Personalised Approaches in the Frailty Service Re-design

Over one hundred thousand people over the age of 65 in Lincolnshire are living with frailty. This means they have reduced reserves and are more likely to be admitted to hospital if unwell or in crisis. As people progress from mild to moderate, and then moderate to severely frail, their contact with the health and care service increases by approximately 35% for each progression, with an associated 78% spend increase for moderately frail people and 87% spend increase for severely frail people.

Proactive management of frailty ( e.g. by screening, comprehensive assessments, multidisciplinary interventions, and personalised care planning) can reduce its progression, reduce hospital admissions by 20%, reduce falls by 10%, improve health, and subsequently reduce care needs.

Partner agencies from across the health, social care, public health and the third sector in Lincolnshire have come together, with people, their families, and members of the public, to co-produce a new strategy based on local experience and best practice from elsewhere. The ambition is to work together strategically to integrate different services for older people and provide a joined-up service.

The personalisation team are supporting this work in a number of ways including;

  • Baseline surveys for 'personalised approaches; knowledge and understanding' among the workforce
  • Supporting the early adopter PCNs with training and guidance 
  • Championing the use of our 'tools' 
  • Challenging intervention design
  • Advocating the Our Shared Agreement approach within this work 

As the work develops, you can expect to see more being added to this page and language starting to change.  

For more information, please send an email to 


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