BGS key messages: Front door frailty

1. Front door frailty services exist to identify people living with frailty as soon as they present to a hospital, to ensure that they are diverted to appropriate services as quickly as possible and, ideally, to ensure they are discharged to the place they call home the same day.

‘Front door’ refers to the part of a hospital where people initially present when they are unwell. This may be an emergency department or urgent care centre with people arriving either by ambulance or independently. Front door frailty services use recognised frailty identification screening tools and divert people living with frailty to a separate physical space for assessment, away from the busy emergency department. There is no ‘right way’ to do front door frailty – models vary depending on the workforce model available, the geography of the local area, the needs of the population and the hospital estate. Effective front door frailty services screen older people for frailty, assess them and proactively manage their care so that they are supported to return home, ideally the same day, without having to be admitted. 

2. Evidence shows that older people living with frailty wait longer than other age groups to be assessed in Emergency Departments and to be seen by a medical specialist.¹

Long waits in Emergency Departments are associated with increased mortality and worse outcomes.² Many front door frailty teams have built in alternatives to providing care in the emergency department, through single point of access (SPoA) pathways, hot clinics and same day emergency care (SDEC) facilities.

3. Identification of frailty at the hospital front door can help trigger early comprehensive geriatric assessment (CGA) and ensure that older people with frailty are diverted to the most appropriate services within the hospital as quickly as possible and, where appropriate, discharged home on the same day. 

Identification of frailty should be undertaken using a validated tool such as the Clinical Frailty Scale,  which is in widespread use and is including in most electronic patient record systems. Prompt CGA increases the chances of an older person being alive and living in their own home 12 months later and decreases the chance of readmission.⁴ It also ensures that a care plan is in place aligned to the wishes of the older person, including in the case of sudden deterioration. 

4. There is evidence that front door frailty services are effective in achieving quick discharge for older people living with frailty.³ 

This is due to the involvement of a multi-professional team completing a holistic assessment as soon as possible after the person’s arrival at hospital. Ensuring that professionals with the right skills are involved from the beginning of the process means that the person can be diagnosed, treated and discharged as quickly as possible.

If the opportunity for quick discharge is missed, older people are at risk of lengthy hospital stays and with delays to their subsequent discharge because of a lack of social care or rehabilitation in the community.⁵ Avoiding unnecessary hospital admission and returning people home on the same day provides better clinical outcomes for individuals and reduces the chances of hospital-acquired infection, deconditioning and delirium.

5. Hospital-based front door frailty teams must have knowledge of the available community services for older people. This enables them to discharge older people on the same day as their presentation and ensures that they have access to appropriate support in the community.

Relationships across primary, community, secondary and social care and the voluntary sector are key to ensuring that people can be discharged early and supported to remain independent. To implement good care attuned to local population needs, teams should develop a good understanding of the availability of community services, as these vary considerably across the UK.  Increasingly there are multiprofessional teams working across traditional acute and community boundaries. Teams such as Urgent Community Response or Hospital at Home/Virtual Ward exist in many health and care systems and provide a key interface to support early discharge from the front door and ongoing CGA in the patient’s own home. The availability of shared integrated care records across primary, community and acute care also enables professionals to refer people to alternative care settings seamlessly. 

6. Front door frailty services require multi-professional team working including senior doctors, advanced clinical practitioners or consultant practitioners, specialist therapists or nurses and liaison with other specialists including mental health and palliative care. 

All of these clinicians should have expertise in caring for people living with frailty. Skills for Care have published a core capabilities framework for frailty which services may wish to consider when planning their front door frailty workforce.⁶

7. Avoiding hospital admission for older people improves flow across the hospital system.

By identifying people living with frailty quickly and ensuring that they are triaged and treated quickly and discharged home on the same day, beds are freed up across the hospital, allowing the system to address elective waiting lists. This improves patient experience and outcomes as well as making the entire system more efficient.