Frailty Risk Identification Dashboard – User Guide

Overview

The Frailty Risk Identification Dashboard provides healthcare professionals with an at-a-glance view of patients aged 65 and over, segmented by their frailty risk levels. This tool enables proactive care planning and helps identify gaps in frailty assessments and care coding.

Dashboard Sections

1. Frailty Overview

This is your high-level snapshot of frailty risk distribution across the selected Primary Care Network (PCN) and practices.

Key Metrics Displayed:

• Total High Risk Patients

• Total Medium Risk Patients

• Total Low Risk Patients

Additionally, it displays:

• Number of Over 65 patients at each risk level without a frailty assessment.

• Average Care Planning Codes recorded per patient by risk level:

  • High Risk

  • Medium Risk

  • Low Risk

Use the dropdown filters at the top to drill down by:

• PCN Name

• Practice Name
  

2. Patients Tab

This view provides a patient-level breakdown of frailty risk.

Data Columns:

• PCN and Practice Name

• Patient ID (anonymized)

• Risk Band (Low, Medium, High)

• QFrailty Score

• Foundry RAG Code

• Existing Frailty Assessment status

• Chronic Conditions (sortable by condition)

You can filter based on:

• Risk band

• Number of chronic conditions

• Existing frailty assessments

• RAG code

• Specific long-term conditions (e.g., COPD, CKD, Dementia)

This helps clinicians identify individuals at risk who might need further review or care planning.

3. Patients Over Time

This chart provides a visual representation of the number of patients per risk band over time, making it easy to:

• Monitor trends in frailty identification.

• Track progress in frailty assessments and care planning.
  

🔍 Use Cases

• Identify gaps: See patients aged 65+ with no frailty assessment, categorized by risk level.

• Prioritize care: Use average care planning code data to assess how well patients are being supported.

• Segment patients: Filter by chronic conditions to isolate vulnerable subgroups for intervention.
  

QFrailty Score is an estimate based on known risk factors. For exact scoring, visit qfrailty.org.