Annual Assessments
The NHS Long Term Plan outlines how people identified as having the greatest risks and needs will be offered targeted support for both their physical and mental health needs, including frailty.
Annual frailty assessments are a key component of proactive care for older adults. They aim to:
- Identify new or worsening frailty
- Review medication and care plans
- Prevent deterioration and hospital admissions
- Support personalised, holistic care planning
| Frailty Level | Assessment Frequency | |
|---|---|---|
| Mild | Annually | |
| Moderate | Every 6 months | |
| Severe | Every 3 months |
( Frailty Collaborative event facilitator notes- TWNS)
Who needs an assessment?
According to the BMA, for patients identified as being severely frail, the practice will be required to deliver a clinical review providing an annual medication review and discuss whether the patient has fallen in the last 12 months. Practices should also provide any other clinically relevant interventions and code them.
Assessment tools
Use appropriate tool, such as the electronic frailty index, to identify patients over the age of 65 who are living with moderate and severe frailty.
The CGA Template is also an effective tool to use when conducting you annual reviews. The new template will be shared soon .
Resources:
See NICE guidelines: Recommendations | Multimorbidity: clinical assessment and management | Guidance | NICE
Identification and management of patients with frailty