Transforming Frailty Management with the Pathfields Tool
A study at Pathfields Medical Group has demonstrated the benefits of a new frailty case-finding tool. The Pathfields Tool is a game-changer in frailty management, offering a superior method for identifying those who need support. This innovative tool doesn’t just find more patients; it finds them with greater accuracy. The study highlighted the positive impact on patient care, clinical decision-making, and practice efficiency. The remarkable results included:
- Superior Frailty Identification: The Pathfields Tool, integrated within an IT system, identifies significantly more patients with frailty compared to the Electronic Frailty Index (eFI) alone. This indicates a more comprehensive approach to case-finding
- Increased Diagnostic Accuracy: A greater proportion of patients flagged by the Pathfields Tool are confirmed to have frailty. This demonstrates that the Pathfields Tool offers a more accurate method for identifying patients who would benefit from frailty interventions.
- Higher Prevalence Estimates: The Pathfields Tool estimates a higher prevalence of frailty in the 65+ population, indicating a more realistic assessment of frailty within the population.
- Proactive Case-Finding: The Pathfields Tool proactively identifies patients at high risk of undiagnosed frailty through criteria such as age, dementia diagnosis, severe frailty, difficulty mobilizing, care home residence, and recent home visits. This allows for earlier intervention and care planning.
- Sub-segmentation Capabilities: The Pathfields Tool allows for the sub-segmentation of frailty by residential status (own home, supported living, care homes). This enables more targeted and effective population health management.
- Streamlined Workflow: Opportunistic frailty case finding with the Pathfields Tool is relatively rapid. Clinicians reported that using the Pathfields Tool within an IT system does not have a negative impact on workload. The tool’s design, including a screen message with the Rockwood Clinical Frailty Scale and a single-button click, greatly assists with categorizing clinically confirmed frailty.
- Advanced Care Planning: A proactive care model, which included IT-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), resulted in a significant improvement in two-year survival rates, highlighting the impact of proactive interventions facilitated by IT systems. A primary care network (PCN) with an MDT-hub offering additional proactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.
How the Pathfields Tool Was Supported in SystmOne
Customisable Platform: SystmOne’s flexibility allows for the creation of the Pathfields Tool and other similar tools tailored to your practice’s specific needs. SystmOne Protocols functionality enabled opportunistic clinical prompts to assess high risk patients for frailty.
Integrated Clinical Support: SystmOne seamlessly integrates clinical decision support tools like the Rockwood Clinical Frailty Scale, ensuring accurate and efficient frailty assessment.
Data-Driven Insights: SystmOne enables the collection and analysis of comprehensive data on frailty prevalence, severity, and residential status, allowing for better informed decisions about resource allocation and service development.
Enhanced Workflows: SystmOne supports a streamlined and efficient workflow, making frailty assessment a seamless part of routine clinical practice.
Read the full studies here:
Does proactive care in care homes improve survival? A quality improvement project