1. Frailty, Falls & Fragility
Dr Dai Roberts -Programme Development Lead
Farah Irfan-Khan – Project Manager
Health Innovation Manchester

2. Falls & Fractures - the facts
Falls and fractures in people aged 65 and over account for over four million hospital bed days each year in England alone
There are ~65,000 hip fractures in the UK each year
33% of people >65 will suffer a fall rising to 50% for people >85 
Costing the health and social care
£2 billion a year
Hip fractures account for 4000 inpatient bed days daily

3. £ Greater Manchester Expected annual costs for falls £62,275,961
Hospital admission rate for falls averages at 44% across GM
Around 10% of people aged over 65 years have frailty
Expected annual costs for falls
£62,275,961
NWAS data shows that 11% ambulance call outs were for falls

4. Ambition for frailty…
‘Everybody should know what to do next when presented with a person living with frailty and/or cognitive disorder’

5. Frailty is not good for you

6. Emergency bed days by age
If the 08/13 years and 12/17 years are compared by age (under 65 vs over 65s), the biggest changes are for those who are over 65 years.
Bed days have been split for the under 65’s and those aged 65 years and over.
Whilst the pattern is essentially the same for the two groups, the biggest absolute changes are for those age 65+.

7. Greater Manchester Strategic Case
Reducing the number of falls is a key priority articulated in the GM HSCP Sustainability and Transformation Plan ‘Taking Charge’
All 10 CCGs have prioritised falls as part of the Locality Plans. It is a key priority for most CCGs. For example Salford has the second highest rate of hospital admissions caused by falls in the country, with 11,667 falls each year.
GM HSCP Five Transformation Themes
Reducing 2750 serious falls

8. Project aim
To reduce falls and fractures related to frailty across Greater Manchester through early identification, treatment and management of patients at risk

9. Tameside & Glossop Neighbourhood Frailty MDT Model
This MDT model aims to identify, review and manage severely frail patients at risk of falls and fractures using the electronic Frailty Index (eFI), Fracture Risk Assessment Tool (FRAX) and Falls Risk Assessment Tool (FRAT)
Cross Cutting Enablers
Digital Technology
Integrated Neighborhoods and Proactive Risk Stratification & Response
Estates
Joint Intelligence & Data
eFI
Key enablers to support T&G Transformation Programmes
1. Collect baseline data on severely frail patients using eFI
3. Review at Frailty MDT
FRAT
FRAX
2. Risk stratification using FRAT & FRAX
Neighbourhoods across Tameside & Glossop
The development of Integrated Neighbourhood Teams is one of the initiatives of the Tameside & Glossop (T&G) Transformation Programme with a specific focus on Frailty. The Stalybridge Frailty MDT is being set up as vehicle to support the identification, review and management of severely frail patients using IT toolkits and systems. Below demonstrates the flow of the patients from being identified as severely frail through to being referred to the appropriate service. This model will be supported by key enablers which cut cross all transformation programmes in T&G
2017/18 GMS Contract requirements for the identification and management of people with frailty
Interventions
Community groups/activities/carers/wellbeing groups
Community Response Service
Extensivist Model

10. Frailty Falls Fragility
The model
Frailty
Falls
Fragility
eFI
FRAX
FRAT

11. Potential Interventions
This project aims to reduce falls and fractures related to frailty across Greater Manchester through early identification, treatment and management of patients at risk
Community physiotherapy
Medicines optimisation of bone sparing therapy drugs
Falls programme
Relevant local authority, domiciliary care and voluntary services
Community Response Service
Complete Summary Care Record
Social dimensions
Social isolation
Short form questions –to impact on resilience and adherence to treatments –e.g. local community groups for referral on to
E.g De Jong Gierveld

12. Outcomes
This project aims to reduce falls and fractures related to frailty across Greater Manchester through early identification, treatment and management of patients at risk
Early identification, treatment and management of patients at risk:
Reduction in hip and fragility fractures
Decrease in mortality rates due to hip fractures
Early and increased identification of osteoporosis and high risk patients
Reduction in non-elective admissions related to falls and fractures
Better outcomes for patients with a reduced risk of disability and loss of independence

13. Milestones achieved
Stalybridge Frailty MDT pilot launched on 31 January 2018
Data Sharing Agreement produced for Frailty MDT which has been approved by the West Pennine LMC
Opportunity to deploy population health toolkit, Vision Outcomes Manager, being progressed
Engagement with:
Martin Vernon, National Director for Older People, NHS England
Industry partners
Bury GP Federation
Northern AHSNs as part of the wider ‘Bone Health Programme’
Stalybridge Neighbourhood Team
Public Health Trafford Council
- 28 severely patients reviewed in the first MDT between 2 practices

14. Finances IT costs Frailty MDT model costs Predictive ROI: £3,925,276
Cost for FRAX licensing is £20,000
Deployment of Vision Outcomes Manager is available via the GP Systems of Choice contractual framework
No costs associated with integrating FRAT
Frailty MDT model costs
The cost to backfill a GP/team for Frailty MDT is £300 per practice
Transformation Funding to Stalybridge Neighbourhood
Predictive ROI: £3,925,276

15. Risks and Challenges Establishing baseline data for each Locality
Engagement with Localities to take up project will be challenging due to increasing demands on general practice
Delays in approval of Data Sharing Agreements
Low uptake of the Vision Outcomes Manager
Continued variation, falls & fractures!