Pathways intended to support people along their entire journey of frailty need to consider all the different settings and services that people may need to provide their care along the way (see Making Our Services Safe Compassionate Care). However, these pathways need to be developed from the perspective of the individuals living with frailty, and not focused upon the agenda and needs of the organisations and services providing the care (see Transforming Models of Care).
In order to do this, when developing frailty pathways we need to consider the three phases of care (proactive, routine and responsive) across the three stages of frailty (early, moderate and advanced).
Along the entire frailty pathway, each phase of care for each stage of frailty needs to be considered in the context of The British Geriatrics Society ‘Fit for Frailty’ guidance (see Part 1 Part 2) and take account of the key themes and principles discussed elsewhere in this toolkit:
- The complexity and dynamics of frailty;
- Frailty trajectories;
- Transforming models of care;
- The role for supported self-care along journeys of frailty.
In this way, developing frailty pathways can support integration and alignment of existing services across all phases of care and all stages of frailty, as well as identifying any key gaps in provision and supporting targeted service development to meet these needs.
The expected impact of improving frailty pathways can be described in the near, medium and longer term. The near and medium-term impacts relate to the needs associated with frailty, whilst the longer term benefit relates to the underlying frailty trajectories:
- Near-term impact: The most immediate impact of improving frailty pathways is seen if changes are made in the responsive phase of care, providing a more appropriate response at the point of need, and therefore offering more effective intervention at critical tipping points in trajectories of need for people with frailty. This can apply across all levels of frailty (for example, as a result of creating easier access and a more holistic approach to the provision of responsive care services, making them ‘fit for frailty’);
- Medium-term impact: The impact of increased focus upon proactive and routine care for people with frailty can be seen in the medium term. This will, in turn, influence and modify trajectories of need at all levels of frailty, with the aim of reducing escalation to the critical tipping points associated with demand for responsive care services;
- Longer-term impact: Influencing the progression of the underlying trajectories of the condition of frailty, rather than simply the trajectories of need associated with given levels of frailty, will have a longer-term impact of improving frailty pathways. This approach is founded upon the evidence that earlier recognition and diagnosis of frailty, and a more proactive approach to the management of the condition, can slow the progression of frailty. This potentially has the greatest overall impact for both individuals and the system as a whole. However, this is a longer-term gain that requires sustained effort and investment over a period of time, from both individuals and from ‘the system’, and is therefore much more difficult both to realise and to measure.