Teams should be willing to apply quality improvement methodology and work towards improving services by committing to delivering at least one of the following programme aims.
1. Proactive community services to support people to live well in the community and avoid hospital admission
Aim:
By March 2027 at least 10% of people aged over 65 will have a documented Rockwood Clinical Frailty Scale (CFS) assessment recorded in the relevant clinical system, and those identified as living with frailty will be included on a frailty register*.
*A frailty register is a list of people over 65 who are living with frailty. This can include a list of people who are on a community team’s caseload.
Example interventions:
- Learning about the Clinical Frailty Scale.
- Frailty identification.
- Recording frailty on the clinical system for community.
Aim:
By March 2027 70% of older people with a Rockwood CFS score of 5 or above will have evidence of proactive support in community settings within the past year.
Example interventions:
- Functional assessment (mild to moderate frailty).
- Medication or polypharmacy review (moderate frailty).
- Future care planning conversation updated on the Key Information Summary (moderate to severe frailty).
- Onward referral to appropriate community services (for example social care, falls prevention or Allied Health Professional (AHP) teams, reablement, community nursing, hospital at home).
2. Acute hospital frailty services
Aim:
By March 2027 acute hospitals will increase discharges within 72 hours for people living with frailty by 10%, through early identification of frailty and initiation of comprehensive geriatric assessment.
Example interventions:
- Agreed frailty pathway.
- Identification of frailty at the hospital front door.
- Access to specialist frailty team.
- Comprehensive Geriatric Assessment.
- Medication/ polypharmacy review (all levels of frailty).
- Future care planning conversation updated on the Key Information Summary/Treatment Escalation Plan (moderate to severe frailty).
- Multidisciplinary team (MDT) huddles.
- Care co-ordination and proactive discharge.
3. Integration and pathways between community and hospital
Aim:
By March 2027 sites will have improved admission avoidance and hospital discharge pathways through integration between community and acute teams.
Example interventions:
- Links to community services (for example social care, falls prevention or AHP teams, reablement, community nursing, hospital at home).
- Care co-ordination and proactive discharge.
- Professional to Professional.
- Links to community pharmacy with ongoing polypharmacy review.
- Rapid access clinic slots/ community MDT.
- Step up/ step down and hospital at home referral pathways.
- Ongoing future care planning conversation updated on the Key Information Summary (moderate to severe frailty).
Get involved
Applications to join the Focus on Frailty programme are open until close of play 13 March 2026. Visit the Get involved webpage to apply.