HealthTech NHS Frailty Assessment Digital Tool — Community Trust

Clinical Frailty Scale Digitisation: Clinical Frailty Scale (CFS) 1–9: digital assessment with clinical guidance at each level. CFS 4 (Vulnerable) → CFS 5 (Mildly Frail): automatic trigger for frailty care coordinator review. CFS 7+ (Severely Frail): immediate escalation to Community Geriatrician. eTriage integration: CFS score feeds into community case management system (SystmOne) via FHIR R4 Observation resource. Assessment history: all CFS assessments stored with date, assessor, and clinical context — trajectory (improving/deteriorating/stable) calculated automatically. Multi-Disciplinary Team Coordination: MDT digital workspace: GP, community nurse, occupational therapist, physiotherapist, social care worker — all accessing the same care plan. Care plan: frailty-specific goal setting (mobility, nutrition, medication review, falls risk), responsible clinician per goal, review date, and outcome recording. Virtual ward: high-frailty patients (CFS 7–9) in virtual ward daily review — care coordinator dashboard with alert for deterioration indicators (unplanned GP visit, A&E attendance from Spine PDS events). NHS Login Patient Access: NHS Login OIDC: patient accesses their own frailty care plan and progress dashboard. Patient-facing content: plain English CFS score explanation, care goals in plain language, upcoming appointments (NHS eRS integration), and medication list (NHS EPS integration). Carer access: nominated carer can access patient record with patient consent (delegated access via NHS Login). Accessibility: WCAG 2.1 AA — cognitive accessibility important for frailty population (older adults with potential mild cognitive impairment). DCB0129 Frailty Clinical Safety: DCB0129 hazard: CFS score incorrectly calculated leading to inappropriate care pathway. Mitigated by: CFS is clinician-entered (not algorithm-derived), clinical guidance displayed for each CFS level, and all CFS assessments reviewed by named clinician before care pathway trigger. Second hazard: care plan not visible to all MDT members. Mitigated by: role-based access with all MDT roles having read access to care plan, and email notification to relevant MDT when care plan updated.