Discharge coordination for older people living with frailty: February 2026

Perth and Kinross HSCP and NHS Tayside were part of the Focus on Frailty programme. The programme ran from May 2023 to December 2024.

Spotlight

Perth and Kinross HSCP identified a need to strengthen the transition of care from hospital to community for older people living with frailty.

The team applied service design methodology. They undertook a discovery phase which involved:

  • process mapping the identification of frailty,
  • using the care experience improvement model (CEIM) to capture patient journey stories,
  • collecting staff feedback, and
  • analysis of baseline data on frailty identification in hospital.

They found that the acute frailty unit in Perth Royal Infirmary (PRI) had a clear pathway, they also had a process in place for frailty identification. However, they identified an increase in their seven day readmission rate. This was by reviewing data contained in the Scottish Care of Older People (SCoOP) report.

This pointed to a need to improve:

  • identification of frailty,
  • the discharge process and
  • coordination with community and primary care.

Ideas tested to address this were:

  • a discharge coordinator for all patients discharged from the acute frailty unit.
  • an electronic discharge template to communicate identification of frailty. The template shared relevant information and actions from the acute frailty unit to community health and social care teams.

Changes for impact

Leadership and culture to support integrated working

The discharge template was co-designed by staff from community and acute care. Data collection on completion rates showed compliance challenges. The team addressed this by:

  • raising staff awareness,
  • providing training, and
  • reviewing the template content.

Proactive person-centred care planning and management

  • A discharge coordinator role was tested. The role was filled by advanced nurse practitioners from the community. They coordinated the care of people discharged from the acute frailty unit.
  • The team ensured the right clinical leadership. There was oversight in place to support the integrated locality approach. They also ensured that older people with frailty were identified and key interventions to improve care were considered on discharge.
  • The median seven-day readmission rate for patients over the age of 65 was 46% prior to this test of change (February 2024). Out of the 59 patients who were discharged from the acute frailty unit and followed up by the coordinator 1.6% were readmitted within seven days.
  • The time from discharge to contact by the coordinator was also reduced from 72 to 24 hours. Data showed that patients regularly contacted other services in the interim for advice.
  • The changes were supported by a programme of staff education. This raised awareness and understanding of frailty.
  • This included simulation sessions designed by Perth and Kinross HSCP. The Scottish Centre for Simulation and Clinical Human Factors assisted and following these sessions, staff knowledge of identifying and assessing frailty improved from 5/10 to 8/10.

Transferrable learning

  • Take time to understand your system to target efforts effectively. Do not make assumptions about what needs improvement.
  • Patient experience data is valuable in designing and evaluating changes.
  • Study the difference that change ideas make to ensure timely adaption and long-term sustainability.

Further information

More information and updates are available on our webpages.   

To find out more about Perth and Kinross HSCP and NHS Tayside’s approach, email: his.frailty@nhs.scot.

To join the frailty learning system, you can also email us: his.frailty@nhs.scot.

Further reading