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Frailty Management Solutions

Our frailty management solution provides the ability to proactively assess, monitor and manage frail individuals and enables care teams from across the care community to create, view and contribute to plans, assessments, contacts and other key information in real-time.

Capabilities of the Frailty Management System


  • View any existing frailty status information contributed from primary care
  • Undertake frailty assessments, such as cognition, falls, nutrition, function, skin, well-being
  • Record vital signs /quick observations
  • Create an integrated Care & Support Plan (including ‘about you’ details, goal tracking and contingency planning) and/or End of Life) record, and enter key care contacts (both personal and professional)
  • Add lifestyle & environment details
  • Record MDT meeting actions and outcomes
  • Record, manage and track plans and actions
  • Link to a number of areas within the shared care record, e.g., GP Problems; Medications; and Vitals


Our Frailty Management solution gives authorised users access to contributed primary care Frailty data, supplemented with additional information recorded directly into the Shared Care Record. This provides a comprehensive view of an individual’s frailty status and areas of concerns, available to all involved in the individuals’ care.

Frailty Dashboard

To support people with frailty conditions, this dashboard provides insight on patients utilising the following criteria:​

  • General demographics​
  • Electronic Frailty Index (eFI)​
  • Rockwood score​
  • Comorbidities​
  • Use of services​
  • Physiological measures, prescribing and diagnostics​
  • Johns Hopkins risk stratification​

​The Graphnet frailty dashboard uses primary care data sources, including clinical tests, prescriptions and encounter activities, as well as acute data sources (for example: A&E, outpatient and admitted patient care activity)​.

​The dashboard defaults to patients aged 65 and over as this is the cohort with the increased likelihood of frailty conditions, however filters will allow users to view patients beyond these age groups. Other filters within the dashboard also provide users with the ability to refine data to the cohorts most relevant to them.​

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