Multiple long-term conditions: frailty register
Indicator
The practice can produce a register of people with moderate to severe frailty.
Indicator type
General practice indicator suitable for use in the Quality and Outcomes Framework.
This document does not represent formal NICE guidance. For a full list of NICE indicators, see our menu of indicators.
To find out how to use indicators and how we develop them, see our NICE indicator process guide.
Rationale
Frailty describes the group of older people who are at highest risk of adverse outcomes such as falls, disability, admission to hospital, or the need for long-term care. Older people with moderate to severe frailty are often well known to local health and social care professionals. They usually have weak muscles and also usually have other conditions like arthritis, poor eyesight, deafness and memory problems.
The appropriate use of an evidenced based tool and clinical judgement to identify people aged 65 and over who may be living with moderate or severe frailty was a requirement in the 2017/18 GP contract. It is assumed that the required data are already routinely collected.
Annual medication reviews, recording of falls and explicit consent to activate their enriched summary care record (SCR) are currently limited to people with severe frailty. This register underpins subsequent indicators expanding interventions to people with moderate frailty.
Source guidance
Multimorbidity: clinical assessment and management. NICE guideline NG56 (2016), recommendation 1.4.
Specification
A register of people with a diagnosis of moderate or severe frailty.
Exclusions: People under 65 years.
ISBN: 978-1-4731-5960-0