It is crucial that the ‘Community of Practice’ creates an environment that supports reflection, development and collaborative actions to enable measurement to be used to advance health and care and minimise unintended consequences.

Regional frailty outcomes and improvement measures will be evaluated across the categories of:

  • health and wellbeing
  • care and quality
  • sustainability of services
  • transformational care delivery

There is growing recognition that measures should be based upon health and wellbeing as that is what is most important to people and communities.  For example, measures such as independence, empowerment and social connection.

There is a need for a balanced dashboard of standards and outcome measures relating to care and support of older people, families and communities living with frailty.  The outcomes should reflect multilevel health and care outcomes around integration and coordination of care, and ongoing relationships (individuals, families, and communities) with principles of inclusion and equity.

The following table is based on a review of regional and national work.  The outcome measures are evidence based and will complement those outcomes being used currently (or in the future) by CCGs, LAs and Public Health to incentivise ‘best practice’ service redesign in older people’s care and support.

The Frailty I-CARE evaluation strategy approach needs to meet the requirements of the toolkit and the purpose of the Community of Practice. The initial outcomes metrics report will provide a clear picture of the current achievement level and degree of variation for each metric at organisation level across the NE&NC. Relevant national targets and standards will be included in addition to appropriate benchmarks, with a one page summary at the start. It is anticipated that the report will help to identify opportunities and challenges. It is important to obtain the continued involvement of Community of Practice members for feedback and input to help identify good practice and priority areas for development. The list of metrics will be refined in line with improved data availability as this is an evolving process. Community of Practice members will also contribute to the development of the outcomes metrics by highlighting key interventions that have been introduced and are planned through the various care approaches across the NE&NC.

Consider frailty I-CARE evaluation strategy

Regional Frailty Outcomes and Measures


No. Part of system Metric Organisation level
1 Primary Care Number of patients who have had a frailty assessment GP practice / CCG
2 Primary Care Number of patients who are identified as living with frailty, and the degree of their condition (mild, moderate, severe) GP practice / CCG
3 Primary Care Number of patients with severe frailty, recorded as having had a fall in the preceding 12 months GP practice / CCG
4 Primary Care Proportion of people with severe frailty who have their written care plan reviewed with them regularly (minimum requirement annually) GP practice / CCG
5 Primary Care Number of patients aged 65+ years with 10 or more unique medications GP practice / CCG
6 Care in the community The proportion of people who use services who have control over their daily life Local authority
7 Care in the community The proportion of people who use services who reported that they had as much social contact as they would like Local authority
8 Mental Health The rate of those aged 65+ with a recorded diagnosis of dementia compared to those estimated to have dementia based on the CFAS II model CCG
9 Emergency care A&E attendance rates for patients aged 65+ years GP practice / CCG
10 Emergency care Unplanned admission rates for patients aged 65+ years GP practice / CCG
11 Emergency care Emergency readmissions within 30 days of discharge from hospital for those aged 65+ years GP practice / CCG
12 In hospital delays Stranded patient: LOS 7+ and 21+ days GP practice / CCG
13 Social care – discharge The proportion of older people (aged 65+years) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services Local authority
14 Social care – discharge Long-term support needs of older adults (aged 65+ years) met by admission to residential and nursing care homes, per 100,000 population Local authority
15 Mortality Percentage of deaths in usual place of residence for those aged 65+ years CCG
16 Primary care Flu immunisation rate in people aged 65+ years CCG
17 Care in the community Reduced loneliness to be determined
18 Care in the community Number of people referred into social prescribing schemes and number of people rejecting a referral (patients aged 65+ years) CCG
19 Primary Care Patients on the MH registers (dementia, depression and anxiety) and with frailty GP practice / CCG
20 Care in the community Carer reported quality of life Local authority
21 Emergency care Conversion rates (A&E attendance to emergency admission) for patients aged 65+ years GP practice / CCG
22 Emergency care Hospital activity in the last year of life for those aged 65+ years GP practice / CCG
23 Secondary care Composite quality bundle: A&E 4 hr compliance, Falls, pressure ulcers, improved patient experience, discharge to normal place of care. Hospital trust