The Frailty I-Care Toolkit: Detail

The following section outlines the Frailty I-Care Toolkit in detail. Each section of the Frailty I-Care toolkit is divided into:

  • Statement
  • Approach
  • Resources
  • Evidence
  • Local stories
  • Top Tips on ‘delivery and implementation’
  • Top Tips on ‘workforce, skills and training’

Overall our approach is underpinned by evidence from a variety of sources, including the European Union ADVANTAGE JA Managing Frailty Programme (, and aligned to national policy and guidance on healthy ageing, multimorbidity and integrated care delivery for older people:

We recommend the use of a Care and Support Planning (CSP) approach to understand the person’s, carers’ and family’s needs, goals and priorities leading to appropriate support and care to be determined.

Care and Support Planning (CSP)

Our frailty I-CARE toolkit is underpinned by a care and support planning (CSP) approach which can be applied across the whole spectrum of ageing and frailty with the aim of improving health, wellbeing and optimising independence at any stage. The core aim is to involve the person (and carers) in planning the future, by wrapping the traditional components of clinical care around what is important to them in living their life. CSP consists of a systematic series of steps to bring together all the issues the person may live with in a more productive consultation (conversation) with a trained professional enabled by preparation. The person receives personally relevant information, explanations and prompts (with support if necessary) with time to reflect on the key issues for them ahead of the conversation.  The professional collects and collates the ‘technical’ information from the clinical and medication record, from others involved with the person and organises assessments including self-assessments, so these can be included and debated as part of developing joint plans with the person during the conversation itself.

CSP will usually, but not always, take place in general practice. The actions agreed may range from ongoing self-management, links with activities in a supportive community directly or via link workers (social prescribing) to specific interventions addressing falls, immobility, mental health, complex medications etc. For those with the most complex combinations of issues or diagnostic problems referral to the local specialist multidisciplinary team for comprehensive geriatric assessment (CGA) may be an important outcome of CSP so that further in-depth assessments, conversations and planning can take place.  The exact distribution of these elements across primary and specialist care will be determined locally as part of care pathway development.