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Assessing Frailty Risk in Clinical Practice

      Frailty is a measure of vulnerability and a “vital sign” that is critically important to assess and track, especially with the continued growth of value-based care, said Steven Buslovich, MD, CMD, and Matthew Wayne, MD, CMD, at the 2022 Annual Conference of AMDA – The Society for Post-Acute and Long-Term Care Medicine during a session entitled “How to Use Frailty Assessments in Clinical Practice to Help Residents and Facilities Thrive.”
      Frailty predicts the risk of hospitalization, sudden decline, length of stay, pharmacy cost, mortality, and other clinical outcomes. “The key is not to look in the rearview mirror but to analyze risk at the time of the visit ... at the bedside,” said Dr. Buslovich, assistant clinical professor of medicine at the University of Buffalo and a medical director of several skilled nursing facilities in the Buffalo area.
      Assessing frailty “will help you understand what’s going to happen around the corner” and who is at greatest risk in both the post-acute and the long-term care settings, he said. It can help frame advance care discussions, align expectations, focus resources, drive optimal prescribing and care processes, and enhance quality of life.
      Dr. Buslovich saw the hospital readmission rate for post-acute patients drop by more than half in one of his facilities after he instituted a process for assessing frailty upon admission. “Quarter after quarter, we saw significant decreases,” he said. “And interestingly, we were also noticing meaningful declines in mortality.”
      The frailty scores obtained by staff at the hospital-based facility “drove how we approached the patient, our focus on risk mitigation and poor outcomes prevention, and early goal-setting,” he added in an interview after the meeting.

      The Tools, How “Everyone Wins”

      Kenneth Rockwood at Dalhousie University, Halifax, Nova Scotia, and Canadian colleagues have developed two tools to measure frailty: a 7-point scale to measure frailty designed for clinical use as well the Canadian Study of Health and Aging (CSHA) Frailty Index, which lists 70 variables or deficits (CMAJ 2005;173:489–495).
      The visual and briefly descriptive Clinical Frailty Scale — a 7-point scale that spans “very fit” to “very severely frail” (CMAJ 2005;173:489–495) — is easy to use, is predictive, can be a conversation starter, and is probably the most widely used scale internationally, Dr. Buslovich said at the meeting. (Frailty is measured and tracked widely in other countries, such as Canada, Australia, China, and the United Kingdom, he noted.)
      “If you haven’t been documenting frailty in your clinical work, try to start with something like this and track your patients over time,” he said. Ask “is your care stabilizing or reducing [the score]? Stability is not a bad outcome, particularly with some of the complex patients where you’re taking risk.”
      The frailty index (CMAJ 2005;173:489–495; J Gerontol A Biol Sci Med Sci 2007;62:722—727), is “more granular and more sensitive to changes,” Dr. Buslovich said. A frailty index score reflects the number of health deficits that are present in an individual proportionate to the total number of measured health deficits. In other words, it considers frailty as an accumulation of “deficits” — signs and symptoms ranging from fatigue and strength to balance, sleep, appetite, and cognitive status. “You don’t see age, sex, abnormal labs, or diagnoses on the [deficit list] ... because frailty is impartial to all these things,” he said.
      “I like [the frailty index] because the deficits are what are really critical in my opinion to developing a more [impactful] care plan,” Dr. Buslovich said in the interview. “Frailty is about physiological age, and responding to it is about caring for the individual’s deficits, and the functional, cognitive, and psychosocial domains that are impacted by their condition and situation. You don’t get there by looking only at the diagnoses.”
      Assessing frailty is vital for medical directors and clinicians, who increasingly need to manage financial risk and prospectively risk stratify under changing payment models, he emphasized at the meeting. “If you don’t control hospitalizations, for example, everyone loses,” he said. “But if you keep a patient or cohort of patients stable and you control hospitalizations” then the facility, insurance plan, and medical practice all benefit, quality measures improve, and patients receive better care.
      By knowing not only who is frail, but also understanding patients’ degree of frailty and how it’s changing, medical directors can “know where to pay attention and how to focus their teams,” Dr. Buslovich said.
      Dr. Wayne, a former president of the Society and currently chief medical officer at CommuniCare, a large Akron, OH–based provider organization that started its own managed care plan, said that in his experience frailty assessments have been helpful for identifying which patients need to be seen more frequently.
      “In our iSNP [Institutional Special Needs Plan], those who are highly frail are automatically seen twice a month, with a special focus on looking for changes in condition,” said Dr. Wayne. “It’s proactive.” Frailty assessment tools are also helpful for families and as “an aligning tool” for advance directives, he emphasized.

      “Know Your Data”

      Dr. Buslovich cofounded and leads Patient Pattern, a frailty-driven, care management software platform. He said there is “no easy way” to routinely track the deficits that determine degrees of frailty and to manage the related workflow without some degree of automation (involving Minimum Data Set data and electronic health record integration, for instance). When automation is not yet optimal, assessments with the simpler Clinical Frailty Scale are a valuable starting point.
      He noted in the meeting that frailty assessment is not used to upcode the hierarchical condition categories (HCCs) that have become increasingly prevalent in value-based payment models.
      HCC coding is intended to communicate patient complexity and predict resource utilization, but it doesn’t necessarily correlate with frailty. “Someone with a high HCC score may be highly functional; and someone may have a moderate HCC score but be severely frail,” he told Caring.
      Dr. Buslovich also urged clinicians to “know [their] data” as they lead in value-based care. “Admissions per 1,000” is a metric that’s important to know, as is Medicare Spending per Beneficiary (MSPB). Both can be found using Nursing Home Compare, he said.
      “A lot of nursing homes aren’t really looking at MSPB, but this is what a lot of quality measures are going to be looking at in the future,” he said.
      Christine Kilgore is a freelance writer based in Falls Church, VA.