The aim of the Frailty at the Front Door collaborative is to improve the process of identification of frailty and the coordination of care to deliver better experiences and outcomes for people living with frailty who present to unscheduled care.  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.

There is compelling evidence to support the benefits of early and effective comprehensive geriatric assessment, re-ablement 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

Phase 1 of the collaborative was delivered between December 2017 and May 2019, we worked with 5 NHS boards to test potential approaches to improving care coordination for people with frailty who present to unscheduled acute care services. An evaluation of the first phase of the collaborative has been completed and will help inform the design and delivery of phase 2.

• This programme report gives a high level summary of the aims and methods of the collaborative approach, the work undertaken by the participating teams in phase 1 and highlights the successes and challenges they faced.
• The subsequent Driver Diagram, Change Package and Measurement plan developed for phase 2 are available here.

Following successful prototyping, the Living Well in Communities team developed the Living and Dying Well with Frailty Collaborative. The collaborative was set up in 2019 to support HSCPs to improve how they identify and enable people aged 65 and over to live and die well with frailty in the community.

• The Guidance document introduces and outlines the content of the collaborative.
• The driver diagram outlines the changes required to achieve the desired outcome that ‘People 65 and over with frailty, will experience a good life and death, including more time at home or in a homely setting’.
• This change package was a resource for teams to use during the Living and Dying Well with Frailty Collaborative. It is a toolkit containing a menu of options for improvement teams working on this topic.

Using quality improvement methods to test and implement new ways of working is important for ensuring that you learn from your tests of change and understand the impact that the changes have on:

• people living with frailty,
• the health and social care professionals who deliver care, and
• the organisations that plan and coordinate services.

The following generic quality improvement resources can be used in conjunction with the frailty specific guidance to help structure your ideas and test new ways of working.

Tools and Resources

• Quality Management System: The ihub’s Quality Management Portfolio is a new portfolio of work offering high-level interventions to support boards and partnerships enhance their quality infrastructure.
• QI Zone: The Quality Improvement Zone (QI Zone) provides information and resources to support people with experience at all levels of quality improvement to develop their knowledge.