Further evaluation of a new frailty care pathway

As frail patients continue to deteriorate over time, frailty services are becoming more important to manage long-term conditions, provide support and champion proactive rather than reactive care.

Following the findings from the first evaluation completed in April 2023, a further evaluation into their frailty service was conducted to expand on the data collected and determine if the results could be replicated.

The evaluation had a strong focus on qualitative insights from the care coordinators to understand the benefits, challenges, and successes from the service. Additionally patient outcomes and feedback were also collected via a Measure Yourself Concerns and Wellbeing (MYCaW) questionnaire.

MYCaW consists of Patient Centred Outcome Measures (PCOM) where concerns or problems, and wellbeing is scored on a scale of 0 – 6 (0 being the best score) at their first visit and final follow-up visit. The results showed a statistically significant improvement from the first to final follow-up visit with scores reducing significantly.

Care coordinators expressed some frustration at the initial lack of structured training, support, and role progression, however, all care coordinators felt their confidence had improved since starting the role.

Patient survey results indicated that 100% of patients felt the service was personalised and all patients felt listened to. Respondents expressed gratitude and satisfaction for the service and valued the support and guidance available through the service, particularly accessibility to onward referrals.

Recommendations included, exploring why patients declined the service, share knowledge within the PCN of how practice implementation has been successful, explore career progression opportunities, and improve communication with staff by holding regular meetings and directing them to useful resources.

In conclusion, patients value the service and support provided as evidenced from the MYCaW data, where patient concerns have reduced and wellbeing has improved. Care coordinator feedback was positive, however more effective communication is required to other organisations and patients. While there is no clear evidence of system-wide benefits, the service provides valuable support for frail patients, addressing their health and social care needs by enhancing their quality of life, and the quality of the service provided.