The Frailty I-Care Toolkit: Summary

The following section outlines the actual Frailty I-Care toolkit:

Preventing frailty and supporting older people, carers, families and communities living with frailty through frailty I-Care (involve, consider, assess, respond, evaluate).

A care and support planning (CSP) approach can be applied across the whole spectrum of ageing and should be considered to understand a person’s, carer’s and family’s needs, goals and priorities thus enabling appropriate support and care to be offered.


Establish partnerships with people, carers and families to tackle the challenge of frailty together, both at:

  • A community level: to make the decisions of today that informs the care and support of tomorrow.
  • An individual level: so people, carers and families are actively engaged and involved in shaping their own care.


Identify people who may be living with frailty [mild, moderate and severe] by understanding populations with a high prevalence of frailty and using frailty screening tools:

The following groups of people have high rates of frailty [6, with modification]:

  • People who are resident in care homes.
  • People known to be living with dementia.
  • People aged over 65 who have experienced one of the major frailty syndromes:
    • Immobility (e.g. sudden change in mobility)
    • Delirium (e.g. acute confusion, sudden worsening of confusion in someone with previous dementia or known memory loss).
    • Incontinence (e.g. change in continence – new onset or worsening of urine or faecal incontinence).
    • Susceptibility to side effects of medication.
  • People aged 65 or above with multimorbidity due to 4 or more long term conditions.
  • People on over 10 medications.
  • People known to community nurses or social care and support services with continuous support needs.
  • People on end of life (EOL) register or cancer care lists or with complex neurological problems (stroke, MS, Parkinson’s disease) or older people with severe mental illness.
  • All people aged over 85.
  • People who are housebound or living in sheltered schemes or extra care or in ‘ordinary’ housing with telecare aids (e.g. ‘life alarms’).

Frailty screening tools

The Electronic Frailty Index (eFI) can be used for population screening in general practice settings.  Tools for screening individuals include PRISMA-7, Gait Speed, Timed Get up and Go Test and the Edmonton Frailty Scale.


Individuals who may be living with frailty to verify the presence of frailty and grade the severity by using clinical judgement and the Clinical Frailty Scale (CFS). Then offer, an individual assessment as part of preparation within a CSP approach (‘preparation, conversation and recording)


To respond appropriately to needs, goals and priorities that have been identified as part of the CSP approach (‘actions and review’), the following should be readily available in local health and care systems to prevent and support people, carers and families living with frailty:

  • Healthy ageing approaches with signposting to keeping active, engaged and independent, including access to frailty-friendly living and homes.
  • Community connectivity with access to and involvement of the Voluntary, Community and Social Enterprise sector.
  • Specific, tailored  support for Long Term Conditions, including supportive self-management and shared decision making to develop a self-management plan (with contingency planning) optimising:
    • falls and immobility,
    • medicine/polypharmacy  and
    • mental health.
  • Access to specialist interagency teams for a comprehensive geriatric assessment [CGA] and case management including the development of an emergency health care plan to coordinate care and optimise:
    • nutrition and hydration,
    • bowel and bladder care,
    • vision and hearing,
    • cognition, dementia and
    • end of life
  • Access to community crisis and recovery services (with active recuperation, rehabilitation and reablement) including:
    • frailty-focused transport
    • timely transfers of care from hospital, involving carers and families.
  • Access to experts offering frailty-based care in hospital with frailty assessment, diagnostics and pathways.


Evaluate the impact of frailty on people, populations and services through regional frailty outcomes and measures.

Making it happen

Each local health and care economy should develop their own ‘local frailty delivery strategy’ which will include local pathways around workforce and digital solutions with support from a regional Frailty Community of Practice.