There is compelling evidence to support the benefits of early and effective comprehensive geriatric assessment, reablement and intermediate care for people living with frailty. However, optimal outcomes are only achieved when community health and social care services and hospital systems are fully aligned, well-coordinated, and care and support are attuned to the specific needs of people living with frailty.

The aim of this collaborative is to improve the processes of identifying frailty and coordinating care to deliver better experiences and outcomes for people living with frailty. While this specific work is focused on the front door of acute care, it is driven by an approach that recognises the importance of thinking about flow across the whole system. Getting the care pathway right for older people and people living with frailty in acute care has a wider impact on the whole system.

The 5 sites taking part in this collaborative programme, which runs from December 2017 – May 2019 are:

  1. Greater Glasgow and Clyde – Queen Elizabeth University Hospital
  2. Dumfries and Galloway - Dumfries and Galloway Royal Infirmary
  3. Forth Valley – Forth Valley Royal Hospital
  4. Lanarkshire –Monklands Hospital
  5. Lothian – St John’s Hospital

The collaborative aims to work in synergy with the ihub’s Living Well in Communities portfolio, Scottish Government’s National Unscheduled Care Team and Integration Authorities to support improvements across the pathway. Taking this integrated approach to improvement will maximise opportunities to improve quality, experience and flow while contributing to the aims of the Health and Social Care Delivery Plan.

Driver diagram

For more information, please contact the acute care team email: hcis.acutecare@nhs.net