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. e

Triage 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-

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&amp
• E attendance from Spine PDS events).

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 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.