Frailty pathways

Frailty pathways letter, May 2023

Hertfordshire and West Essex ICS update of frailty pathways for our population 

All the documents referred in this document can be found here


The ICS Frailty Programme has now refined the pathways based on the feedback from organisations across the ICS. As the SRO for the workstream I am writing to inform you of the changes made to the updated pathways:

  1. Falls Risk Identification within the community
    • All hyperlinks updated
    • Reference to STP Ageing well pack removed


  1. Management by a clinician of a person who has fallen in the community
    • Contacted NHS111 for advice – changed contact NHS 111 for advice to ‘consider contacting local SPA and onward referral to prevention of admission teams and rapid response vehicles.’  This change is to reflect new services within the ICS.  New contact numbers added into click for more information hyperlink. 
    • Endeavour to ensure patient is checked on over next 24 hours – added ‘where clinically indicated’ and safety netting advice. 
    • Remove hospital pathway link as it was determined these were not going to be created
    • 111 removed and contact details for local prevention of admission services added


  1. Proactive Management of a person at risk of falls in the community
    • Falls and frailty hub renamed to care coordination centre 
    • Reference to STP Ageing well pack removed
    • All hyperlinks updated
    • Changed medication review to review Anticholinergic Burden 


  1. A pathway for the identification and management of risk feeding in the acute setting
    • Added in more reference to patient choice, Advance Care Plans, and encouraging patient to be the centre of decision making throughout the pathway
    • Added in awareness of oral health and increased risk of aspiration pneumonia

Added in explanation of risk feeding and Eating Determined At Risk

Local guidelines updated 


  1. A pathway for the identification and management of risk feeding in the community 
    • As above


The pathways outlined above were developed to reduce duplication, avoid gaps in care and ensure that the frail person receives high quality, coordinated and seamless care, whichever part of Hertfordshire and West Essex they live in.