Acute Frailty Intervention Team

Aims To provide a timely, effective multi-disciplinary community based response to patients presenting with decompensated frailty syndrome.

Anticipated outputs Create a mobile triage team to provide rapid on site triage for illness and assessment of needs Triage team created comprising Band 4 SCAS technician and band 4 Associate Practitioner. Creation of a frailty Hotline at LNFH Frailty Hotline manned by Consultant Geriatricians, Consultant Practitioner and GPs Provide on-going support and care for the duration of decompensation Provided by the triage team, frailty GPs and Consultant Practitioner with onward referrals to the ICT as required. Provide a comprehensive geriatric assessment Completed by GPs, registrars and Consultant Geriatricians

Anticipated Outcomes Allow older people with frailty to access the support they need Referrals made to relevant services as identified but main input has been education regarding their medical situation and support to manage their own social situation To avoid delays, hand off, recurrent triage and waiting times for different services. Identification of the correct clinical pathway reduction of duplication. To provide immediate clinical triage & assessment Provided by the band 4 and Hotline clinician To keep Common Care record for the period of decompensation and after CGA Mostly achieved through our own determination, not by IT systems.

Anticipated Outcomes To de-layer the traditional primary care/secondary care interface AFIT sits comfortably across primary care and secondary care services but has also bridged across into SCAS To improve General Practice sustainability Acceptance of complex individuals has released GP time To improve general practice retention ? To reduce hospital admissions in the short term 61% of our referrals have not been admitted, also contributing to the development of SCAS PMPs.

Weekly referrals by GP practice

Referral by source

Discharge outcome

Patient experience

Where are we now? Recruitment 2 more Consultant Practitioners recruited 3 band 6 frailty practitioners SCAS are recruiting 5 more band 4 technicians Admin co-ordinator in post Recruitment remains a challenge in the Forest

IT systems RiO is being altered to capture clinical outcomes On-going challenges with using numerous systems We are benefiting from other developments with The Practice at LNFH

Training and Education Developing SCAS technicians to complete the triage assessment as a solo responder. Developing the role of the frailty practitioner. Developing a proactive service to residential nursing homes to empower them to manage frailty syndromes effectively. Supporting and educating community colleagues to recognise and manage frailty.

Hindsight is 20:20 Project management HR support Equipment Training and education IT systems