Abstract
Introduction: Frailty is a clinically recognized condition characterized by increased vulnerability due to age-related decline across various physiological systems, leading to reduced ability to cope with daily and acute stressors . Managing frailty requires a person-centred approach, involving patients, families, and caregivers, and utilizing evidence-based practices such as Comprehensive Geriatric Assessment (CGA), delivered by specialist multidisciplinary (MDT) teams. Research indicates that older individuals receiving CGA are more likely to be alive and living independently at home six months after an acute illness. To support the development of Older People’s Services, a review of the service model was conducted to deliver a rapid access service for patients referred by general practitioners (GPs). This service aims to avoid emergency department (ED) visits while providing necessary CGA assessments. Method: The initiative involved creating a direct referral option within the GP’s electronic referral system (Clinical Commissioning Group), developing a standard operating procedure for the triage process, establishing an education process for staff to clarify roles and responsibilities including data collection, and scheduling MDT members for triage support. Results: Following the implementation of the agreed procedures, there was a notable improvement in scheduling urgent GP referrals within three days. A daily referral system with live triaging was established, along with daily post-clinic MDT meetings. The backlog of urgent GP referrals was cleared. This successful system was replicated using Plan-Do-Study-Act (PDSA) cycles to integrate ED referrals. Conclusion: Collaborating with a team whose values aligned with Health and Social Care (HSC) principles—working together, striving for excellence, openness, honesty, and compassion—was a rewarding experience. The project provided valuable learning opportunities in team-building and service development. The success of the GP referral system was also leveraged to expand the service to other areas, such as ED referrals, demonstrating effective duplication of successful strategies.