Summary
Using a design-led methodology and cross-organisational partnership, we worked with people living with frailty, unpaid carers, and professionals to explore the challenges of navigating care and develop new digital tools.

Abstract
With an increasingly frail population (1) and stretched health and social care services, the third sector has become essential for supporting people living with frailty (PLWF) and unpaid carers in navigating complex and fragmented care systems (2). Through an innovative partnership between Midlothian Health and Social Care Partnership (MHSCP), the British Red Cross (BRC), VOCAL (Voices of Carers Across Lothian) and Scotland's Digital Health and Care Innovation Centre (DHI), funded by the Scottish Government, we are developing new digitally enabled approaches which can help PLWF and carers to navigate care.

Using a design-led methodology, we began with a multidisciplinary professional workshop which explored how IT systems and risk-averse information governance policies siloes information and requires individuals to tell their story many times. Next, interviews with PLWF and carers identified that many people struggled with navigating the system, coordinating care, and tracking who was involved. Application forms for services and benefits were overly complex, requiring information to be inputted multiple times. Professionals such as BRC and VOCAL advisors who helped people navigate these processes were highly valued.

With this in mind, we focused on the BRC "What Matters to You?" assessment. This person-centred conversation builds a holistic picture of the person, helps them navigate options, and sets goals for living independently. BRC then agrees actions with the individual to take forward. However, BRC staff found that the paper form used for the assessment interfered with their ability to build rapport and follow the natural flow of conversation.

Through participatory workshops, we unpicked the knowledge embedded within the current process and co-designed ideas with staff. We identified moments in the conversation where the tool should 'disappear', and moments when the tool could be used to support improved communication. From this, we developed digital prototypes for a new assessment tool which records information about the individual in a more holistic way, shows the people involved in someone’s care, and makes it simple to record and track actions. The information can also be shared with other professionals or used to complete applications using a transparent consent process.

The prototypes were validated in workshops with BRC staff, VOCAL staff, PLWF, and unpaid carers. Their feedback showed that the tool was considered extremely valuable in helping citizens understand what information was being recorded about them and taking charge of their care. The learning gained in the project offers insight into the potential for digital tools to support person-centred frailty assessments, and the design-led process for collaboratively developing innovative tools that meet the needs of citizens and professionals. In the next phase, we plan to develop a working proof of concept, which can be trialled in Midlothian.

(1) Reeves D, Pye S, Ashcroft DM, Clegg A, Kontopantelis E, Blakeman T, et al. The challenge of ageing populations and patient frailty: Can primary care adapt? BMJ (Online). 2018;362.
(2) Xie Y, Hamilton M, Peisah C, Anstey KJ, Sinclair C. Navigating Community-Based Aged Care Services From the Consumer Perspective: A Scoping Review. Gerontologist. 2023;(April):1–14.