1. Frailty identification and management
North Sydney Local Health District and
Sydney North Primary Health Network
Cynthia Stanton: General Manager, Primary Care Advancement & Integration SNPHN
Chanelle Stowers: Integrated Care and HealthPathways Redesign Project SNPHN
Lyn Olivetti: Service Development Manager: Chronic & Complex Medicine, Rehabilitation & Aged Care NSLHD

2. Problem Statement
Frailty is a common syndrome effecting 25-27% of the popn aged 70+ (approx. 35,000).
It is associated with vulnerability and poor health outcomes. Frail older people have increased risk of falls, longer length of hospital stay, decline in function, increased chance of institutionalisation, and death
Early identification and targeted intervention can reduce frailty, avoid inappropriate hospital admissions, and improve health outcomes for people who are frail.

3. Mission
We will work together with patients and providers to ENABLE…
ONE PERSON (AND THEIR CARER/S) Supported by people working as ONE TEAM From organisations behaving as ONE SYSTEM

4. Aim and Objective
Aim: To optimise the wellness of (socially isolated/older) people who are frail in the Northern Sydney region.
Objectives:
Work as one team to deliver supporting and integrated care
Reversal of frailty in some cases
Reduced adverse patient outcomes whilst in hospital
Increase hospital avoidance
Reduced length of hospital stay
To increase patient satisfaction with health delivery system

5. Analysis

6. Approach
Aligned with current evidence and the 2017 Asia Pacific Guidelines:
Implementation of a simple screen to identify frailty (FRAIL Scale) in
Acute care, ED
Hospital Inpatient
Primary Care
Enable referral to relevant management options;
Physical activity plan
Address polypharmacy
Nutrition plan for weight loss with appropriate supplements
Addresses self reported exhaustion
Vitamin D deficiencies

7. Diagnostic Phase Actions
Socialise the idea with stakeholders
Community needs assessment
Define scope (eg, socially isolated)
Establish project governance group
More robust data analysis to inform problem definition
Community (and provider) engagement
Source patient stories
March
2018
Diagnostic Phase
July 2018
Implementation Strategy
Value Case
Agree Vision and mission
Communication Plan
Evaluation Framework
Ensuring mutual
October
Implementation

8. Timeline April – May 2018 July 2018 Aug-Sep 2018 Oct 2018 Dec-Jan 2019
Diagnostic
Value Case, agree vision, mission and strategy
Communication & generate support
Pilot
Evaluate impact
Refine
Scale
April – May 2018
July 2018
Aug-Sep 2018
Oct 2018
Dec-Jan 2019
Feb 2019
March onwards 2019