Chapter 5: Review, expansion and sustainability

Clinical guidelines
Simon Conroy
Date Published:
28 August 2018
Last updated: 
28 August 2018

It may be that your effort to improve care for frail older patients secures funding for an initial, time-limited period. A review at the end of that period will be an opportunity to show the contribution of your work to improving care rather than a prelude to ending the service.

Services that not only receive continued funding but expand their capacity often build their success on committed use of evidence in reviews, and sharing this evidence widely to ensure a growing buy-in from funders and colleagues.  

This chapter is part of a series. See the full series here

“We started [as] a funded project about 12 years ago with funding for 2 years for a registrar, clinical nurse specialist, an OT and a social worker. That was it essentially. And [we] started in orthopaedic elective patients only. [After] having shown a reduction in post-operative complications and improvement in length of stay without an increase in readmission, the Trust continued to fund the service, and has gradually supported the expansion of the team. [We now] cover all of the surgical subspecialties at [organisation 1]; the only one we don’t cover at the moment are cardiothoracic.” (Consultant Geriatrician)

“We were getting a lot of resource and a lot of support because we were doing what was evidenced, and we evidenced it was making an impact” (Consultant Geriatrician)

Securing sustainability

Sustainability can be vulnerable when efforts are seen as ‘projects’ or when they rely on particular individuals. From an early stage, projects need to identify future funding sources, or identify ways to use resources more efficiently in order to sustain improvements. Successful outcomes should be written into standards, guidelines and procedures to ensure they are embedded in routine activities.

Considering the side effects of change

It’s not uncommon to successfully target one issue but also cause new problems elsewhere. This can cause people to lose faith. Be vigilant about detecting unwanted consequences and be willing to learn and adapt.

National Audit Office Guide: Initiating successful projects, 2011

Developing Informatics Skills and Capability

Portfolio, Programme and Project management (P3M) Resource Centre

  1. Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database of Systematic Reviews 2017(9):CD006211.
  2. Fox MT, Persaud M, Maimets I, O'Brien K, Broo D, Tregunno D, Schraa E. Effectiveness of acute geriatric unit care using acute care for elders components: a systematic review and meta-analysis. Journal of the American Geriatrics Society 2012;60(12): 2237-2245.
  3. Van Craen K, Braes T et al. The effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis. Journal of American Geriatric Society 2010;58(1): 83-92.
  4. Kammerlander C, Roth T, Friedman SM, Suhm N, Luger TJ, Kammerlander-Knauer U, Krappinger D, Blauth M. Ortho-geriatric service-a literature review comparing different models. Osteoporosis International 2010;21(Suppl 4): S637-646.
  5. Linertová R, et al. Interventions to reduce hospital readmissions in the elderly: in-hospital or home care. A systematic review. Journal of Evaluation in Clinical Practice 2011;17(6): 1167-1175.
  6. Conroy S, et al. A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from aucte hospital: 'interface geriatrics'. Age and Ageing 2011; 40(4): 436-443.
  7. Fox MT, et al. Acute care for elders components of acute geriatric unit care: systematic descriptive review. Journal of American Geriatric Society 2013;61(6): 939-946.
  8. Tremblay D, Charlebois K, Terret C, Joannette S, Latreille J. Integrated oncogeriatric approach: a systematic review of the literature using concept analysis. BMJ Open 2012;2(6): e001483.
  9. Deschodt M, Flamaing J, Haentjens P, Boonen S, Milisen K. Impact of geriatric consultation teams on clinical outcome in acute hospitals: a systematic review and meta-analysis. BMC Med 2013;11:48.
  10. Ellis G, Whitehead MA, O’Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital: (Review) Cochrane Library 2011a;DOI(DOI: 10.1002/14651858.CD006211.pub2.
  11. Baztan JJ, et al. Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta analysis BMJ 2009;338: b50.
  12. Fealy G, et al. Effectiveness of gerontologically informed nursing assessment and referral interventions for older persons attending the emergency department: systematic review. Journal of Advanced Nurses 2009;65(5): 934-935
  13. Dixon-Woods M, McNicol S, Martin G. Overcoming challenges to improving quality: Lessons from the Health Foundation’s improvement programme evaluations and relevant literature, 2012
  14. Rubenstein, L. Z., A. E. Stuck, A. L. Siu and Wieland D. Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence. Journal of American Geriatric Society 1991;39(9 Pt 2):8S-16S
  15. Harari D, Hopper A, Dhesi J, et al. Proactive care of older people undergoing surgery ('POPS'): Designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients. Age Ageing 2007;36(2):190-96.
  16. Dhesi J. Improving outcomes in older patients undergoing elective surgery. Aging Health 2012;8.4:329+.
  17. Pronovost P. Navigating adaptive challenges in quality improvement. BMJ Quality & Safety 2011;20(7):560-563.
  18. Wallis SJ, Wall J, Biram RW, Romero-Ortuno R. Association of the clinical frailty scale with hospital outcomes. QJM. 2015;108(12):943-9
  19.  McCusker J, Bellavance F, Cardin S, Belzile E, Verdon J. Prediction of hospital utilization among elderly patients during the 6 months after an emergency department visit. Ann Emerg Med. 2000;36(5):438-45.
  20. Di Bari M, Balzi D, Roberts AT, Barchielli A, Fumagalli S, Ungar A, et al. Prognostic stratification of older persons based on simple administrative data: development and validation of the "Silver Code," to be used in emergency department triage. J Gerontol A Biol Sci Med Sci. 2010;65(2):159-64.
  21. Hebert R, Durand PJ, Dubuc N, Tourigny A. Frail elderly patients. New model for integrated service delivery. Can Fam Physician. 2003;49:992-7.
  22. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age and Ageing. 2006;35(5):526-9.

Feedback on this resource?

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.