A holistic framework used in geriatric care: Mind, Mobility, Medication, Multicomplexity, Matters Most.

Used to refer to older people whose frailty has progressed to a moderate or severe stage.

Defined as communities that actively work together to provide social, emotional and practical support.

Defined as a wider social network around the older person. This can be close relatives, but also friends, neighbours and community connections.

Defined as a space, not a place.

Defined as a state of interconnection with others, based on connectedness, mutuality and reciprocity.

Defined as the possibility of multiple different outcomes.

Defined as an approach to care  that engages assessment over time, but does not always require changes to intervention.

Current and future wishes and goals of care

Level 1 

Supporting older people living with frailty requires engagement in conversations about values, preferences and goals of care

What the current and future wishes and goals of care looks like:

Care that involves timely discussions about both current and future priorities and goals
Care that involves the consideration of contextual factors that can support priorities and goals, e.g. presence of a family network
Care that involves a mutual understanding of expectations and assumptions of the service(s)

Care that enables the collaboration between services delivered at home for those who wish to receive them there

Supported by death literacy, and normalises conversations about loss, death and dying
Supported by national conversations about ordinary dying in older age

Use of standardised documentation across services
Use of shared systems and processes across different parts of the care system that communicate with each other
Engagement and training with staff across services to enable partnership working and conversations over time

National Resources and guidelines