Front door frailty: Advice on setting up services

Introduction

Front door frailty services (FDF) exist to identify people living with frailty as soon as they present to a hospital, to ensure that they are diverted to appropriate services as quickly as possible and, ideally, to ensure they are discharged to their normal place of residence (home or care home) the same day. Evidence suggests that these services benefit older patients as well as reducing pressure on hospitals. They have had a positive impact everywhere they have been introduced.  

There is no ‘right way’ to do front door frailty – models vary depending on the staff available, the geography of the local area, the needs of the population and the hospital estate. In this document, we aim to summarise what these services might look like and provide practical tips to colleagues looking to establish front door frailty services. This document has been developed by a BGS clinical fellow through research and discussion with colleagues working in established and new services. It is intended to support healthcare professionals in setting up new front door frailty services and making a business case to managers.  

This document is not a ‘how to’ guide for front door frailty services. Rather it uses the experiences of others to set out some principles to guide those wanting to improve the experiences of older people at the front door of the hospital. This document comprises three sections. The first section sets out why front door frailty services should be prioritised and why we need to focus on people living with frailty. The second section suggests five principles to guide people looking to set up front door frailty services with advice from colleagues around the country who work in established services. The third section includes take-home tips intended to help and inspire those wishing to establish these services in their localities. 

Who is this resource aimed at? 

It is widely accepted that there is significant variation in FDF practice related to hospital design, local geography, population demographics, and healthcare provision. The impact of the COVID-19 pandemic on service development and redeployment of staff affected FDF service delivery at many sites. Mirroring an established service may therefore be inappropriate due to these variations. Services need to be customised to each locality and this toolkit will focus on the principles of establishing a front door frailty service. It is aimed at clinicians whose FDF services are in their infancy, those struggling to develop new services or those whose FDF services have stagnated in their development and who are looking for further ideas and inspiration. 
 

2. Principles for setting up a service

We have identified five principles that those wishing to establish FDF services should follow. This section details these principles and shares tips from sites that have established services. 

Principle one: Prioritise the development of the service  

To establish an appetite for change in our complex healthcare system, space and time are needed to allow for this to develop. Focusing on patient flow and early discharge can help to embed this change. Without this focus, patients are more likely to have long hospital stays and, consequently, poor outcomes. Prompt decisions and interventions can reduce the risk of patients getting stuck in hospital, and if you get it right first time you can reduce the bed base downstream. Focusing on flow can demonstrate the impact that senior healthcare professionals with expertise in frailty can make at the front door and create a common narrative with management to support this change. Hospital management teams need to understand the clinical impact that a FDF service can offer, and the interventions that are needed to fulfil the wider aims of the organisation whilst also serving the needs of the individual patients. Involving an Improvement Manager can enable project oversight, expertise and maintain the momentum of improvement.  

Development of a Standard Operating Procedure (SOP) enhances the transparency of the service that is being provided and reduces variation in its delivery. To mitigate concerns over a change of service model, small, measured tests of change, with appropriate permissions and governance, can help to predict the impact of the change. 

Top tips from the development journeys of experienced sites: 

• Start somewhere, start small. Don’t be disheartened if it doesn’t seem possible to get a service fully operational from the outset.  
• Establish a clear vision:
  
  • e.g. every patient to leave in a better condition, and to add value with every interaction.
• Include timelines and goals to maintain sustainability of funding streams. 
• Establish what is the demand or gap in the current system:
  
  • e.g.  time to complete CGA, bed moves or length of stay. 
• Complement services already in place, avoid duplication of work. 
• Get all key stakeholders involved for a collaborative approach, including the executive team to ensure all are aware of current policy drivers and understand the expectations from management.  
• Support the change and evolution of the service with enthusiastic and dynamic staff, from its conception and throughout the development. 
• Use funding opportunities or availability of physical space as a lever for change. 
• Be curious. Embrace ongoing learning from long stay patients or community service relationships to further develop patient selection for frailty service input and timely discharge. 

Principle three: Map your organisation and consider intervention points 

As there is significant variation in population, hospital design and workforce across the country, there are a range of approaches and models being used for FDF. Ideally a front door service should remain geographically close to admission areas to ensure good communication and complement processes already in place. A collaborative design method is needed to establish a service that is suitable for the local demand. In this section we outline some of the key components of FDF services, regardless of model used. 

Preadmission  

Silver phone or Consultant Connect: Connecting community services with specialist frailty secondary care advice facilitates an expert assessment of the patient’s needs. This optimises their care by community-based interventions or scheduled secondary care review using services such as Same Day Emergency Care (SDEC). As patients with frailty are often conveyed to hospital by ambulance, this is a sensible point of intervention and would aim to avoid hospital attendance where possible. This system is run by a frailty team usually managed by a geriatrician working on a frailty or SDEC unit or as part of a service providing frailty expertise to EDs (known as frailty in reach). 

Example: An ambulance team were sent to an older patient who has fallen in their home. The paramedics are able to establish no injuries requiring immediate hospital conveyance but recognise the immediate falls risk. Paramedics are then able to refer to a frailty team who schedule falls follow up review, avoiding unnecessary admission. 

Front door hospital attendance

Frailty services working within the ED can facilitate proactive rather than reactive patient reviews and prioritise getting the right patient to the right team as quickly as possible. Frailty services should focus on identifying those with complex needs that the ED does not have the capacity to address. Unwell patients with frailty often require more comprehensive and joined-up management. Prioritising patients who have recently been discharged from geriatric medicine wards or patients attending from care homes can be effective as these patients can often be managed by the FDF service and it is more likely that admission can be avoided and prearranged social care can be maintained. 
There has been concern over the impact of FDF services on the four-hour wait limit in EDs. Trust needs to be built up using data that demonstrates that services can have a positive impact on admission avoidance and ED workflow. Collaborative design of services is needed to ensure that services operate successfully. We have outlined below two of the common designs for FDF services: 

In-reach or liaison work 

This is the method most used for initial scoping work of front door frailty services, for example a limited service to prove concept. Rapid reviews taking place at ambulance arrival can enable early commencement of CGA to limit the risk of deconditioning from the point of arrival to hospital and provide an increased opportunity to discharge without an increase in care needs. Many sites have promoted the role of Advanced Clinical Practitioner (ACP) alongside therapy teams to support the ED with identification of patients who are able to be managed in the community with simple interventions. They can initiate a CGA independently with close support from a geriatrician and enact referral to community services. These teams have also been able to develop specific pathways for common conditions affecting older patients with frailty such as fracture, loss of independent mobility or falls with head injury. This can enable rapid structured assessment for potential community management. In-reach teams can also review patients who have been deemed appropriate for admission and are awaiting a bed to identify those who could instead be diverted to frailty units or SDEC. In-reach teams can also work as mobility assessment teams for more straightforward reviews, to complement the work in the frailty unit. 

Some advocate this approach and feel it reduces potential inequalities in patient care as teams can go to the patient without reliance on hospital flow. A roving service may enable more patients to be seen, delivering SDEC as a process not a place. However, concern has been raised over focussing all resources on the front door. Covering large areas of the ED and admissions can spread the team and dilute MDT efficiency.  

Frailty ED space  
Creation of a dedicated space to review patients with frailty within the ED can enable the MDT to work more effectively. It can provide two-way learning opportunities and upskill the teams to pick up on subtle presentations through repeated direct collaborative working. Patient selection can be through ED admission screening for case identification. However, some have found that moving to a designated space can interrupt investigations initiated by the ED and remaining within ED can facilitate rapid onward referrals.  

SDEC or frailty unit 

As with the frailty ED space, a frailty or SDEC unit can provide the designated area for rapid MDT working and can develop from proof-of-concept projects. Many Frailty Units function with dual purpose: to provide an assessment SDEC area as well as a bedded frailty area for those who are likely to require admission and need a proactive approach. This co-location enables sharing of the MDT resource and the ability to take a bigger spectrum of patients with frailty. These units are designed as a more suitable location for assessment of patients with frailty, for example providing space to wander and a calmer environment to that of ED, alongside staff who have the skill set to manage patients who may have cognitive impairments. The SDEC space can also be used as a ‘hot-clinic’ for scheduled reviews through an admission avoidance pathway, although ensuring this maintains rapid access is 
a priority. 

Intentionally reducing the number of trolley spaces can encourage mobility and reduce deconditioning. Scoping projects are needed to understand the levels of patient capacity needed to enable the unit to work effectively, and to gain an appreciation of estimated frailty SDEC admission rates. An initial high admission criterion (e.g. Clinical Frailty Scale [CFS] score 6 or greater) may be needed to ensure a deliverable service, balanced by a caution that this may limit its impact. Units must ensure that patients maintain equity of access to emergency inventions and specialty opinions, regardless of where they are cared for. Expansion of increased service hours should aim to match the demand of frailty presentations and potential same day interventions achieved.

The availability of a senior decision-maker close to the front door can enable frailty teams to review more complex and unwell patients. There is clear evidence of the benefit a timely review can have on patient outcomes.⁴ Senior decision-makers are also necessary to provide oversight of the ED and SDEC caseload and therefore maintaining patient flow. Continuity of senior decision-makers is also beneficial as it enables proactive management. Some established sites have noted variability in service delivery due to consultants’ different approaches to tolerating risk within the acute geriatrics setting. A clear standard operating procedure (SOP) or review template is essential to ensure a unified approach to risk. 

Patient-centred practices have encouraged some sites to have a rolling take rather than formal post-take ward rounds at a specified time. Having touch-point meetings (huddles) throughout the day encourages proactive working. Timing of these meetings is important to ensure actionable interventions on the same day. Follow-up work through phone calls or community interface interventions such as virtual wards can help to facilitate early supported discharge. 

Some established services have raised concerns about the risk of lack of flow and exit block when creating a designated frailty unit space. For an SDEC unit to function effectively, proactive flow management and ring-fencing of beds is required during development of the service.  

Community and interface teams 

Knowledge of the available community services and the funding and management streams that dictate them is essential to enabling FDF services to connect with community care. Creating an open dialogue and involvement in service development furthers integration of services. Geriatrician engagement with interface services facilitates further community linkage and supports two-way learning across the MDT. There is added complexity when the hospital catchment is supported by multiple community providers, so services can vary depending on locality. 

The lack of social care in the community remains a problem across the country, contributing to avoidable hospital admissions and delayed discharge. In the short term, supporting families to assist with care needs may help to reduce these admissions and support early discharge. This however relies on patients having families who are willing and able to provide care, and it risks exacerbating inequalities.  

Early supported discharge can be assisted through: 

• Virtual Ward or Hospital at Home teams. 
• Discharge to assess pathways. 
• General practitioners with specialist interest (GPwSI), who can support the proactive workstreams of community frailty interventions, alongside care home reviews and proactive patient discussions.  
• Local Age UK branches and other voluntary service providers such as the Royal Voluntary Service, who can provide support, e.g. welfare calls. 
• Community Specialist Nurses e.g. Heart Failure or Respiratory Specialist Nurses. 
• British Red Cross, who offer discharge support e.g. getting the home ready. 
• Hospice at Home provision, with pathways in place to ensure seamless patient referral when needed. 
• Community Geriatricians, to develop connection of services. 
• Silver phone or Consultant Connect services. 
• Rapid access CGA clinic.  
• Community hospitals. 

Other pathways

There are other hospital-wide pathways that focus on supporting our patients with frailty including perioperative pathways, delirium discharge pathways and reducing deconditioning pathways. Those working in FDF services should be aware of these pathways in their locality and build relationships to ensure ease of access for appropriate patients. 

Principle five: Build relationships and plan the workforce 

Relationship-building 

A priority of developing a FDF service is building relationships between departments and services currently managing people with frailty. These can include emergency medicine, acute medicine, hospital managers, community services and social work. Working together encourages learning from each other and creates opportunities to upskill colleagues in frailty identification and care. Experienced sites recall difficulty starting the process within the ED and acute medicine, and report that this difficulty was overcome by building relationships and gaining trust, thus enabling the service to progress. 

Frailty team workforce 
CGA requires MDT working to be delivered effectively and the required workforce staffing can demand change from traditional models of secondary care provision. The challenge now is how to support and empower the MDT to deliver this care. Touch points or co-location of staff encourages effective MDT working. Staffing gaps need to be identified early with proactive recruitment, alongside MDT roles being defined to ensure the right people are performing CGA. 

Top tips for workforce planning: 

• Advanced Clinical Practitioner (ACP) and Consultant Practitioners:
  
  • Develop a culture of supporting nurses and therapists to progress into ACPs or Consultant Practitioners.
  • ACPs typically develop from nursing or therapy roles working closely with senior decision makers. These progression routes to ACP and Consultant Pracitioner grades create a method to retain and increase the impact of experienced clinical nurse and therapy resource rather than experienced staff moving into managerial positions. 
  • Investing in these roles and encouraging individuals to develop in this way has resulted in many sites seeing a lower turnover of staff. It is important to ensure appropriate pay banding for their skill level and contribution to the service. 
  • ACPs can provide consistency to service delivery and help to educate rotational junior doctors. 
  • ACPs often coordinate and run FDF services and are skilled at managing protocol and medicine delivery. 
  • Some individuals considering an ACP role may appreciate the opportunity for a secondment before taking a post.  

• Senior decision maker, e.g. Geriatrician: 

  • This enables rapid input to patients with increased complexity. 

  • Enthusiastic clinicians, with an interest in acute frailty, are required to move to the front door to make these services work. Back fill for the roles left vacant is essential to ensure patient flow is not impacted. 

  • The on-call requirements need to be considered e.g. General Internal Medical (GIM) take – working out which patient cohort will have already been seen to avoid duplication and create a successful job plan. 

  • A lack of available geriatricians can hamper service development. Established services encourage use of the wider MDT but highlight the need to maintain geriatrician input in FDF work. 

• Other senior decision makers e.g. ED/acute medicine clinicians/General Practitioner with Special Interest (GPwSI): 
  
  • Build on the workforce delivering the service. 
  • Further the development of relationships between services. 
• Therapists:
  
  • Encourage role blurring of therapists, to enable a specific dedicated frailty MDT at a FDF generic functional assessment. This allows for more robust services as it can be provided by all therapists involved. 
• Front door social worker liaison role: 
  
  • This role provides a connection to community services, care homes and the community hospital bed base to facilitate priority discharge and can help to keep care packages and placements open when patients are admitted for a short time. 
  • A discharge co-ordinator role also enables liaison with relatives to alleviate concerns about early discharge and can offer a safety net though a follow up phone call. 
• Further subspeciality liaison: 
  
  • Mental health and behavioural and psychological symptoms of dementia (BPSD) management.
  • Palliative care and hospice at home identification.
  • Specialist Frailty pharmacist 
  • Emerging roles for speech and language therapists (SALT) and dieticians at the front door.