As part of a wider group (looking at end to end system wide Frailty Pathway) we have begun working on an acute frailty pathway to implement early identification (screening at front door) and holistic overview assessment (CGA) to identify key risk and needs and facilitate timely discharge and handover of care to the most appropriate community teams. The programme is reviewed and modified through a PDSA cycle.
Ongoing implementation however at this stage the data is encouraging. Increased compliance with screening at front door, opportunities identified and actions taken to prevent admission, increased implementation of anticipatory care plans etc.
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