1. Frail Older People Co Chairs Maura Devlin and Dr April Heaney Engagement through a workshop with a wide range of stakeholders Key priorities areas identified

2. Frail Older People Issue Minimise inpatient transfers Ensure safe appropriate discharge from hospital No discharge or non medically indicated transfers after 8pm without the agreement of the individual or family. The need to improve information provided from nursing homes when patients are transferred to hospital. Ensure prompt assessment by nursing homes to facilitate discharge. Action CMO/CNO letter Agreement on minimum data set for discharge CMO/CNO letter HSC Safety Forum development of a Transfer Form currently being rolled out. RQIA reissued letter to Nursing Homes

3. Frail Older People Priorities Appropriate care of the frail older person at home Early identification of frailty in the community with triggers that prompt comprehensive geriatric assessment. Targeted interventions on falls, dementia and polypharmacy Timely access to primary care including out of hours and access to shared records. Further development of admission prevention models, rapid assessment and assessment for admission rather than admission for assessment.

4. Frail Older People Priorities Acute Hospital Care Early decision making in the hospital setting. Liaison in reach to the frail older person in a medical or surgical unit 7 day working across all disciplines with early supported discharge Dedicated older persons transport for discharge and diagnostics

5. Frail Older People Priorities Rehabilitation /Re enablement after acute illness Enhanced use of home enablement models, step up/step down. Support to nursing homes regarding managing higher level nursing needs and associated training requirements, end of life planning, consultant/MDT in reach, medication reviews etc Standardise enhanced training for nursing home staff, eg management of sub cut fluids, catheter insertion. Review of nursing home assessment process Regular Medical review of residents in Care

6. Frail Older People Priorities End of Life Care Agree triggers to advanced care planning Establish a process to identify people in their last year of life Review documentation and communication for advanced care planning

7. Keeping momentum.....shared learning South Eastern Trust Population: Older Adults over 75 Purpose: Improve wellbeing, health and social care experience and outcomes. Focus: Enabling older people to be cared for at home East Belfast Integrated Care Partnership Population: Older Adults over 65 Purpose: Right care, right place, right time Focus: Acute care at Home