Document type
Clinical pathways
Hertfordshire and West Essex ICB
Output type
Clinical Pathways
Proactive Management of Frail Patient in the Community

Proactive Management of Frail Patient in the Community

Proactive Management of Frailty

NB: this pathway is primarily aimed at the proactive planned management of the frail patient, but please note:

  • Refer to specialist services as required/appropriate (e.g. dementia, IAPT if screening positive for anxiety and depression, etc.)
  • Patients with an acute exacerbation/crisis should be managed in accordance with the Acute Urgent/Emergency Frailty Pathway described further down the page

Management of mildly frail patient:

  • Ensure patient has received an STP information resource pack
  • Refer to care navigator, if appropriate
  • If a person is at risk of/suffering from depression and/or anxiety, refer to appropriate services/ the hub so this can be managed.

Care navigators should follow-up with individuals with loneliness within 6-12 months (check if any interventions have made a difference)

  • Social prescribing (could be done by care navigator)
  • Signpost to voluntary/third sector for support (e.g. HILS, Age UK)
  • Promote the concept of the patient volunteering (helps loneliness wellbeing, physical activity) – signpost/ help to find opportunities to volunteer
  • Signpost to HertsHelp: Phone: 0300 123 4044 Email:
  • Advice on keeping warm
  • Home safety checks – if not done in the last year
  • Technology innovations e.g. alarms
  • Signpost to social opportunities (e.g. lunch clubs, local older people’s groups, digital inclusion)
  • Signpost to physical activities opportunities – consider exercise on prescription and falls prevention (see STP Falls Risk Identification in the Community pathway)
  • Social needs assessment

Management of the moderately frail

Clinical and health advice and care planning

  • Refer all moderately frail to community services for active case management
  • Give STP Ageing Well information resource pack
  • Postural hypotension assessment
  • Assess for risk of falls (see STP Falls Risk Identification in the Community pathway)
  • Polypharmacy review – use STOPP START methodology (ideally in clinical system)
  • Consider mild cognitive impairment/ dementia screening  
  • Review long term conditions as appropriate
  • Signpost to and recommend sight and hearing checks
  • Exercise self-management and advice e.g. signpost to NHS livewell - exercise for older adults:
  • Offer health promotion advice e.g. vaccinations, healthy eating, stop smoking, etc.
  • Identify informal carers and record on clinical record and patient held care plan – consider carers assessment and referral as appropriate

Begin Discussions about Care Planning, Social Signposting, and Self-management

  • Discuss individuals interests and priorities
  • Use STP My Plan documentation – start / maintain / update as appropriate
  • Agree self-management goals and actions with patient if appropriate


Management of the severely frail

Patients should be managed in the same way as the moderately frail but with an enhanced support and regular MDT/Gold standards review

All severe frailty patients should be managed in the same way as patients identified to be in the last year of life.  By definition the Gold Standards Framework (GSF) predictive tool means that people with severe frailty are likely to be in the last 12 months of life.  Please note, some patients with severe frailty have the otential to move to moderate frailty with appropriate assessment and management.  These patients should be considered for referral for Comprehensive Geriatric Assessment (CGA) and case management as per the moderate frailty pathway