What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?

The Pathfields Tool was validated as a Frailty Casefinding Tool in the last year (link: https://academic.oup.com/ageing/advance-article/doi/10.1093/ageing/afaa119/5868063). In adddition to diagnosing frailty severity (mild, moderate, and severe), it subsegmented the population by residential status (not housebound, housebound, and in a care home).

The Pathfields Tool also showed its worth as a population health management tool in the pandemic where entire population segments could be referred to partner organisations to offer targeted care (see case study one, link: https://www.bgs.org.uk/policy-and-media/beneficial-innovations-from-covid-19).

Delivering this required partnership working between primary care, community services, City Council, VCSO, and carehome providers.

What does your project aim to achieve?

During the time of the pandemic, we also conducted an in-house one year followup of patients from the time of frailty diagnosis. The one year mortality data was  stark with the outcomes as below:

1. Mild frailty ~25%

2. Moderate frailty ~50%

3. Severe frailty ~90%

What surprised us most was the mild frailty mortality data. This patient are generally living in their own homes and are independent but showing signs of slowing up and are beginning to struggle with higher order activities of daily living.

We would like to conduct a more in-dept analysis of this group to ascertain:

1. Cause of death

2. Whether upstream intervention can prevent death

How will the project be delivered?

This project will be delivered in two phases:

1. Analysis of deaths from mild frailty in Pathfields Medical group to determine the main causes of death. This will be written up and published as no one knows the causes of death in this group.

2. The next phase will be largely determined by the outcomes of the first phase. Depending on the disease, upstream interventions will take place to see if it possible to reduce these adverse health outcomes. For example if stroke is the leading cause of death, patients with mild frailty could be screened for atrial fibrillation and be brought in for blood pressure monitoring.

The team will involve colleagues in the Q community and the Centre for Better Ageging to ensure analysis is robust.

How is your project going to share learning?

This data has never before been discovered but has potentially massive ramification on how frailty is managed in the community. We would hope to publish this data and share it in international conferences such as the British Geriatrics Society Autumn meeting.

We would also hope to publish it in a leading journal and use organisations such as the South West Academic Health Science Network to support with webinars and dissemination.