Joining the dots: Chapter three - System touchpoints and examples

Blueprint working group
British Geriatrics Society
Professor Anne Hendry
Date Published:
06 March 2023
Last updated: 
06 March 2023

This section of our blueprint describes the key touchpoints of care and support for older people across the system, from prevention through to end of life care. It describes the evidence-based approaches and interventions that are required to prevent and manage frailty across the continuum of care. 

The evidence-based approaches and interventions that are required to prevent and manage frailty across the continuum of care are interdependent and mutually reinforcing and should be designed as ‘wrap around’ services that are available for all older people, wherever and whenever they are needed. Services that are designed around the needs of older people will reduce the number of people admitted to hospital as an emergency, promote early discharge home, and ensure that fewer people are readmitted to hospital or to long term care. This in turn improves outcomes for older people and reduces costs for the NHS and social care.

Wellbeing encompasses physical, mental, emotional and spiritual health. Loneliness and social isolation are associated with higher mortality, increased risk of coronary heart disease, stroke, high blood pressure, depression and suicidal thoughts, and contribute to frailty and dementia risk as much as physical inactivity.58 There is strong evidence that regular exercise, particularly strength and balance training, reduces falls and partially reverses or slows progression of frailty.59 Inadequate nutritional intake is an important modifiable risk factor for frailty and falls and is highly influenced by social determinants such as poverty, food insecurity and social isolation. Action needs psychosocial solutions as described in the Eat Well Age Well programme.60 Age-friendly Communities61 enable people of all ages to live healthy and active later lives, live at home for longer, participate in the activities that they value, and contribute to their communities. Targeted approaches and support are needed to fully involve people with communication, cognitive, sensory or physical impairments.
Case study

Make Movement Your Mission (MMYM), developed by the Later Life Training charity, broadcasts freely accessible 15 minute ‘movement snacks’ three times per day on Facebook (live and recorded) and YouTube. The key message, ‘sit less, move more’ applies to all ages and abilities. Participants (age 40 to 90+ at home and in care settings) include people with neurological or musculoskeletal conditions that need regular movement to slow progression or reduce symptoms. Participation and activity levels are promoted by support from the online instructor, Facebook messages pre and post live sessions, peer support, and self-motivation from noting improvements in balance and posture. Feedback indicates that the regular short movement snacks are felt to be achievable, provide a routine and offer opportunities to engage with others. In an independent evaluation, 90% of respondents said they moved more frequently and regularly every day; 53% reported better quality of life; and up to half reported improvements in activities of daily living (ADLs). Participants on waiting lists for joint replacement were kept mobile and had less pain.

Other examples

Mid & East Antrim Agewell Partnership (MEAAP), Ballymena, Larne & Carrickfergus, Northern Ireland

Age Friendly Manchester

Other useful resources

Proactive anticipatory care targets people at risk of poor health and social outcomes in order to offer tailored support to stay well. Individuals at risk of poor outcomes are identified using validated population level screening tools combined with professional judgement.

Those with significant or escalating risk are offered a comprehensive multi-disciplinary assessment and appropriate interventions co-ordinated by a local multidisciplinary team of healthcare, social care and community or voluntary service partners working together. The older person and their carer or family will be involved in developing a personalised care plan based on their goals and preferences. Emerging evidence shows that the approach can improve care continuity and coordination and reduce emergency attendances. In the long term, the approach aims to reduce healthcare inequalities and improve system outcomes.

‘Polypharmacy’, the prescribing of multiple medicines, increases the likelihood of adverse effects, impacting significantly on health outcomes and use of health and care resources.62 Structured medication reviews63 to ensure appropriate polypharmacy are a core element of anticipatory care for older people. Scotland introduced an evidence-based seven steps approach and guidance on how to undertake medicine reviews for people with multiple morbidities and/ or frailty. Guidance and tools are available at
Case studies and examples

North Lanarkshire HSCP developed an innovative collaboration between the health/ social care locality team, primary/ secondary care professionals and a voluntary sector partner to provide person-centred, anticipatory care for older adults with escalating levels of frailty and high risk of deterioration in the community. Initially the holistic frailty assessment was completed by a Health Visitor band 5. Covid-19 prompted an innovative partnership with Equals Advocacy (EA) who already had a track record in facilitating Anticipatory Care Planning (ACP). With initial support EA workers were able to undertake home frailty assessment focussed on ‘What Matters to Me’. Moving to a virtual MDT format has saved time and travel. Attendees include Advocacy Worker, Primary Care Senior Decision maker, Older People’s Community Mental Health Team, Care at Home Manager, Advanced Clinical Services Pharmacist, Frailty Specialist, Community Nursing and Community Rehabilitation Team Lead. The MDT developed six standard interventions for all and additional tailored interventions depending on need. The Advanced Clinical Services Pharmacist within the MDT has resulted in improved pharmaceutical outcomes and reduced inappropriate polypharmacy. A formative evaluation is underway.

Other examples

Proactive Telecare provided by Delta CONNECT, West Wales

Other useful resources

Many older people who experience an acute illness or decompensation of a frailty syndrome prefer to receive healthcare at home or closer to home.

All localities should offer a high-quality multi-professional integrated urgent community response (UCR) that provides both intensive short-term hospital-level care at home through Virtual Wards64 and Hospital at Home,65 and goal-oriented home-based and bed-based reablement and intermediate care services that optimise recovery through rehabilitation.66 Together, these services reduce risk of deconditioning, delirium and hospital-acquired infection, improve hospital flow, support older people to regain independence and reduce demand for readmission and long-term support.67 Close working between hospital same-day assessment units, primary care teams, ambulance providers, community rehabilitation, and intermediate care and reablement services is required to ensure an efficient and sustainable integrated network of UCR and intermediate care services. Although UCR is most often reactive in response to a crisis, it should include proactive elements such as realistic care planning and treatment escalation discussions based on what matters to the person and their preferred place of care. Success requires a multi-professional team led by clinicians who can provide CGA, first line diagnostics and create both acute and rehabilitation care plans.68 Technology can be used to enhance proactive care by monitoring for early signs of deterioration.
Effective care for older people with frailty requires early mobilisation in hospital, rapid establishment of rehabilitation goals, and continued therapy input until their condition has stabilised. Older people leaving hospital often do not have access to the rehabilitation services they need to support their recovery. Rehabilitation must be available to older people leaving hospital, regardless of whether they are discharged to their own home, a care home or other setting. Where delayed transfers of care to community rehabilitation services are unavoidable, rehabilitation should commence in hospital. Older people with rehabilitation goals should not be transferred to a care home or community bed without assurance of appropriate rehabilitation being available. Without rehabilitation, older people being discharged from hospital experience further deterioration of their health. Already on average 15% of older people being discharged from hospital are readmitted within 28 days. With each admission their level of frailty and care needs increase, generating even more demand for health and social care at home or in a care home.
Case studies and examples

The Western Health and Social Care Trust in Northern Ireland established a Hospital at Home (H@H) service in rural County Fermanagh. Initially restricted to four Care Homes, the service now supports older people at home across the County. Current staffing is a less-than-fulltime Lead Consultant, two WTE Specialty doctors, ten WTE Nurses, three WTE Health Care Assistants and one WTE Pharmacist. The service provides acute care for between four and six patients per day seven days per week with over 97% of patients assessed within two hours of referral. 82% were identified by GP or ambulance colleagues. The remainder were early facilitated discharges from the acute hospital. For 229 patients managed between December 2020 and May 2022, median length of stay was 5.5 days. There were no complaints or reports of adverse incidents. Any deaths during or within 30 days of H@H care are discussed at the Acute Hospital’s Morbidity and Mortality meeting, to support assurance and learning and to increase the visibility of H@H to acute clinicians. There is a need to build productive alliances with primary care and with the local Ambulance service to enhance acute care options for older patients. Through linking with Ambulatory and Geriatric Clinic services, generalist and palliative care services, and specialist community respiratory and cardiac services the team aim to build a productive, bureaucratically-light suite of options for acute care and follow-up to best meet the needs of older people in the local community.

Other examples

The Frailty Support Team in the New Forest69

Heathlands Intermediate Care Unit

Other useful resources

Older people with frailty account for a significant amount of hospital admissions and often have poor experiences and outcomes from urgent care.70 Many older people with frailty admitted to hospital as an emergency could be fit to return home on the same day if they were assessed, diagnosed and treated swiftly on arrival at hospital.

The Geriatric Medicine: GIRFT Programme National Specialty Report71 highlights there is much that hospital staff can do to improve the quality and safety of care and contribute to holistic and anticipatory care for older people with frailty: proactive identification of frailty and delirium, early comprehensive geriatric assessment alongside interventions to reduce harm and improve outcomes, and better coordinated transfers of care to the community. Despite evidence that CGA can improve care outcomes and experience, implementation in hospitals remains patchy outwith geriatric medical units. This contributes to considerable variation between hospitals for many quality metrics.72 Other contributing factors to this unwarranted variation are systematic differences in recognition and management of frailty and delirium, prevention of deconditioning, and in discharge practice. Solutions require pathways attuned to the needs of older people with frailty across the whole hospital. Guidance on managing frailty in acute care can be found in the Silver Book II.73
These integrated pathways should include the following elements:
  • Acute care at the front door - Emergency medicine specialists and geriatricians worked together to develop shared competencies in frailty and emergency care to enable early holistic assessment of older people in urgent care in order to alter their care trajectories and to improve experience and outcomes.74 The work was supported by a common vision, trusted relationships and joint education and training between the two specialties.
  • Acute frailty services routinely and systematically identify frailty in people attending Urgent and Emergency Care services. They consider the personalised needs, including the level of frailty and degree of illness, and are supported by clear reliable hospital-wide pathways aligned to the level of frailty identified.
  • Same day emergency care (SDEC) can allow specialist senior clinicians to care for patients on the day they arrive at hospital as an alternative to admission, removing delays for patients requiring investigation and/or treatment. Patients with conditions such as frailty can be assessed, diagnosed and treated without being admitted to a ward and, if clinically appropriate, return home on the same day. Some episodes of care may require follow-up for review and/or treatment to eliminate the need of overnight admission. SDEC can provide an opportunity to embed the acute frailty pathway within an Acute Trust. This may be particularly effective when linked with integrated frailty services. These services include integrated primary and acute care models (GPs working in hospital or interface geriatricians working in A&E departments) or community models with neighbourhood health and social care teams wrapped around GP practices.
  • Orthogeriatric services and Perioperative medicine for Older People undergoing Surgery (POPS) - Increasing numbers of older people undergo emergency or elective surgery.75 Clinician-reported, patient-reported and process-related outcomes are poorer in older surgical patients compared to younger people.76 Clinical and cost effectiveness data show that older surgical patients who receive CGA-based perioperative care have better outcomes and experience in both emergency and elective surgical settings.77 However, implementation of such services remains patchy78 as evidenced in national audits of falls and fragility fractures. A new guideline79 coordinated by the Centre for Perioperative Care and the BGS covers all aspects of perioperative care relevant to adults with frailty undergoing elective and emergency surgery.
  • Dementia management – 944,000 people in the UK are living with a diagnosis of dementia and this is projected to increase to 1.6 million people by 2050.80 The cost of dementia to the economy is projected to nearly double by 2050, from £25billion in 2021 to £47billion.81 A quarter of hospital beds are occupied by older people who have dementia and the majority of people who have dementia have at least one or two other long-term conditions – only 12% of people with dementia have no co-morbidities.82 Older people with dementia are at higher risk of poor health outcomes when they present at urgent care settings and may spend longer in emergency departments. Patients with dementia may have vague symptoms or be unable to report their symptoms, resulting in higher rates of burdensome or invasive testing.83 Further advice on managing dementia in an urgent care setting can be found in the Silver Book II.
  • Delirium management – Poorly identified, assessed and managed delirium not only extends length of stay but can cause significant distress for patients, carers and staff. The Frimley ICS introduced a specific delirium pathway that runs for up to 12 weeks, recognising that delirium takes time to resolve. Inpatients with possible delirium are referred to the acute frailty team who undertake a comprehensive geriatric assessment and suggest a management plan. If the patient’s discharge care needs have increased as a result of delirium, increased funding is available and continues until review by an integrated care team comprising mental health/GP/community matrons and social care. The team review patients at six and 12 weeks and assess if the delirium has resolved, or if they need to stay on the pathway. If a new cognitive baseline has been reached care is then funded through the usual arrangements. Further advice on managing delirium can be found in the BGS Delirium Hub.
  • Reducing deconditioning – The University Hospitals of North Midlands NHS Trust began a ‘Sit up, get dressed, keep moving’ campaign to raise awareness of how to prevent deconditioning. This campaign encourages older people in hospital to be active and supports healthcare professionals to help their patients to remain active. This supports older people’s recovery, reducing the chances of them being readmitted to hospital in the days following discharge. Their work is complemented by an international campaign to enrich the last 1000 days for older people with frailty. #endPJparalysis84
  • Hospital discharge and D2A pathways – The NHS England National Health and Social Care Discharge Taskforce85 identified 10 best practice initiatives that should be implemented in every trust and system to improve discharge and flow. The recommended approach includes framing delays to discharge as a potential harm event. The best practice initiatives are similar to the Home First principles and actions in Scotland’s Discharge without Delay programme.86 Both programmes promote Discharge to Assess87 at home or in the community and acknowledge the need to ensure capacity for intermediate care and rehabilitation to optimise recovery after discharge to improve outcomes for people and reduce further demand for services.
Other useful resources

The need to adjust the traditional outpatient model for older people is increasingly pressing. There is growing evidence for personalised patient-initiated follow up, albeit more studies are needed to assess outcomes for older people.

The Covid 19 pandemic forced new ways of working to be adopted at rapid pace. We can now learn from and adapt these innovations. The Royal College of Physicians has called for a shift from traditional outpatient models in order to embrace technology, improve patient experience and reduce the carbon impact. Older people often have multiple conditions, visit multiple specialists and clinics and have to retell their story many times. This is both frustrating and wasteful. Innovations such as one-stop frailty clinics and community-based ambulatory care hubs and clinics can help to improve patient experience and ensure that already stretched services operate more efficiently.
A rapid review88 found outpatient telemedicine for older people was beneficial, cost effective, and well received by patients. Whilst due consideration must be given to the risk of digital exclusion, there are many advantages to embracing technology to enable new models of ambulatory and outpatient care for older people.
Advantages for the older person:
  • Decreased need for transport to attend clinic; the home environment is more comfortable.
  • Decreased requirement to wait in hospital waiting rooms/corridors for appointments.
  • Increased opportunities for family members or translators to ‘dial in’ and participate.
  • Increased opportunities for multi-professional input in a single appointment.
  • Opportunities for remote monitoring to allow early recognition of physical problems, or ongoing assessment of existing issues in real time.
Advantages for the health and care system:
  • Decreased numbers of ‘Did Not Attend (DNA)’ due to issues with hospital transportation systems.
  • Increased efficiency with a greater number of telephone appointments feasible.
  • Decreased carbon footprint of outpatients with fewer in-person attendances.
Systems should be integrated to provide the right care to the patient in the format that is most appropriate to them. Systems will ideally be flexible, patient-centred and work towards a hybrid model that utilises the benefits of remote telehealth whilst embracing face to face one stop clinic models if appropriate. We understand however that systems are under a lot of pressure and that providing a fully flexible service may not be achievable immediately.
Case studies and examples

Hull and East Riding provides a hybrid proactive / reactive Community Frailty Anticipatory Care Model in an area with high levels of health inequalities and deprivation. A specialist Frailty MDT includes Consultant Community Geriatricians, GPs with Extended Roles (GPwER) in Frailty, Advanced Nurse Practitioner, Pharmacist, Pharmacy technician, Social worker, OT and PT, Carers Support service, Clinical Support Workers and Chaplain. The team offer CGA as a one stop ambulatory care model at the Jean Bishop Integrated Care Centre, with dedicated ambulance transport support. A virtual CGA is also delivered weekly for those living in rural / remote locations. Observed benefits include good Patient Reported Outcome Measures (PROMs) for individuals, a reduction in use of unscheduled primary and secondary care, high levels of staff satisfaction, innovative workforce development and successful recruitment into a historically under resourced service area and location.

The Jean Bishop Integrated Care Centre

Other examples

Lancashire and South Cumbria Health and Care partnership’s Hot clinic:

Dwyfor Primary Care Cluster

Virtual geriatric perioperative care clinic, North Bristol NHS Trust
Age and Ageing 2021;50:1391–1396

Other useful resources

Care homes are home to around 400,000 older people with frailty.89 The average care home resident is 85 years old, has six medical diagnoses and takes eight medications.90 The majority of residents have high care needs and are in the last two years of life.

When comprehensive geriatric assessment, co-ordinated multidisciplinary care and care management are organised around the care home and recognise the vital contribution of the care home staff, residents, families and staff are more satisfied and less likely to use hospital services.91,92 Access to specialist expertise in dementia and end-of-life care is essential.93 BGS Ambitions for Change94 makes 11 recommendations for how healthcare delivered in care homes can be improved.
Integrating healthcare support with long term social care at home is less well-developed and researched, with the exception of time-limited episodes of intermediate and palliative care. Homecare staff are important members of the MDT as are family and friends who deliver most long-term care and must be identified, supported and considered equal partners in community teams.
Case studies and examples

Rushcliffe in suburban Nottinghamshire has a 1:1 relationship between GPs and care homes, with GPs supporting quality improvement and co-ordination of care in addition to routine primary care. The enhanced service specification comprises regular scheduled visits to care homes and proactive review of medications and care plans accompanied by community nurses who offer peer support, training, signposting and review of direct referral pathways to community services. Regular meetings between NHS and care home staff build relationships and a care home managers network is facilitated by Age UK. The service achieved a 40% reduction in emergency admissions to hospital from care homes, 50% reduction in avoidable admissions for ambulatory care sensitive conditions, and a 43% reduction in Emergency Department attendances.

Nottingham City Care Home Vanguard established a 1:1 relationship between GPs and care homes, with contractual specification for regular visits and scheduled proactive review of medications. A dedicated Care Homes Nursing Team provided all community nursing input in to care homes in the locality, including proactive assessment and case management of all new residents. The service established specific MDTs to work with care homes around dementia care and falls prevention, streamlining referral pathways to minimise bureaucracy and delays. Care home staff and managers were actively involved in service design and service-level decisions about care homes and in structured training and forums for staff and managers. The service achieved 34% reductions in emergency admissions and 39% reduction in potentially avoidable admissions, contributing to a trend towards cost savings. Staff, resident and carer satisfaction with care delivery was higher than for comparator sites.

Other examples

South Sefton Care Home Improvement Project

Tameside and Glossop Integrated Care NHS Foundation Trust’s digital hub

Other useful resources

End of life care for older adults living with multiple health problems and frailty is different from dying with a single disease. The range of trajectories of decline includes sudden death, slow progressive deterioration (such as in advanced dementia), catastrophic events (such as stroke or hip fracture), and periods of prolonged uncertainty associated with fluctuating episodes of acute illness associated with delirium or functional decompensation.95

As recovery from acute illness in the context of severe frailty is uncertain, parallel planning for recovery or deterioration is essential. Recognition of advanced frailty and incurable illness should trigger early sensitive and evolving conversations related to the benefit versus burden of active treatment, the identification of realistic personalised goals of care related to current circumstances as well as a shared understanding of future goals and wishes.
Integrated Care Boards in England have a duty to commission palliative care services.97 The principles of palliative care are fully consistent with both CGA and person-centred care: meticulous assessment of problems, open communication with patients, families, and other stakeholders, setting realistic goals and expectations, good understanding of potential therapies and their likelihood of success, minimisation of treatment burden, anticipating and planning for the future, and attention to social, emotional, psychological, and spiritual aspects of care.98 A model integrating the principles of palliative, geriatric, and rehabilitative medicine and care is needed.99 Integrated health and social care with access to expert generalists is as important as access to specialist palliative care to enable the best possible end of life care for older people.
Case studies

The Geripall service in Sutton, Surrey aimed to improve the clinical pathway for people with advanced frailty (CFS 7-9) approaching the end of their lives. To be included, patients must be registered with a Sutton GP, have late-stage dementia or other neurodegenerative conditions, be at risk of recurrent unplanned admissions and have no specialist palliative care needs. Referrals are accepted from: Acute Frailty Unit and staff, other medical and surgical areas, Rapid Response Team in community, or social services.

A frailty consultant provides advice as and when required and a Geri GP works three sessions supporting a Band 7 nurse. The nurse is responsible for:
- Communicating with patients, family, carers, ward staff and discharge team, convening a family conference if required
- Reviewing medication, prescribing “just in case” medicines, and updating records accordingly
- Advance Care Planning
- Fast Track referral for CHC funding, and follow up in the community including by phone and through visits, referring to appropriate agencies as needed
- Communicating with the patient’s GP and other agencies as required.
- Service outcomes are reduced length of stay, reduced readmission at end of life, improved carer and patient involvement and experience of care.

Other examples

The Bromley Care Coordination Team

Other useful resources

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