Primary Care Enhanced Frailty Scheme 2021 – 23 Year 1

Introduction:

NHS Leeds CCG has historically invested resource to provide a pro-active primary care response to registered patients residing in care homes for older people. This was a voluntary scheme and did not provide equal access for all residents. The CCG has undertaken a review of the scheme following the introduction of the national Enhanced Health in Care Homes Direct Enhanced Service scheme and identified a need to shift the proactive care to a wider population basis. This scheme builds on the historic work recognising the national and local evidence and drivers to support a population health management (PHM) approach to enable people living with severe frailty to achieve the best outcomes possible. It has been developed with clinical leaders and colleagues working alongside commissioning and improvement managers, taking into consideration feedback from Members.

This scheme will sit alongside the national PCN DES for Enhanced health in care homes; however, the population will encompass all people living with severe frailty living in their own homes, supported living units and care homes. It complements the PCN DES, focusing on a multi-disciplinary/multi-skilled approach to coordinate and deliver individual personalised care for people living with frailty. The scheme takes a phased approach over 3 years starting with defining the cohort and baselining the outcomes, then moving on to service change, measuring outcomes and improving the experience of care. The scheme is designed to support a quality improvement approach and leaves the model of delivery for Practices and PCNs to determine in partnership with their community, social care and third sector colleagues as appropriate. The national enhanced scheme ensures that all care homes are supported by a consistent team of multi-disciplinary/multi-skilled healthcare professionals delivering proactive and reactive care, led by named GPs and nurse practitioners, organised by the local Primary Care Network. It is encouraged but not mandated that this approach should be expanded to deliver this specification and incorporate the whole severe frailty cohort. 2021/22 is the first year of the scheme, which is a three-year scheme providing additional financial resource into primary care. The scheme will be reviewed at the end of Years 1 and 2 and the specification and financial allocation may be altered to take into account feedback and learning, as well as changes to DES service specifications. We know that people living with Frailty wish to remain independent, receive care closer to home and have a good quality of life. One of the key messages from the patients living with frailty has been encapsulated in the following statement and is the cornerstone to this scheme:

Person centre coordinated care “I can plan my care with people who work together to understand me and my carer(s), allow me control and bring

together services to achieve the outcomes important to me” The Cohort Severe frailty is defined by the Rockwood frailty score of 7 or above. We understand that practices don’t currently code this in the medical record and so in the first-year funding will be made based on the proxy of severe frailty cohort as defined by the Leeds Data Model (LDM) set.

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The outcomes Commissioners and providers in Leeds continue to work together to support integration of care through strategic commissioning for outcomes. This work has established a citywide set of outcomes which focus on improving outcomes for people living with frailty and at the end of life. An outcomes framework based on five key outcomes has been agreed:

1. Living, ageing and dying well, defined by “what really matters” to local people. 2. Reducing disruption to people’s lives as a result of avoidable harm and numerous contacts with hospital

services. 3. Identifying all people in this population group and working with people to assess their needs and assets 4. Caring well, defined by “what really matters” when caring. 5. Professionals working well together across the system around the needs of people.

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The scheme will focus on all outcomes, with data collected and reported for those measures and indicators that are contributable to general practice, although the wider data set will be available for sharing and learning. These indicators and measures will be collected as a baseline in year 1 and phased over the 3 years in the schedule as indicated below in the phased approach of scheme.

Specific Key Indicators aligned to the end of year achievement report and payment The following indicators for each outcome will require measuring and reporting as part of the specification. 1 Living, ageing and dying well, defined by ‘what really matters’ to local people XX of people with severe frailty (Rockwood 7 or above) with completed PROMIS-GHS & P3C-EQ (left shift blueprint). XX of people with severe frailty (Rockwood 7 and above) demonstrating a consistent or positive change. XX% of people with severe frailty (Rockwood 7 or above) offered opportunity to create Advance Care Plans (ACP) and report numbers completing an Advance Care Plans. XX of people with severe frailty (Rockwood score 7 or above) who have an Advance Care Plans. Of those with Advance Care Plans – xx proportion of people achieving preferred place of death. 2 Reducing disruption to people’s lives as a result of avoidable harm and numerous contacts with services XX Proportion of people living with severe frailty and people living with dementia who have had a Collaborative Care and Support Plan holistic annual review which results in a co-produced care plan using an agreed template. XX Proportion of people with severe frailty and a structured medication review (SMR) in last 12months. XX Proportion of people with severe frailty and a falls assessment. 3 Identifying people in this population and working with people to identify their needs and assets Practice uses the electronic frailty score to identify all patients at risk of severe frailty (score of 0.36 or more) and then clinically validate this group, coding those with severe frailty as defined by Rockwood score of 7 or more. Percentage of patents’ in the eFI risk score of severe frailty cohort with a read code of severe frailty diagnosis. 4 Caring well defined by ‘what really matters’ when caring Carers recorded as carers in own health record, proportion offered carer health check and offered referral to Carers Leeds. XX percentage of the severe frail cohort “Has a carer” recorded on the individual’s record.

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5 Professionals working well together across the system around the needs of people XX % of completed PHM 'Your Feedback' Staff Survey Monkey for General Practice staff groups. (*XX in the above indicators will be clarified subject to baseline data and population cohort details) Core contractual elements where there are interdependencies with the severe frailty population. Core contractual aspects outlined below and embedded across all Practices & PCNs

*Link to Supporting Routine Frailty Identification through GP Contract 2017/18 : https://www.england.nhs.uk/publication/supporting-routine-frailty-identification-and-frailty-through-the-gp-contract-20172018/ PCN DES contract: Structured Medication Review and Medicines Optimisation Identify patients who would benefit from a structured medication review (referred to in this Network Contract DES Specification as a “SMR”), which fall within the defined cohort and includes people in care homes, on complex and problematic polypharmacy, specifically those on 10 or more medications; with severe frailty, who are particularly isolated or housebound patients, or who have had recent hospital admissions and/or falls; Enhanced Health in Care Homes Work with community service providers (whose contracts describe their responsibility in this respect) and other relevant partners to establish and coordinate a multidisciplinary team (“MDT”) to deliver these Enhanced Health in Care Homes service requirements; have established arrangements for the MDT to enable the development of personalised care and support plans with people living in the PCN’s Aligned Care Homes. Deliver a weekly ‘home round’ for the PCN’s Patients who are living in the PCN’s Aligned Care Home(s), with a prioritisation approach and specific key requirements linked to the service delivery and the development of the personalised care and support plan. See Appendix II for further details and links to the service specifications. Specific key indicators reported for QI use These outcomes are monitored routinely by CCG and will be reported as part of the dashboard for interest Outcome 2 Reducing disruption to people’s lives as a result of avoidable harm and numerous contacts with services Percentage of people in severe frailty cohort who have place of care/residence recorded and/or Housebound

• Time people living with frailty or at the end of life spend at their place of residence • Number of serious falls per 100,000 population

Identification of people with frailty

• Identify any Registered Patient aged 65 years and over who is living with moderate to severe frailty.

• Use the Electronic Frailty Index or any other appropriate assessment tool to support identification.

•Information about the Electronic Frailty Index is available in guidance published by the Commissioner entitled "Supporting Routine Frailty Identification through the GP Contract 2017/18". *This guidance is available at: https://www.england.nhs.uk/publication/supporting-routine-frailty-identification-and-frailty-through-the-gp-contract-20172018/

When a Patient aged 65 or over is identified as living with severe frailty, the Contractor must:

• undertake a clinical review in respect of the Patient which includes: (a) an annual review of the Patient's medication; and (b) where appropriate, a discussion with the Patient if they have fallen in the last 12 months.

• provide the Patient with any other clinically appropriate interventions

• where the Patient does not have an enriched Summary Care Record , advise the Patient about the benefits of having an enriched Summary Care Record and activate that record at the Patient's request.

• Use the codes agreed by the Commissioner for the purpose, record in the Patient's Summary Care Record any appropriate information relating to clinical interventions provided to a Patient under this Clause.

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• Number of carers identified on primary care systems, and evidence of health check or review in their own right as carers

Phase 1 - House in order

Understand your cohort and conduct a holistic annual review underpinned by “what matters to me” and the CGA principles resulting in a co-produced care plan to be in place. Practice uses the electronic frailty score to identify all patients at risk of severe frailty (score of 0.36 or more) and then clinically validate this group, coding those with severe frailty as defined by Rockwood score of 7 or more and as a major problem in the clinical record. Phase 1 will commence in April 2021 and will build on the core GMS/PMS and APMS contract requirements seen as the building blocks of this phase, supports closing the prevalence gap and provides an opportunity for the identification and treatment for people living with severe frailty. This phase is ongoing throughout the 3-year scheme. At the heart of proactive care is the requirement to understand your population and those people who are at greater risk of adverse outcome. You can then offer a tailored package of person-centred proactive care in order to mitigate the common issues that arise. It therefore follows that there is a need to clinically validate a group of people who would stand to benefit and apply codes which allows easy identification both in practice but also across all services in the city. A GP is ideally placed to do this validation. We have purposefully chosen a Rockwood score of 7 or above as these people will be largely house bound and be the most similar to people living in a care home. This will create a manageable cohort and allow you to deploy staff and systems and processes that are being used for people living in care homes. Suggested way of achieving Member of the team runs the eFI to create a list of patients with a score of 0.36 or above.

• The majority of these patients will be eligible for an annual medication review. At this review the PCN pharmacist asks additional questions that allow them to complete the contractual requirements outlined above and also ascribe a Rockwood frailty score and code appropriately.

• Care co-ordinators working in PCNs may also be able to support the identification of people at risk of severe frailty and be included in discussions during the diagnosis verification process, recognising that the diagnosis will need to be completed by a HCP

• Many of these people will be receiving care from other providers and their involvement in the identification and possible verification of diagnosis may be helpful, similar to that above

• Other PCN roles, such as Physios and OTs; which are funded through the ARRs may be able to support the identification and verification of severe frailty.

Accurate diagnosis and verification of frailty for all people: with any stage of frailty, is made by a virtual clinical review using the Rockwood Clinical Frailty Scale (Appendix III).

Clinicians are recommended to use this approach regardless of the stage of frailty, however for the purposes of the enhanced scheme it only encompasses those people who fall within the PHM of the severe frailty cohort. Where Practices have diagnosed and read coded frailty based on the eFI score, this should be reviewed in accordance with the above approach. This should be read coded (See BI/DQ guidance for details) and included as a major problem. To note this should be reviewed if their clinical condition improves or worsens over time.

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Conduct a Holistic annual review for all people diagnosed with severe frailty utilising the framework of the comprehensive Geriatric assessment (Appendix II) and “What matters to me” resulting in the development of a personalised care and support plan, goals set. Run the eFI report twice a year six months apart Baseline data collection (this will be extracted from clinical systems linked to the key indicators outlined on page 1 and 2).

Phase 2 – Integrated multi-disciplinary/multi-skilled team working ethos

Using the tools for patient experience and staff experience – phase 2 will commence no later than the beginning of Q4 2021/22 in order to ensure the MDT/multi-skilled integrated approach will be in place across all PCNs from April 2022 for the severe frailty population cohort. We know that what matters to people who suffer from severe frailty is the ability to remain in control for as long as possible, have a fulfilled life and receive a co-ordinated offer of support from services. There are many services and people required to support someone with severe frailty and by its very nature good care and achievement of a person’s own wishes can only be done by excellent multi-agency working. The PROMIS-GHS tool asks a person to self-rate their health and wellbeing and provides an indicator of perceived quality of life and P3C-EQ measures a person’s experience of how joined up/coordinated their care is or has been. Both tools if completed before and after an intervention, not only allow us to understand the impact of care but they can also play a part in the assessment of an individual. Also, advance care planning and increased support to carers is seen as important and why measures around these areas have been introduced. Phase two supports the implementation of ways of working, using the tools with their patients and staff to learn the best way of using in day to day clinical activity. Suggested way of achieving One of the aims of this phase is to review, understand, plan and implement an MDT/multi-skilled approach to support the PHM severe frailty cohort across Leeds, which ensures people are supported with the right place, right time, right person philosophy, underpinning the person centred coordinated approach. This will include:

• Undertake a review of Multi-disciplinary/multi-skilled teams within their Practice and PCN to identify the variation of approach, attendance, outcomes, including the PCN EHCH MDT approach, through a what works well, what could be improved QI methodology.

• Understanding of the Neighbourhood Teams (NT) approach to case management review meetings with the Community Geriatrician and how could primary care be integrated.

• Understanding of the Community LYPFT approach to case management which could lead to the integration with primary care and the wider MDT/multi-skilled approach.

• Development of MDT meetings and conversations which are aligned to principles of the EHCH MDT approach which are enhanced and inclusive and support the inclusion of all the severe frailty cohort regardless of place of residence.

• Identification and sharing of specific priorities, indicators and measures which are relevant to the PCN Population health management (severe frailty cohort) that will lead to an improvement of patient outcomes.

Key Indicators XX% of people with severe frailty (Rockwood 7 or above) with completed PROMIS-GHS & P3C-EQ who have an improvement and /or remained stable from their baseline position. XX% of people with severe frailty (Rockwood 7 or above) offered an opportunity to create an Advance Care Plans and report numbers completing an Advance Care Plans. Of those with Advance Care Plans –XX proportion of people achieving preferred place of death.

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Carers recorded as carers in own health record, proportion offered annual health check. All indicators outlined on page 1 and 2 will be collected and show progression.

Phase 3 – PDSA Quality Improvement and ongoing service delivery

This phase relates to continuous quality improvement, which will support the delivery of quality enhanced care delivered by a multi-disciplinary team/multi-agency working leading to achieving the best possible outcomes for people within the severe frailty cohort. It will commence no later than 1 April 2023. Achievement in this phase will be through demonstrating an improvement in the P3C-EQ scores of their patients and a positive improvement in staff experiences from the baseline through surveys and focus groups. Outcome 1 Living, ageing and dying well, defined by ‘what really matters’ to local people XX % of people with Rockwood 7 or above with completed PROMIS_GHS & P3C-EQ (leftshift blueprint). Outcome 5 ‘Professionals working well and seeing other parts of the system working well around the needs of people.’ XX of general Practice staff will demonstrate a positive increase through the completed PHM 'Your Feedback' Staff Survey Monkey for General Practice staff groups. PCNs and practices will be able to define the clinical model working alongside partners to deliver continuous improvement. The focus will include:

• Continued refinement of MDT/Multi-skilled integrated working and MDT meetings/conversations which support patient outcomes.

• The Frailty outcomes, indicators and measures will be tracked and shared with Practices and PCNs to enable them to review and demonstrate continuous improvement through a PDSA approach.

• Patient experience through PROMIS GHS and P3C-EQ scores.

• Staff experience measures, with a specific focus on General Practice workforce and a general consideration of the wider multi agency team.

It is expected that delivery against the outcomes, and all indicators and measures will be achieved across a PCN footprint and this will be considered in the end of year achievement payment. Remuneration is based on a PHM approach for severe frailty at a PCN population level (September 2020 Leeds Data Model (LDM) set used to model the financial allocation). This will be reviewed and realigned on an annual basis each January subject to feedback from Business Intelligence, PCNs and review of the severe frailty cohort. The funding will remain at practice level aligned to their proportion of the eFI severe frailty population at a PCN level; however we would actively encourage local practices and Primary Care Networks to consider how they can support initiatives that deliver the strategic outcomes for the local population. Where Practices and PCNs wish to pool funding resources to deliver components of the scheme, integration of workforce, single approach for the PCN, the CCG can accept instructions to make payment to a central organisation. In line with the Quality Improvement Scheme principles, 85% of the funding will be made available to Practices on a quarterly basis (in advance).

Funding

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The CCG will reserve the remaining 15% of the funding as an end of year payment aligned to an Annual PCN report which incorporates a qualitative element:

• What will you do/ what did you set out to do and how will you do it - including any additional indicators and measures above the baseline ones.

• What will success look like.

• What actually happened.

• What did you achieve/ deliver against the above, why did that happen and progress against baseline indicators/ measures (What is the difference and why did it happen).

• What did you learn and what can be shared with others.

• What will you do the same and what will you do differently.

This report will be reviewed by a panel in Q1 of the subsequent year to support the release of the achievement funding. A reporting template will be provided for year 1, with adaptations for future years which will incorporate relevant indicators and measures in line with the scheme and enable PCNs to set their aspirations for achievement linked to baseline data.

*The CCG will review the scheme in conjunction with colleagues on an annual basis and provide a summary of changes. It reserves

the right to amend/cease the scheme at the end of each year giving specific consideration to the release of the PCN service specifications. For example, the release of the anticipatory care specification expected later in 2021/22 may give rise to review the cohort due to overlap between the two specifications. ** If a practice chooses not to participate in the scheme, we would encourage a PCN review to take place to consider the impact and approach to supporting Practices and the cohort population and ensuring equity. Consider a transfer of the patient cohort to PCN level to ensure that they receive the same level of proactive care leading to positive patient outcomes.

Indicators and measures have been developed as part of the citywide Frailty Population Health Management approach in 2019/20. These have been reviewed and refined in accordance with the left shift Blueprint which supports a shift to strategic commissioning for outcomes in 2020. Data Quality guidance will be produced in conjunction with the scheme which will provide further details of the template, coding and reporting searches. A dashboard for this scheme will be developed in the Practice Quality Improvement Dashboard, under local enhanced schemes tab which will enable Practices/PCNs to see and review the indicators and measures for their population. The following templates have been reviewed and amended to support the delivery and recording of patient information for this scheme:

• Revised Frailty template with associated links to relevant templates, which will support the capturing of the indicators and measures for the scheme.

• CCG EHCH local scheme developed for the historic scheme and adapted to support the EHCH PCN DES delivery.

• The new Planning Ahead (EPaCCs/ReSPECT) template which replaces the current EPaCCS (Electronic Palliative Care Coordination System) template. ( As outlined in PC bulletin 21 Jan 2021: https://mailchi.mp/nhs.net/coronavirus-primary-care-3pm-briefing-wednesday-20-january-6131927?e=060df81db0).

• CCSP template.

Data reporting and monitoring

Templates

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Appendix I NHS Leeds CCG Primary Care Enhanced Frailty Scheme 2021 – 23 Year 1

Practice Name: Address: Preferred Contact email address: Preferred Telephone Number: PCN:

GP Lead for Commissioning Name and Contact Email Address

GP/clinical lead for Enhanced Frailty Scheme

Name and Contact Email Address

Nominated GP Prescribing Lead (can be the same person)

Name and Contact Email Address

Practice Manager

Name and Contact Email Address

Lead Practice Nurse

Name and Contact Email Address

Lead GP/Clinician for PCN EHCH DES at Practice & PCN level

Name and Contact Email Address

PCN lead for Frailty if different from PCH EHCH lead

Name and Contact Email Address

Note: the names and email addresses will be used as point of contact by the CCG for the purposes of sharing and collating information at Practice/PCN level and creating distribution lists. On behalf of the practice:

Signature Name Date

On behalf of Leeds CCGs Partnership:

Signature Name Date

Associate Director of Primary Care

15 April 2021

Please return to the Primary Care Team: leedsccg.primarycare@nhs.net by 30 April 2021

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Appendix II: PCN DES specifications Structured Medication reviews and EHCH including the Comprehensive Geriatric assessment PCN DES: Structured Medication Review and Medicines Optimisation A PCN is required to: a. use appropriate tools to identify and prioritise the PCN’s Patients who would benefit from a structured medication review (referred to in this Network Contract DES Specification as a “SMR”), which must include patients:

i. in care homes45; ii. with complex and problematic polypharmacy, specifically those on 10 or more medications; iii. on medicines commonly associated with medication errors46; iv. with severe frailty47, who are particularly isolated or housebound patients, or who have had recent hospital admissions and/or falls; v. using potentially addictive pain management medication;

b. offer and deliver a volume of SMRs determined and limited by the PCN’s clinical pharmacist capacity, and the PCN must demonstrate reasonable ongoing efforts to maximise that capacity; c. clearly record all SMRs within GP IT systems; 45 Patients in a ‘care home’ are those resident in services registered by CQC as care home services with nursing (CHN) and care home services without nursing (CHS). 47 Based on the validation of the eFI, on average around 3 per cent of over 65s will be identified as potentially living with severe frailty. However, in some practices this number may be significantly higher. Severe frailty is defined as a person having an eFI score of >0.36. https://www.england.nhs.uk/ourwork/clinical-policy/older-people/frailty/efi/

Enhanced Health in Care Homes 8.3.3 A PCN must: a. work with community service providers (whose contracts will describe their responsibility in this respect) and other relevant partners to establish and coordinate a multidisciplinary team (“MDT”) to deliver these Enhanced Health in Care Homes service requirements; b. have established arrangements for the MDT to enable the development of personalised care and support plans with people living in the PCN’s Aligned Care Homes; 8.3.4 A PCN must have in place established protocols between the care home and with system partners for information sharing, shared care planning, use of shared care records, and clear clinical governance. 8.3.5 A PCN must: a. deliver a weekly ‘home round’ for the PCN’s Patients who are living in the PCN’s Aligned Care Home(s). In providing the weekly home round a PCN:

i. must prioritise residents for review according to need based on MDT clinical judgement and care home advice (a PCN is not required to deliver a weekly review for all residents); ii. must have consistency of staff in the MDT, save in exceptional circumstances; iii. must include appropriate and consistent medical input from a GP or geriatrician, with the frequency and form of this input determined on the basis of clinical judgement; and iv. may use digital technology to support the weekly home round and facilitate the medical input;

b. using the MDT arrangements referred to in section 8.3.3 develop and refresh as required a personalised care and support plan with the PCN’s Patients who are resident in the PCN’s Aligned Care Home(s). A PCN must:

i. aim for the plan to be developed and agreed with each new patient within seven working days of admission to the home and within seven working days of readmission following a hospital episode (unless there is good reason for a different timescale); ii. develop plans with the patient and/or their carer; iii. base plans on the principles and domains of a Comprehensive Geriatric Assessment including assessment of the physical, psychological, functional, social and environmental needs of the patient including end of life care needs where appropriate; iv. draw, where practicable, on existing assessments that have taken place outside of the home and reflecting their goals; and v. make all reasonable efforts to support delivery of the plan;

c. identify and/or engage in locally organised shared learning opportunities as appropriate and as capacity allows; and

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d. support with a patient’s discharge from hospital and transfers of care between settings, including giving due regard to NICE Guideline 27. For the purposes of this section 7.3, a ‘care home’ is defined as a CQC-registered care home service, with or without nursing.

A PCN’s Core Network Practices must ensure the coding of care home residence is accurately recorded on a continuous basis, using the relevant SNOMED codes as published in the supporting Business Rules PCN DES Network Contract link, page 44 onwards for further service requirements: https://www.england.nhs.uk/wp-content/uploads/2021/03/B0431-network-contract-des-specification-pcn-requirements-and-entitlements-21-22.pdf Comprehensive Geriatric Assessment https://www.bgs.org.uk/resources/resource-series/comprehensive-geriatric-assessment-toolkit-for-primary-care-practitioners https://www.bgs.org.uk/sites/default/files/content/resources/files/2019-03-12/CGA%20Toolkit%20for%20Primary%20Care%20Practitioners_0.pdf

A suggested framework for applying the elements of this guide is provided below

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Appendix III: Suggested actions for people with a Rockwood scale 7 or above, local adaption. Suggested actions for patients with frailty score 7-9 Clinical Assessments:

• Undertake a structured medication review.

• Antiplatelets, anticoagulants, opiates, anti-cholinergics, antidepressants, sedatives/ hypnotics, ACE inhibitors and other anti—hypertensives should be used with caution.

• Stop inappropriate/ unwanted medications or those without indications (may need to taper before stopping completely).

• Start any new medication at low dose with very gradual increments.

• Consider need for vitamin D if housebound depending on expected life-expectancy and tablet burden

• Avoid over-treating hypertension and diabetes.

• Review falls-risk -increasing medicines for people who have fallen or at high-risk of falls. Risk Assessment and Care Planning:

• Use advanced care plan when applying disease-based guidelines e.g. for diabetes, hypertension and CKD, dementia etc. outlining treatment goals/wishes with supporting anticipatory care plans for urgent care.

• Discuss the patient’s preference for end of life and complete a DNACPR from if appropriate. Anticipatory care plans as part of advanced care planning.

• Screen for falls and refer to NCH&C if required.

• Check for postural hypotension if falling.

• Ask about memory problems and refer on if indicated. Ongoing referral:

• Consider whether the right social care is in place considering carers support, signposting.

• Refer to community matron if 3 or more long-term conditions.

• Consider referral to geriatric medicine if significant complexity, diagnostic uncertainty or challenging symptom control.

• Consider referral to Old Age Psychiatry if complex cognitive or behavioural problems.

• Consider entering patient onto the GSF register.

• GP practice to deliver a clinical review providing an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12 months and provide any other clinically relevant interventions.

Rockwood Clinical Frailty Scale

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Appendix 4: PROMIS-GHS & P3C-EQ Tools to use and support the scheme.

PROMIS-GHS.pdf

P3C-EQ.pdf

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NHS Leeds Clinical Commissioning Group Primary Care Enhanced Frailty Scheme 2021/22: PCN End of Year Evaluation Report

PCN Name

Practices in the PCN who are delivering the scheme

Practices in the PCN who are not participating in the scheme

Complete in Q1 What will you do – including any additional indicators/ measures above the baseline?

Complete in Q1 What does success look like - what are your measures of success including details of timelines

Complete in Q4 at end of year

What was planned / tasks you needed to do?

What was achieved/ tasks that you completed?

Work in progress

Please complete at end of year What has worked well? What makes the biggest impact? How have you achieved the desired outcomes for people with severe frailty? What are your measures of success? What information can be shared with other practices/ PCNs on how you’ve achieved this?

What lessons have you learned from this? What information can be shared with other practices/ PCNs What will you do the same and what will you do differently?

How do you plan to embed and sustain the improvements made? What information can be shared with other practices/ and PCNs

Please return this completed form to the primary care team by 21 April 2022 to Leedsccg.primarycare@nhs.net