Frailty Specialist Service Redesign

Short Title Increase the number of 0 day discharges
Category Living with frailty (mild / moderate)
Organisation Hampshire Hospitals NHS FT
Contact Name Alison McGinnes
Contact Email
Web Link
Sector Hospital/Acute Care
Region Hampshire
Postcode RG24 9NA
Active Yes


Patients over 75 often with complex co-morbidities are not getting access to specialist geriatric assessment and care planning early enough across HHFT. As a result some are being admitted unnecessarily or staying longer than they medically require. They are subject to multiple moves, multiple assessments and significant levels of deconditioning. This can have an adverse impact on patient outcomes.

Organisationally this causes delayed transfers of care, increased bed occupancy and puts significant pressure on the available bed capacity across the trust. This situation is no longer sustainable.
At BNHH we will aim to increase the number of 0 day discharges for frail patients by September 2019.

Frailty refers to patients with 1 or more of the 5 frailty syndromes: falls, immobility, delirium, incontinence and polypharmacy.
Key Principles
• 24/7 pathway for frail older patients
• Earlier specialist intervention
• Comprehensive multidisciplinary assessment in an appropriate environment
• ‘Home first’ principle
• Prevention of deconditioning
• Integrated model in collaboration with community partners (SHFT)
• Increase the number of frail patients being seen in emergency department.
• Reduce the time taken to recognition of frailty diagnosis
• Reduce the time taken to initiation of CGA by a further 50%
• Reduce the number of over 75yrs admissions by 10% within 1 year
• Increase patient/carer satisfaction with regards to frailty pathway


Results of this project will be shared following completion

« Project Map« Healthy Ageing Line« Project List