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A risk of frailty assessment tool to encourage prevention pathways in Macvia France EIP-AHA reference site


Michel Noguès ,

Carsat, FR
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Justine Millot-Keurinck,

Carsat, FR
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Valérie Bruguière,

Carsat, FR
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Anne Bosc,

Carsat, FR
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Gabrielle Onorato,

Carsat, FR
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Jean Bousquet

Macvia France, FR
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Context: Since the European Union is experiencing an increasing demographic ageing, it created in 2011 the European Innovation Partnership for Active and Healthy Ageing (EIP-AHA).

MACVIA France (fighting Chronic Diseases for Active and Healthy Ageing), of which Carsat LR (Retirement and Occupational Health Insurance Agency of Languedoc Roussillon) is member, is one of the EIP-AHA reference site based in Occitanie region in southern France.

Short description of practice change implemented

People are mainly identified through the IRV’s (Regional Institute of Ageing) Frailty Observatory, then invited to meet with a prevention case manager in one of the “Concerted service window” (CSW) premises spread over the territory. The interview allows orienting seniors towards welfare services, health insurance, prevention and health centers or housing redesign. More than 1000 people have been welcomed since 2014.

Aim and theory of change: To develop prevention pathways and an autonomous life, Carsat LR created and animates the IRV that plays a role of regional governance. It identifies and acts on the determinants of frailty early on.

The IRV is inspired by the multidomain frailty approaches developed by Rockwood (2005) and Gobbens (2010), addressing the concept of frailty in its social, psycho-cognitive and physical dimensions.

Targeted population and stakeholders: The target population is in situation of economical precariousness, lack of access to health care, at risk of isolation & with difficulties with its habitat and daily activities. In 2016, about 150 stakeholders are involved to detect and orientate people.

Timeline: Still ongoing, the CSW has been implemented in 2014. The last version of the questionnaire is effective since mid-2016.


Highlights: A multidimensional frailty assessment questionnaire, created according international validated grids (WHODA WHOQOL EQ5D TFI GFI), allows assessing people’s needs within the CSW. Its 31 questions cover the social, psychological, mobility, cognitive, nutrition, QoL and ADL thematic field.

Comments on sustainability: Professional partners working along with the CSW are trained to use the questionnaire in their daily practice. Meanwhile, an ICT tool is under construction to digitalize the process.

Comments on transferability: The Sunfrail project, including MACVIA, has developed a multidomain 9-question grid, among which 8 are similar with the IRV grid. The idea is to compare the ease-of-use of the tools for professionals and the resulting orientations and pathways. It’ll be tested among several EIP-AHA reference sites in Europe.

Conclusion: This experiment tends to prove the ability for a network to develop common tools and data-sharing to foster frailty prevention pathways.

Discussion: Despite the European scaling-up strategy, it might be challenging for partners to use the same tool considering each local context and needs (limit to standardization).

Lessons learned: Building pathways is a dynamic work-in-progress implying acceptability issues, articulation between existing and new tools, and training to share a methodology and a culture of prevention.   

How to Cite: Noguès M, Millot-Keurinck J, Bruguière V, Bosc A, Onorato G, Bousquet J. A risk of frailty assessment tool to encourage prevention pathways in Macvia France EIP-AHA reference site. International Journal of Integrated Care. 2017;17(5):A126. DOI:
Published on 17 Oct 2017.


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