Integrating care for frail older people in Northern Sydney – an implementation journey

1. Frailty is a common syndrome affecting 25% of the population aged 70+ in Australia, equating to approximately 26,000 people residing in Northern Sydney. People living with frailty have 2-3 times the healthcare utilisation and poorer outcomes in hospital compared to their non-frail counterparts.2. Sydney North Health Network is working collaboratively with Northern Sydney Local Health District, health professionals and consumers, to co-design and implement targeted interventions to identify and reduce frailty, avoid inappropriate hospital admissions and improve health outcomes for our elderly population. Phase one includes delivery of education and support to health professionals, to increase understanding and implementation of:• The concept of frailty• Appropriate screening using the FRAIL scale• Preventive and reablement management plans in primary care.This included consultation with clinicians and consumers to understand existing knowledge and screening practices, co-design of resources, including protocols to support handover of care and development of pathways to support appropriate referral and management.Phase two will identify service gaps in the community and develop a co-commissioning strategy to shape service delivery to meet local need.3. Implement recommendations from the Asia Pacific Clinical Practice Guidelines for the Management of Frailty.4. The target populations for phase one are health professionals from primary care, community and acute settings.5. Phase one, 2 years. Phase two, 3-years.6. Education and awareness events were implemented in both settings:- 82 LHD health professionals and 79 general practice and allied health professionals have participated to date. - 53 general practices have received intensive, in-practice training on use of FRAIL scale and resources available to help them navigate service and management options. A trial of screening has been implemented in 2 acute hospitals. Screening of 387 patients identified high prevalence of frailty and pre-frailty (82-93%)Screening results and management plans have been included in patient discharge summaries to improve handover to primary care.7. Primary care is most likely the more appropriate setting to continue screening on an ongoing basis and likely to yield more sustainable, long term results, particularly on hospital avoidance.8. This framework includes a multi-disciplinary team approach to care and encourages screening at any point during the patient journey, in any care setting.9. Screening for frailty and implementing management plans to improve patient outcomes is possible in both the inpatient and community setting.Further data is required in primary care to measure impact and outcomes.10 & 11. Hospital screening is feasible, but capacity for intervention is limited. With some patients receiving appropriate intervention in hospital, aiming to prevent deterioration, analysis in progress will confirm impact and gaps.A vendor has been engaged to develop a screening app that integrates with GP clinical software systems, to support data collection in primary care.Next steps include:- development and implementation of primary care data app- follow up with general practices, to gauge acceptance of interventions and tools provided- utilise data from screening and mapping of community services to inform development of commissioning strategy.