Transforming Outcomes for Older People Through an Integrated Frailty Crisis Pathway

Background: Older people with frailty frequently experience fragmented, reactive care across multiple services, leading to avoidable hospital admissions, deconditioning, and poor outcomes. Working with partners across the system, we co-designed an Integrated Frailty Crisis Pathway, across both community and acute Hospital based services, underpinned by evidence base behind Comprehensive Geriatric Assessment (CGA). This was supported by the Frailty Academy to build workforce capability. The programme aimed to reduce hospital demand, improve flow, and ensure consistent, high-quality care closer to home.

 

Approach: transformation programme was implemented using A3 Quality Improvement (QI) approach including:

- Co-designed with older people, carers, and professionals using Whose Shoes? workshops and Experience-Based Design (EBD) tools.

- A system wide frailty strategy, multi-agency governance structure and vision for joined up frailty crisis service.

- A QI programme built new services including a community single point of access (SPoA), Urgent Community Response (UCR), Hospital at Home (H@H), Frailty Same Day Emergency Care (FSDEC) unit. This created alternatives to Hospital admission.

- daily tests of change using PDCA cycles and "Big Room" improvement meetings every month.

- The Frailty Academy delivered tiered frailty education aligned with the national core capabilities framework and QI Practitioner training.

- Governance: Clinical leadership, project management, and data oversight ensured accountability at Trust, and system levels.

- Development of an integrated clinical governance processes including a acute hospital and community morbidity and mortality meetings.

- Development of a frailty dashboard to track outcomes and measure improvement.

 

Results: Service impact:

- 25% reduction in time spent in ED for over-85s and 40% increase in same-day discharge for over-75s.

- UCR two-hour response improved from 40.6% to 80.8%.

- 14.2% reduction in medical admissions for people aged 75+ via ED.

- Average LOS reduced by 15%, median LOS by 22%, and ‘super stranded’ (LOS > 28 days) patients by 41%.

- Discharges to new care home following admission to Hospital fell by 66%

-45% reduction in 28-day readmissions for over-85s.

- Estimated savings > £5 million through reduced admissions, shorter stays, and fewer care-home placements.

 

Implications: The Integrated Frailty Crisis Pathway at Royal Surrey NHS Foundation Trust transformed outcomes for older people by joining up acute and community services. Co-designed with patients, carers, and system partners, the pathway embedded Comprehensive Geriatric Assessment and Quality Improvement methods to improve safety, flow, and experience. Outcomes include a 66% reduction in care-home discharges, 41% fewer super stranded patients, and a doubling of Urgent Community Response performance. Over 1,800 staff were trained through the Frailty Academy, embedding capability and culture. This scalable model demonstrates how workforce development and co-production can deliver safer, more integrated, person-centred care.

 

This demonstrates the impact of integrated care across acute and community based services and outlines the value of teams working together towards the same vision. Our frailty strategy has been adapted by over 14 other healthcare systems in the NHS. Our methodology for change is subject of widespread interest and out dashboard demonstrating measurement for improvement principles has influenced national policy.