The Integrated Frailty Crisis Pathway; Transforming Outcomes for Older People through Quality Improvement

Introduction

Limited alternatives to hospital care and fragmented frailty services led to unwarranted variation and poor outcomes for older people. Half of emergency department (ED) patients could potentially have been managed through frailty same-day emergency (FSDEC) care; average time in ED for over 85s was eight hours; and the Urgent Community Response (UCR) two-hour rate deteriorated to 40%. A three-year continuous improvement programme aimed to develop an integrated frailty crisis pathway, improve access to Comprehensive Geriatric Assessment (CGA) and reduce unnecessary hospital conveyance.

Methods

A change programme across acute, community and ambulance services used quality improvement (QI) methodology to develop FSDEC; Hospital at Home; UCR; single point of access for pre-hospital frailty triage. 

Completed PDSA cycles tested direct ambulance conveyance to FSDEC, CFS identification, consistent application of CGA activities, alternatives to ED, daily huddles and standard work.

Implementation was supported by: 

• Whole system frailty strategy 
• co-design with patients and carers,
• programme management, 
• multiprofessional development through a QI practitioner programme and education through a Frailty Academy
• measurement for improvement through a frailty dashboard 
• integrated clinical governance through joint morbidity and mortality review.

Results

• ED admissions fell by 14.2%; 
• UCR two hour response increased from 40.6% to 80.8%; 
• Time in ED for over 85s fell by 25%; 
• same-day discharge for over 75s increased by 40%. 
• Discharge within three days increased by 24%, 
• Length of stay over 28 days fell by 41%, surgical outliers by 59%, new care-home discharges by 66%, and 28-day readmissions for over 85s by 45%.

Frailty identification in the ED increased from 0% to 79% and standardised pre-hospital triage from 0% to 100%. Over 6,000 staff received training, with 87% reporting improved knowledge, skills or confidence.

Conclusion

The combination of QI methodology, building workforce QI capability, frailty education and training and a whole system approach can be used to establish the key components of an integrated pathway of care for managing frailty crisis. This can lead to sustained system-wide improvements in outcomes and the flow of older people at reduced system cost. These approaches could scaled to meet the ambition of the NHS 10 year plan