Frailty made news in the U.S. healthcare community during the first phase of the COVID-19 pandemic when the United Kingdom-based National Institute for Health and Care Excellence’s (NICE) COVID-19 Rapid Guideline: Critical Care in Adults recommended that clinicians use frailty as a factor in determining whether patients would benefit from the most aggressive treatment (i.e., admission to the intensive care unit and ventilator use), says Margaret Sayers, MSc, NP, co-founder and vice president of product and research at the geriatric care solutions technology company Patient Pattern in Buffalo, NY.
“Frailty is becoming more well-known in the United States, but it has been used around the world for about 30 years,” explains Sayers. “In fact, since 2017 everyone over 65 in the United Kingdom has a frailty score calculated each time they have a healthcare encounter in any setting.”
Healthcare providers in the United Kingdom and other countries, including Canada, pay attention to frailty because it is a measurement of risk in people with multiple chronic illnesses, says Sayers. “Frailty is a measurement of risk that is agnostic to age and diagnosis. If a person is frail because their chronic conditions have impacted them cognitively or functionally, then they are frail whether they are 50 or 90.”
“In other words, frailty is a predictor of poor outcomes that is more strongly based—and more objective—than simply looking at a person’s diagnosis,” points out Barbara Bates, RN, MSN, RAC-CT, DNS-MT, QCP-MT, a clinical nurse consultant based in Rochester, NY.
Frailty is a particularly valuable risk metric for nursing homes because residents have become more clinically complex with more chronic illnesses over even the last decade, says Sayers. “The higher the risk—the higher degree of frailty someone has—the harder it will be for them to recover and return to baseline, if they are in fact capable of doing that. By and large, nursing home residents are frail, which means that they are at risk of adverse outcomes—even with the best of care—because they don’t have the physiological reserves to fight off a change in condition or an acute illness.”
Frailty scores help providers identify which residents are most at risk and not doing well, points out Sayers. “For example, two residents with the same diagnosis who are receiving the same treatment may be at different risk levels based on their frailty. Knowing each resident’s frailty score enables staff to take care of residents based on their degree of frailty and the specific areas of decline that are problematic for them, improving their ability to deliver individualized, resident-centered care.”
“So it’s a proactive approach to looking at prevention,” explains Bates.
Choosing an assessment tool
There are many tools available for assessing frailty based on a range of factors, including functional and cognitive losses, if no tool is available within a facility’s electronic health record, says Sayers. “Ultimately, you want a tool that will fit into your workflow.” It also should be beneficial in completing the following tasks, she suggests:
- Framing difficult but necessary conversations;
- Supporting patient-centered decision-making; and
- Empowering residents and families in making informed decisions on the basis of risk and the benefits of each care option.
Here is a sample of available tools identified by Sayers and other sources:
|Some Frailty Assessment Tools
5. Frailty Index from a Comprehensive Geriatric Assessment. Note: There are multiple comprehensive geriatric assessment tools that include a frailty index. For example, another option is available here.
The most easy-to-use of these tools that is still beneficial is the Clinical Frailty Scale or CFS (No. 1 in the above chart) from Dalhousie University in Nova Scotia, Canada, says Sayers. “It is a quick reference to how frail someone might be.”
The CFS is a one-page pocket-card tool that shows clip art of a person at certain degrees of frailty in their life, explains Sayers. “It starts with a person upright and running (a CFS score of 1 or very fit) to show that they are vital and energetic. Each succeeding picture shows someone who is a little less well and a little less functional. Ultimately, the person is lying flat in a bed and totally dependent in their activities of daily living (a CFS score of 8 or very severely frail) and then sitting in a chair (a CFS score of 9 or terminally ill for a person whose life expectancy is less than six months but shows no other signs of frailty). Each picture in the nine-point scale also has a few sentences describing what a person with that frailty score might be like or might be able to do at that level of frailty.”
All nursing home residents will have a CFS score of at least 4 (vulnerable), says Sayers. However, while 4 is the minimum, the majority of residents will be 5 (mildly frail) or higher, according to Using the Clinical Frailty Scale to Rapidly Assay Grades of Fitness and Frailty in Long Term Care. Note: Learn more about how U.K. clinicians use the CFS as a COVID-19 triage tool here.
Some critical ways that directors of nursing services (DNSs) can use frailty scores include the following:
Re-focus care planning
Most care planning teams base care plan interventions solely on diagnoses that show what is wrong with the resident, notes Sayers. “For example, if the resident is diabetic or hypertensive or if they have had a stroke or paralysis, they have a care plan for that diagnosis. However, a resident realistically may have 10 separate diagnoses. If the team puts a care plan in effect for all 10 of those diagnoses, that will lead to difficulties in staff completing the care plan on the floor because interventions will overlap or intersect in ways that are impossible. It also can lead to the resident receiving too many medications if they get a pill for every diagnosis.”
Planning resident care on the basis of frailty—the level of risk that residents have for declining or recovering—will level the playing field by changing the culture of care from disease-based to goal-based and resident-centered, advises Sayers. “For example, it won’t matter if the resident is severely frail because they have diabetes or because they have had a stroke. Instead, what will matter is that the team knows the resident’s risk and starting degree of frailty, they have identified the resident’s areas of decline, and they have developed interventions to see if they can either prevent further decline or stabilize the resident where they are at. This approach will improve the team’s ability to inject the best quality of care in the resident’s life as possible even when the resident may never return to their prior baseline.”
The frailty metric also assists the care planning team to identify a resident’s strengths, says Bates. “Many care plans never pick up on a resident’s strengths. However, centering frailty helps the team build strengths into the care plan to guide the resident in their care based on what the resident can still do.”
For example, if the frailty assessment shows that a resident who is 20 pounds overweight and sometimes has left hip pain due to arthritis still walks really well, the team may want to build in a care plan for the resident to do five small walks a day to control their ambulation, decrease pain in their hip, and possibly accentuate their weight loss—if the resident chooses to do it, says Bates. “The bottom line is that frailty assessments give the team a clinical rationale for guiding what the goals should be, identifying priority problems that need to be worked on, and developing appropriate interventions to maintain, slow, or resolve some of those issues.”
Communicate objectively with families
DNSs and other interdisciplinary team members should incorporate frailty scores into discussions with family members, suggests Sayers. “You really want families to know when their loved one’s condition has changed, and explaining that condition change in terms of frailty is an objective way of describing it to a family member. You can tell the family, ‘This is how the resident changed in a measurable way (i.e., from one frailty score to another), and these are the functional and cognitive changes that took place that have contributed to that escalation of frailty.’”
Communicating the message of frailty to families on a fairly regular basis will ensure that no family members are surprised when the resident declines, says Sayers. “They will better understand that the team is doing everything possible for the resident, but that the resident’s frailness means they will decline irrespective of the team’s care.”
Understanding frailty can help every discipline better communicate with families, adds Sayers. “For example, it can be difficult for therapists to communicate with families about the need to end aggressive restorative therapy because the resident can’t tolerate it. Many families become upset by the idea of ending skilled therapy or transitioning to maintenance therapy because they don’t understand the Medicare coverage rules. They sometimes want to blame the problem on a poor physical therapy department that isn’t adequate to the job.”
In this type of situation, therapists can benefit by using frailty to frame the conversation, says Sayers. “While no family member will be excited by this discussion, they can understand the problem if they know that both the therapists and the resident are doing what they can do, but that the resident’s functional or cognitive areas of decline are not setting the stage for great recovery and are instead making it impossible to meet Medicare requirements.”
It’s important to sell the concept of frailty before all of these discussions begin, says Bates. “You should make a good sales pitch both one-on-one and through resident and family councils. You need to explain how using a frailty metric will benefit residents and families, as well as what factors you will look at so that they can participate fully in care decisions.”
Improve advance care planning and advance directives
Frailty scores give providers the opportunity to base advance care planning discussions on solid, unbiased data, says Bates. “That can help residents and their families make decisions with less guilt because they feel like they have permission to be realistic. Then when there is a time of crisis (e.g., an infection), the resident and family will be able to better understand the progression of the disease due to the resident’s frailty, as well as make additional care decisions based on already known information. This could be particularly important during the ongoing COVID-19 pandemic.”
In many facilities, social workers are the first person to talk to residents and their families about advance care planning, adds Sayers. “You want them to know who is frail and who is becoming frailer so they have a sense of urgency for completion of these documents.”
Beef up supporting documentation
Sayers offers this scenario: A resident is assessed as very severely frail upon admission. Their skin breaks down during their stay, and the resident has facility-acquired pressure ulcers.
“This could result in an unhappy family and a lawsuit,” she points. “However, if the interdisciplinary team understands this resident’s frailty score, nursing staff will know to document that the team was aware of their risk and that staff followed the facility’s policies and procedures, as well as clinical best practices. Having that supporting documentation in place makes it very easy for the physician or nurse practitioner then to document that the pressure ulcers were an unavoidable occurrence based on the resident’s degree of frailty. Attorneys would find it difficult to form a case against your facility because the documentation shows that the risk was identified and your team did everything that could reasonably be expected of them to prevent the pressure ulcers.”
Build teamwork—and higher quality care
Understanding frailty can help interdisciplinary team members communicate with each other to improve the quality of care, says Sayers. “DNSs and other nurse leaders should use frailty as a standard framework of discussion in team meetings. For example, if you are in morning report or in a weekly risk discussion, find out who is the frailest resident, whose frailty score has gotten worse, and why that happened. This will spur you to strategize with the team about how to correct it if possible or how to stabilize it.”
In addition, nurse aides should become familiar with the term frailty and what it means, says Sayers. “Much like nurse aides report clinical changes in condition, you want them to report changes that affect a resident’s frailty score to their supervising nurse or unit manager. They need to understand that what they observe is important and will be addressed by the team when reported.”
Communicating with therapy about frailty can improve care as well, says Sayers. “Understanding the resident’s frailty score can assist the therapists to tailor the resident’s therapy program to their degree of frailty. For example, a resident who is moderately frail probably will not be able to do a single two-hour therapy session. The therapist may need to alter the therapy plan to reduce the duration or intensity, or they may need to break up the therapy into separate morning and afternoon blocks.”
Help MDs and nonphysician practitioners prioritize
“Communicating the message of frailty to physicians and mid-level clinicians can help them understand which residents need extra focus, which residents need to be visited more often, and which residents and families may require assistance having advance care planning discussions,” says Sayers.
“Bringing clinicians on board will only work if DNSs almost form a joint venture with the medical director,” says Bates. “The DNS cannot do it alone. The DNS and the medical director need to work together, with the support of the administrator, to ensure clinicians understand why using a frailty framework is good for the resident, good for the family, and good for the entire interdisciplinary team.”
See trends over time
“The trending of frailty is a very important part of the concept of frailty,” says Sayers. “So you want to establish specific time points for obtaining frailty scores, such as in conjunction with each MDS.”
In the best-case scenario, providers also would be able to trend frailty scores across the healthcare continuum, says Sayers. “For example, in the United Kingdom, everyone has a centralized electronic medical record, allowing clinicians and other healthcare providers to access frailty scores calculated in other settings and identify how each resident is trending over time.”
Improve Five-Star QMs
Frailty assessments often address many of the same care areas covered in the Quality Measures (QMs) in the Five-Star Quality Rating System, points out Bates. “This gives the team a lot more solid information to be able to document in those care areas.” One facility that transitioned to frailty-based care went from two stars to five stars in the QM domain, which is the rating preferred by Medicare Advantage plans.
Frailty scores can help DNSs plan staffing levels for each unit, notes Sayers. “For example, if you know that half the residents on a particular unit are severely frail and the other half are moderately frail, you probably will want to staff it differently—with more nurses and aides to provide care to the severely frail residents—than if you have a unit where all residents are moderately frail. It’s another way of knowing how to staff a unit so that there are enough hands on deck to meet the needs of that particular unit and to prevent as many adverse outcomes due to frailty as possible.”
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