1. Acute Frailty Intervention Team

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

3. 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

4. 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.

5. 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.

6. Weekly referrals by GP practice

7. Referral by source

8. Discharge outcome

9. Patient experience

11. 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

12. 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

13. 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.

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