Frail Patients Referred to a Community Specialist Team- What Were Their Frailty Scores?

Background Frailty is synonymous with older patients, where multiple body systems slowly lose their reserves and lead patients to become more vulnerable. When developing the inclusion criteria for our integrated care programme for older persons (ICPOP), the limited resources and large geographical area played a role. In order to maximize the outcomes for patients we targeted those with a Rockwood Clinical Frailty Score (CFS) between 4 and 6. We perceived that these patients would benefit from multidisciplinary intervention. Methods All patients referred to ICPOP were reviewed from November 2022 to April 2024. Our electronic patient database records information on ICPOP patients. Using this database we searched for the word “frailty” in the reason for referral field. We also correlated this with any patients who had a CFS recorded. The level of frailty in older patients with the scores ranging from 1 (very fit) to 9 (terminally ill) was recorded. Results 182 patients were found during the database search. 55 patients were referred for frailty alone, 64 patients were referred for frailty with balance/mobility issues, 47 patients were referred for frailty with falls, 16 patients were referred for frailty with memory issues. CFS were available for 132/182(73%) patients. 119/132(90 %) patients with a CFS score were classified as scoring between 4 and 6 on the Rockwood scale. 3/132(2%) scored 2, 6/132(5%) scored 3 and 4/132(3%) scored 7 on the CFS. Conclusion The national ICPOP framework prioritise improving care of frail older patients. A measure of a persons’ frailty level is subjective and dependent on clinical judgement along with a good understanding of the term “frailty”. Overall, our findings highlight that the referrers to our service have a good knowledge of frailty as a term. Our ICPOP hub is also effectively targeting the appropriate cohort of patients as per our inclusion criteria.