach to care. There is a requirement for the development of a health system that is adept and proactive in recognising and adapting care around frailty. Workshop The workshop on 17 th April 2014 brought together a range of stakeholders to discuss the future of the care of frail older people in the community. The audience was purposefully multi-disciplinary, with representatives from GP practice, Geriatric Medicine, Gerontology, Nursing, Clinical Commissioning Groups, NHS Trusts, NHS England, HSCIC, Age Concern, the British Geriatric Society, the wider academic community and private industry. A major focus of the workshop was how technology and research, in particular a newly derived electronic frailty index (efi), can help transform the way elderly care is delivered. Frailty Our resilience to events, such as a change in environment or an infection, and our ability to bounce back diminishes as we age due to the accumulating impact of stressors over a lifetime. An increase in frailty may be managed through assistive resources, be these physical, financial or social. From a health and social care service delivery perspective, this involves ensuring that rising needs are met. The key aspects for this are to identify a patient s grade of frailty, measure any achievable level of return to resilience, and mobilise the resources required to manage the condition. This is recognisably the guidance for treating all long-term conditions (LTCs); frailty is likewise chronic, widespread, and tends to progress slowly along observable trajectories (Young, 2014). Appropriately, the house of care model for LTCs may be initiated to place the patient in the centre of a single coordinated plan for care, with individual needs being aggregated into informed local care commissioning (Coulter et al, 2013). Essentially, there needs to be a means to implement a network of care that has been formed around a measure of both a patient s resilience and their goals. There are currently difficulties to achieving person-centred, long-term management of frailty, and this begins with the issue of identifying and quantifying frailty. Measurement of individual fitness or frailty currently involves either a time-intensive clinical process or a simple instrument that may be inaccurate (Box 1). Better methods of identifying frailty could be used to guide the process of care planning that applies a more goal-oriented approach to care. Having identified frailty, barriers to defining a meaningful care pathway include differences in language and goals between older people and health and social care professionals. A common language for frailty and the communication of management strategies is essential, which must be sensitive to societal connotations that traditionally link frailty to failure, helplessness and death. An older person's aspirations have to be seen as the focus of a care pathway. Effective communication would enable the alignment of shared, person-centred goals between patient and provider. A clinician must then have the capacity to mobilise the provision of services that can enable the patient to reach their goals. These goals may, for example, be visiting grandchildren, attending a forthcoming family celebration or eating home-cooked meals. Physical, financial or social support from a range of parties may be involved. Objective measurement, a common language for communication and goal development, and meaningful service provision are required for pro-active and personalised frailty management. A House of Care approach The House of Care model is a checklist for the building blocks of high-quality, person-centred, co-ordinated care and is especially relevant for older people with frailty (Figure 1). Some common building blocks for a House of Care model for frailty may become standardised practice, while others will be set by local demographics and the patient s agenda. Patient aims remain central to the development of a House of Care. As such, an integrated care approach may assist with care delivery where multiple organisations are involved in defining a House of Care. The outcomes of this approach therefore remain relevant to the patient and provider. 2

3 Figure 1. House of Care model (NHS England, 2014) Living with Frailty Frailty needs to be considered in a wider context than just health. It is a state that captures the resilience of an elderly person in financial, mental, physical and social terms. An elderly person may have low physical health reserves but have the ability to mobilise social resources in a crisis; they may have the financial reserves to opt for private medical treatment quickly in response to health problems. The impact of a crisis on the life of an elderly person depends on this aggregate resilience. Frailty is a lived experience and, whilst a medical term, is a word that is often associated with judgement. For many elderly people, it is not a word they associate with themselves, even though it can often be recognised in others. It can be an unwelcome label due to the resistance of people to recognise their reduced capacity. The notion of being frail and elderly is surrounded by stigma, fixed, cultural ideas and a fear of dependency. It is often crisis that is to blame for the changing circumstances of an elderly person. The risk of a crisis having severe consequences for a person s health and wellbeing is a component of their frailty (Age UK, 2014). In order to manage this risk, the focus should be on maximising the person s capability and by agreeing individual care goals with them. These goals need to be creative, based on the wants and needs of the person. For example, staying indoors may reduce the risk of falls, but significantly affect wellbeing. The goals should be enabling, rather than just preventative. These discussions should begin early, so the expectations of both the individual and the provider can be managed and appropriate support mechanisms put in place. There is a challenge with the language of frailty and how it can alienate people from their own care. Perhaps the focus should be inverted, talking about levels of fitness and wellbeing, rather than frailty. This is the aim of an upcoming Age UK report, to determine the language we should use, that is free from stigma and stereotype. A common language around frailty is essential for engaging older people in the special challenges associated with the condition. Development of the Electronic Frailty Index Electronic health records (EHRs) have the potential to assist in the care of older people by enabling a severity grading of frailty to be quantified using routinely collected data. The University of Leeds and ResearchOne have collaborated on the development of an efi, using the cumulative deficit approach to frailty (Box 1). The electronic frailty index is based on patterns of frailty coded in primary care EHRs. These were identified from the symptoms, test results, diagnoses, medication and additional coded information recorded on the clinical research database, ResearchOne (Box 2). 3

4 After some initial data mining work, the research team reviewed over 8,000 codes and categorised around 3,000 of these into relevant deficits, such as falls or hearing loss. The 36 deficits that showed a strict increase in prevalence with age were included, following published guidance on creating a frailty index. The resulting deficits spanned the physical, mental and social condition of the individual, all drawn from routinely-collected primary care data. The frailty index score is calculated simply by counting the deficits that are indicated on the patient s EHR and dividing by the total possible number of deficits. Following international standards, there is no additional weighting. For example if 9 deficits were present on the record, the frailty index score would be 9 / 36 = The coded record information from the full EHR of over 220,000 patients aged between 65 and 95 were used to construct the index. This was internally validated on a further independent 220,000 records that matched well on demographic details, number of co-morbidities and number of prescribed medications. Mortality HR (95% CI) One year Three year Five year Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted Mild frailty 2.91 ( ) 1.91 ( ) 2.56 ( ) 1.74 ( ) 2.38 ( ) 1.66 ( ) Moderate 6.89 ( ) 3.39 ( ) 5.84 ( ) 3.02 ( ) 5.05 ( ) 2.73 ( ) Severe ( ) 5.23 ( ) ( ) 4.56 ( ) 9.54 ( ) 3.88 ( ) Care home admission HR (95% CI) One year Three year Five year Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted Mild frailty 3.37 ( ) Moderate 9.95 ( ) Severe ( ) 2.00 ( ) 2.46 ( ) 3.84 ( ) 6.27 ( ) 5.94 ( ) ( ) 1.52 ( ) 2.70 ( ) 3.42 ( ) 2.34 ( ) 4.88 ( ) 9.11 ( ) 1.56 ( ) 2.34 ( ) 3.00 ( ) Table 1: Hazard ratios with 95% confidence intervals for one, three and five year mortality and care home admission (in comparison with patients in the fit category) The next stage involved splitting the index into four distinct states of frailty, namely fit, mild, moderate and severe. Firstly, the 99 th centile was calculated - the frailty score below which 99% of the elderly population currently live. The index was then split into even quartiles below this score, each quartile being assigned one of the four states of fit, mild, moderate and severe, with increasing frailty. The discriminative and predictive capacity of the efi was analysed and the index scores were categorised based on the associated risk of mortality and care home admission over one, three and five years. In comparison to patients in the fit category, those with mild, moderate and severe frailty had around two, three and five times the risk of mortality within one year (Table 1 and Figure 2), adjusted for age and gender. Similarly, care home admission within one year was two, four and six times more likely, with increasingly frailty state. 4

5 Figure 2. Kaplan-Meier survival curve for each category of frailty For each patient the score has a moderate discrimination of 74% and 71% likelihood of correlating with one and five year mortality, comparing favourably to a research standard frailty index and the clinical frailty scale (Theou et al, 2013). The index also has moderate discrimination for outcomes of care home admission within one and five years (a C-statistic estimate of 0.76 and 0.65, respectively). The frailty index shows a strong correlation with social deprivation (Figure 3) and the anticipated trends with both age and gender (Figure 4). 5

6 Figure 3. Mean frailty index vs IMD rank (grouped by 1000s) Figure 4. Mean frailty index vs age in years 6

7 Box 1: Some existing approaches to frailty assessment Phenotype model frailty is identified by presence of three or five indicators such as weight loss, low energy expenditure, slow gait speed or weak grip strength. This is largely used in research rather than clinical assessment and does not highlight changes in frailty. Cumulative deficit model the number of indicators or deficits (clinical signs, symptoms, disease states, disabilities) that are associated with frailty are summated to calculate a frailty index, by dividing the number of deficits present by the total possible. Between 30 and 70 deficits are commonly used in this approach (Rockwood et al, 2005). Comprehensive Geriatric Assessment following identification of frailty, CGA is often initiated as a multi-dimensional process for developing a care pathway. It usually involves inter-disciplinary teams deriving a diagnosis of physical, social and mental health, and planning and providing care. Gait speed test this simple test is not resource- or time- intensive and offers a survival probability based on age and gait speed (Studenski et al, 2011). Assessment is not comprehensive and does not consider other factors affecting gait speed. It may be used to identify patients requiring a Comprehensive Geriatric Assessment. Next Steps with the Electronic Frailty Index Index Validation The efi requires validation so that it may be used with confidence across the health, care and research communities. This is being carried out in two main ways: The index is being externally validated to test the accuracy of deriving the frailty score on electronic health records from other clinical systems. This is being conducted using the THIN database (THIN-uk.com). In particular, the THIN database uses data from a system which employs a different clinical terminology to that of ResearchOne. Several individual practices, CCGs and Trusts have expressed interest in piloting the index for both case studies and clinical trials. This will help to test the clinical validity of the index, for example, in comparison to gait assessment or CGA, as well as assessing methods of implementation, such as protocols and care pathways designed for multi-disciplinary teams. Recent software developments mean that protocols which implement the frailty index can now be created, deployed and shared immediately. There are a number of planned case studies. For example, can the index be used to reduce unplanned hospital admissions for those patients whose frailty condition is changing rapidly? Can it be used to prompt and guide better medication reviews? Randomised control trials will provide a scientifically rigorous assessment of interventions and can investigate the long-term impact of embedding the index in an integrated house of care approach. Using a model which brings together the clinical system and the research data set can facilitate such research on a local and national scale. For example, researchers have already engaged organisations using TPP SystmOne, whose data is available in ResearchOne, to perform randomised controlled trials in an efficient, cost-effective manner. 7

8 Calibration Any predictive clinical tools that are developed around the frailty index will require calibration to ensure they deliver meaningful predictions across the population. The frailty index could, for example, sit at the core of new risk tools for one year mortality or one year entry into elderly care facilities, as we have seen above. Calibration against observed data would enable such models to be adopted with confidence. For example, the predicted probabilities for patients one year mortality must closely reflect the observed data, across all four categories of frailty state. If such tools are poorly calibrated, then their adoption across the clinical community will be low and their lack of accuracy could be harmful. Implementation One of the fundamental aims of this project has been to develop an index that can be used flexibly in clinical settings during routine care. It is a lost opportunity if the work remains confined to journal papers. Furthermore, a real strength of the index is that it is calculated proactively, from existing records, on routinely collected data; it does not require a reactive clinical assessment in order to be used. The use of clinical reporting and protocols within modern systems presents us with an opportunity to implement tools which can improve the management of the elderly across the health and care community. The electronic frailty index can be used to automatically trigger these protocols or to further stratify lists of patients derived from clinical reporting. Implementations of this work should aim to support all aspects of the integrated House of Care model. They should help to inform and support the patient, their clinical team and their wider network of carers, enabling better organisation of the care and clinical processes in place. At the same time, wider assessments should help drive local commissioning policies with regards to the care of the frail elderly. There are opportunities for implementations at national level, following some of the existing nationally - recommended clinical tools for electronic health records, as well as a local level, taking into account the available resources for referrals, night-sitting or charitable organisations, for example. Some potential opportunities are outlined below. Box 2: ResearchOne ResearchOne enables approved research access to consented, non-identifiable information from 5.5 million shared health records. Developed by TPP with the University of Leeds, ResearchOne is run not-for-profit to promote the use of records in both developing clinical insights and feeding these back into evidence-based practice. The NHS Research Ethics Committee approved the process for providing information (which is de-identified at source) for research that is approved by a Project Committee. ResearchOne supports a range of projects including feasibility studies for grant proposals, comparative research of existing practice, and trials of innovative interventions. Around 5,000 health organisations that use SystmOne can opt for their recorded patient information to be deidentified for approved research, and individuals may opt out. These organisations are across 23 care settings in primary, secondary and social care. Information from around 5.5 million of the 30 million records held by SystmOne is currently contributing to ResearchOne. As information is linked across organisations in SystmOne, ResearchOne can facilitate cross-sector research. This is particularly relevant to providers of integrated care. Research teams can, with consent, request further information from clinicians and patients, and embed clinical decision support into health records. Researchers publish questionnaires, templates and protocols to SystmOne and SystmOnline (the patient-facing portal for record access) to standardise the sharing of information, with outcomes feeding back to ResearchOne for evaluation. Research outcomes are published openly. Clinical and research teams can embed outcomes in clinical systems to support point-of-care decision-making. For example, a protocol can be set to automatically calculate a patient s frailty index when a record is opened and suggest any clinically relevant actions, or to calculate frailty when an appointment is being booked and, if the score is above a relevant value, prompt for a longer appointment duration to be considered. This illustrates a cycle of ongoing development in which records securely close the gap between clinicians, researchers and patients. 8

9 Opportunities for the Frailty Index Primary Care As the frailty index is based on the available primary care data for the patient, new opportunities for impacting elderly care in GP practices and community care settings should be broad and readily achievable. Some potential opportunities include: Exercise promotion: Increasing the activity levels of frail older people can improve their health outcomes and their general functional ability (Clegg, 2013). Protocols in the primary care clinical system, automatically checked on patient record retrieval or when a relevant action is performed within a consultation, could trigger purpose-designed activity templates or questionnaires, for a given range of frailty grades. An appropriate activity package could then be prescribed for the patient, with the aim of disrupting their current frailty trajectory. Unplanned admissions: A key target for GPs in will centre on the new Enhanced Service for Unplanned Admissions. The aim of this service is to reduce emergency unplanned admissions to hospital, especially in the vulnerable elderly group. Falls are a leading cause of hospital admission for elderly people and can lead to a significant change in frailty state. They can also impact on care requirements and reduce mobility and confidence. Again, automatic protocols may help prompt GP and community staff to assess the vision, posture and balance of an elderly patient with frailty in order to help prevent avoidable falls. Medication reviews: Elderly people are often prescribed multiple medications, with the prevalence of polypharmacy among the elderly population rising to almost 80% by age 80. Although often necessary, there is evidence of inappropriate medication regimes for frail patients, and frequent medication reviews are required to ensure the regime is suitable tailored to the individual and their circumstances. Protocols which trigger on the records of frail patients could prompt a START/STOPP medication review in order to achieve this on a regular basis. Health service utilisation: Brief GP consultations or short district nursing visits are often inadequate for frail patients; it may take longer for a patient with frailty to get to the consultation room and for complex needs to be discussed, for example. By automatically calculating the frailty of a patient at the time of appointment booking, suitable length appointments could be given out instead. This would clearly benefit both the clinician and patient, but also all subsequent patients with a scheduled appointment that day, which may be more likely to be carried out on time. Secondary Care Sharing the frailty index from primary care to secondary care settings has a range of potential uses. For example, knowledge of the aggregate frailty score of the admitted patients on each hospital ward could be used to schedule nursing resources or estimate planned ward round duration. In fact this could be done somewhat proactively, using pre-admission information from the hospital Patient Administration System, combined with knowledge of the frailty scores. Further, upon discharge this additional information could be used to better co-ordinate the patient s transition back to community care, based around their individual frailty needs. Tertiary Care Opportunities in specialist medicine should not be overlooked. As an example, earlier this year Macmillan raised the issue of the under-treatment of older cancer patients, with treatment being withheld purely on the basis of age (Macmillan, 2014). This was echoed by Sean Duffy, the National Clinical Director for Cancer, who reiterated the complex nature of cancer and that treatment should be based on what is right for each individual patient" (Duffy, 2014). Knowledge of the frailty grade of the patient, drawn from the rich primary care data source, could help specialists to better stratify which older cancer patients to treat and how to treat them, to assess the potential for successful treatment versus quality of life. Elderly Care Homes Presenting frailty information to staff at care homes may allow for better pre-admission assessments and resource scheduling especially, for example, in the case of urgent weekend admissions for new residents. Data from care 9

10 homes can become a very important component of accurate frailty tracking once a patient has started to have a requirement for residential care. It will allow for continuous data quality across this transition as well as a new opportunity to capture deficits such as physical mobility in the electronic health record (see Box 2). Carers Identifying those people caring for vulnerable elderly people, such as those suffering with dementia, is an important aspect of maintaining good communication between all teams involved in the patient s care. It is also important that the carers themselves are aware of the health, care and charitable services available to them. Keeping an accurate record of this information has been proposed as a new QOF indicator for 2014/15 by NICE. Identifying missing carers is a challenge. Finding elderly patients with a high frailty grade, who don t have carer information recorded, do not live in a residential home or do not have obvious regular contact with community services, presents an opportunity to do this. Similarly, the index may assist in finding and supporting frail couples, living together at home, and mutually caring for each other. Challenges There are many issues to discuss about how we respond to the increasing challenge of elderly care. How do we use technology and data to drive change? How do we engage patients and providers? What is the common language we should use? How do we grow the evidence base? What are the interventions and when should we intervene? Some of the main discussion points from the workshop are outlined below. There is a need to develop, validate and evaluate new care pathways for the care of older people with frailty. Implementation of a series of interventions will enable ongoing learning of how to move in the desired direction of change. These care pathways need to be interdisciplinary and involve, for example, GPs, care homes, charities, social care, community staff, gerontologists, and the individual and their wider network of carers. Everyone who can contribute to the patient s care and wellbeing should be included; it should not just be restricted to professional teams. The end measures of any interventions or pathways must be relevant to the individual - they cannot just be focussed on reducing unplanned hospital admissions. We need to assess these measures and their effectiveness, perhaps via Patient Reported Outcome Measure (PROM) methods and patient-facing questionnaires. Importantly, the individual s expectations about the care they receive must be set so that, for example, they do not just associate good care with an increased medication regime. The frailty index could be used in routine care in order to trigger a Complete Geriatric Assessment (CGA). This is currently the gold standard measure of frailty when carried out by trained, professional geriatricians. CGAs are an expensive task but may be cost effective in the long term, by helping people to be transferred more quickly from hospital back into community care. This needs to be researched and financially modelled. The frailty index may be a powerful tool which can complement the CGA and reduce some of the cost burden. It is no longer enough to just target the most vulnerable elderly patients. The goal must also be to target those individuals with low or medium frailty and its associated risks but whose situation is moving out of control. We need to go beyond point-in-time risk scores and start to think more dynamically, looking at the trajectories of individuals moving through the frailty risk pyramid. Engagement with clinical staff is fundamental and there needs to be serious consideration about how to incentivise any new ways of working. A hospital referral may still be easier than a check on a patient s financial or social resilience. With the already increased strain on primary care services, the benefits to all stakeholders 10

11 need to be highlighted in order to gain adoption. We need new research to determine what the suitable thresholds for intervention are - what are the levels of physical, mental, social and financial resilience that should trigger action? Interventions need a strong evidence base and need to be broad enough to encompass all of the needs of the individual. Often these needs are not medical and can be addressed proactively with a letter followed by a home visit. Being proactive in the care of frail individuals can certainly work but positive communication is paramount. Implementations of the index can be based either on the four frailty states discussed or on the continuous value of the index. This should be driven by use case and developing evidence. Protocols within clinical systems must be flexible enough to allow for either implementation, with actions in the system being triggered either by change of discrete state or by significant change in the numeric value of the index. There may be future implementations that require more granularity than the global index clinical tools that explore the actual combination of deficits to look specifically for falls risk, for example. Again systems should be flexible enough to accommodate this, triggering actions on the frailty index that can be further refined by the presence of certain deficits. We need to be ambitious about what can be achieved for frail elderly patients and acknowledge that in many circumstances their situation can be improved. Their individual care goals need to allow for this. For example, a patient may currently be too frail for combination chemotherapy, but the situation should be re-addressed over the coming weeks if suitable interventions have been put in place to raise their resilience. Frailty is not just a number and time must be taken to assess the individual situation. For example, a feeling of loneliness may be very difficult to improve in an elderly person; it can be seen as a trait rather than a state. However, at an individual level the cause of this loneliness is important - there may be far more traction for improvement if the cause is due to a change in their social network rather than a significant bereavement. Those caring for frail elderly friends and relatives can benefit from training about best practice regarding befriending. This should not be overlooked. For example, simple gardening activities may be far more beneficial than regular, passive visits indoors, and can benefit patients as part of a soft intervention. Any clinical tools based on the frailty index must be recalibrated on a regular basis to reflect changes in the population due to age, immigration, lifestyle and treatment. With these increasingly rapid changes, we cannot expect a tool to remain well calibrated if left unmaintained for several years. There are certainly opportunities for improved end-of-life care that can come from using the frailty index to identify the patients with the greatest likelihood of one year mortality. For example, once identified, a priority should be to record death preferences and emergency care plans, as well as maintaining an active palliative care register across primary care organisations. The work regarding the correlation of frailty with social deprivation and geography should be extended. This is important for local commissioning, for example, both for areas of high deprivation where individuals may live with frailty from an earlier age, as well as for areas with low deprivation, whose aggregate frailty burden may be very high. In order to meet the proposed health economic budget cuts we need to be ambitious; cutting unplanned admissions just for the most vulnerable patients will not be enough (Roland, 2012). Care of the frail elderly forms a large part of the health and care budget. For example, the cost of dementia in the UK currently stands 11

12 at 23 billion for the 800,000 people living with the condition, an average of almost 30,000 per person (Alz, 2013). Identifying patients with frailty is an important first step in innovative approaches that may result in costsavings. For example, identifying those patients with lower frailty but on a rapidly rising trajectory may allow for interventions to prevent unnecessary admissions for larger groups of patients lower down the traditional risk pyramid. Box 3: Care Homes With 20% of people over the age of 85 permanently residing in care homes, care home teams are increasingly being included in coordinated care delivery for patients with frailty (Oliver et al, 2014). An essential part of this work is to broaden access to electronic health records to include the wider community, including residential facilities. As an example, a number of care homes in Yorkshire are piloting the use of the TPP SystmOne clinical software, free of charge. With patient consent and the involvement of local providers, this enables record sharing so that homes can connect with the wider care community, including GP practices and urgent care providers. This ensures the delivery of care is based on timely, comprehensive record information. Staff at Donisthorpe Hall Care Home are enthusiastic about how this whole systems approach informs more individualised care planning (TPP, 2014). Maria Holdsworth, Registered Manager, says there are a lot of homes providing good quality care. We are able to plan the resident s care more effectively by sharing a health record with the local health providers. They can also share their expertise, which is particularly relevant when referring a resident for onward care. Conclusion Frailty is potentially the most problematic expression of population ageing, with considerable adverse implications for older people, their families, and society. In this White Paper, we have described the development and validation of an efi to identify and severity grade frailty using existing EHR data. The results indicate that the efi is a valid measure of frailty, with strong predictive validity and moderate discrimination for the outcomes of mortality and care home admission. We have set out a vision for improved care for older people, based on the routine identification of frailty using the efi, which considers a House of Care approach to planning and delivery of services. This approach has potential benefits for primary, secondary and tertiary health care, and local authority services. There is a need to develop a shared language around frailty in partnership with older people so that person-centred care planning, based on individual health goals and aspirations, can be achieved. The development of better integrated systems of care, based around the clinical condition of frailty and that incorporate a goal-orientated approach to care planning, have the potential to achieve a paradigm shift in the care of older people, with associated benefits in the health and quality of life of this especially vulnerable group. References Age UK (2014). Understanding the lives of older people living with frailty. A qualitative investigation. IPSOS MORI for Age UK, March 2014 Alzheimer s Society (2013) Dementia 2013: The hidden voice of loneliness Clegg, A., Young, J., Iliffe, S. et al. (2013) Frailty in Elderly People. The Lancet. 381 (9868): Collins, G.S. and Altman, D.G. (2013) Identifying patients with undetected gastro-oesophageal cancer in primary care: External validation of QCancer (Gastro-Oesophageal). European Journal of Cancer. 49 (5): Coulter, A., Roberts, S. and Dixon, S. (2013) Delivering Better Services for People with Long-Term Conditions: Building the House of Care. The King s Fund: London, UK Duffy, S. (2014). Older cancer patients should not be written off, BBC News,

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