Signal of reduced length of stay for people living with frailty (NHS Greater Glasgow and Clyde).

South Ayrshire HSCP and NHS Ayrshire and Arran

• The Electronic Frailty Index (eFI) is being used in one GP practice to identify individuals living with frailty who are suitable for a wellbeing review carried out by an occupational therapist. The team plan to spread this service to other GP practices in South Ayrshire.
• A frailty training package has been developed to increase knowledge of frailty among home carers. The aim is to increase identification of frailty related issues and facilitate timely interventions.
• Patients with long term conditions and respiratory care needs who are restricted to their homes are reviewed by a specialist district nurse. A frailty assessment using the Rockwood clinical frailty scale and CGA is completed and Future Care Plans are initiated and uploaded to the Key Information Summary.

• A Grampian wide frailty network has been established. This has led to the development of frailty plans for each health and social care partnership which cover acute and community care.
• There has been a focus on improving links between the emergency department and Discharge Liaison Nurses in Dr Gray’s Hospital Elgin.
• Self-assessment questionnaires have been issued to people who attend seasonal immunisation clinics. These highlight signposting and engagement opportunities for people living with frailty who may benefit from preventative support.

• The latest data shows an increase in the percentage of people aged over 75 who are screened for frailty at the front door.
• The data also shows a signal of reduction in the length of hospital stay for people identified as living with frailty.
• The team began testing CGA huddles in February. They include community-based frailty and social work professionals.

• The latest data shows an increase in the number of people identified as frail across three hospital sites.
• University Hospital Monklands focus is on reducing the time it takes for people with frailty to reach the Frailty Assessment Unit.
• University Hospital Wishaw are testing a frailty roving team in the emergency department.
• University Hospital Hairmyres has established a dedicated frailty unit.
• The team have established a multi-disciplinary frailty network which supports a whole system frailty approach.

• An ageing well toolkit is in development with support from Public Health Scotland and the Right Decision Service at Healthcare Improvement Scotland. This is for health and social care staff to inform and educate the public on ageing well.
• Level two British Geriatrics Society frailty training and Rockwood clinical frailty scale training is in progress for staff in a community rehabilitation and reablement home team.
• Testing of a pre-admission call between community health professionals and geriatricians has started with two care homes and one community hospital. The aim is to reduce unnecessary hospital admissions.

• Testing the role of discharge coordinator for people living with frailty. This is currently an advanced nurse practitioner with the team planning to consider the suitability of other posts taking on this role including community-based locality integrated care service nurses.
• Trialling an electronic discharge document template co-designed with the frailty unit and local GPs. It aims to improve the quality of information sent to GP practices.
• Frailty awareness and simulation sessions designed and run by the team have been well received by staff.  They team were supported by the Scottish Centre for Simulation and Clinical Human Factors.