Challenges in management of frailty by primary healthcare teams: From identification to follow-up

Abstract

Background

Assessment and management of frail elderly patients is organised in primary care worldwide. Multidisciplinary organisation in France is now becoming structured within multidisciplinary health centres (MHCs).

Objective

To describe the functioning of multidisciplinary management programmes in MHCs, identification and assessment of the frail population, and difficulties encountered by the professionals.

Methods

This prospective study was carried out in 2 components from October 2016 to March 2019 in all the MHCs in our region that are involved in the management of frail patients. To examine the functioning of management programmes, we questioned the general practitioners (GPs) and registered nurses (RNs) involved in the management of frail patients. The medical records of the frail patients managed were analysed after anonymisation.

Results

A validated scale was used for patient identification in one-third of cases. Geriatric assessment was carried out by nurses. Patient follow-up was conducted according to a protocol and reproducible in half of cases. The geriatric characteristics of the 235 patients assessed were similar to those of the frail population assessed in hospital facilities. Three-quarters of the 574 proposed personalised care plans were implemented, whether follow-up followed a protocol or not.

Conclusions

Management of frail elderly patients in primary care is complex but feasible. Primary care teams that are novices to patient assessment and follow-up could at first manage pre-frail patients. The more complex patients could be assessed in hospital facilities. Use of the dedicated GFST questionnaire, rather than subjective assessment, would enable early identification and management of these patients.