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Establishing holistic planning and discharge for complex, frail patients

28 October 2015

By Dr Suraj Bassi, Dr Surinder Chaggar, Adrian Woolmore

The challenges around frailty

The current provision of care for frail, elderly patients is often based on a complex and siloed model of working between the multiple agencies involved, mainly from the acute, primary, community, social, and voluntary sectors. The care provided tends to focus more on the patient's medical conditions and is usually in response to a medical or social crisis. Patients enter the pathway at different levels, or may require identification in the community at a time of crisis in order to access appropriate services along the pathway. This often results in poor communication and coordination at the multiple handover points, resulting in a system not designed to treat frail patients and their needs in a holistic way.

In addition, there is evidence to show that increased length of time spent in the emergency department (ED) can result in harm, with complex, older patients more likely to be at risk. Research has shown a 43% increase in mortality at 10 days after admission through an overcrowded ED[1].

Working with Coventry and Rugby GP Alliance on delivery of their Prime Minister's Challenge Fund application, we co-developed a clinical model for frailty with leading organisations in the area including Coventry and Rugby CCG, University Hospitals Coventry and Warwickshire NHS Trust, Coventry and Warwick Partnership Trust, Coventry City Council, and Age UK. This paper shares our experience and learning from the process. 

Designing a model fit for the future

There are a number of care models and guidelines available on addressing the unique challenges around frailty. Based on our experience of designing a health economy wide frailty pathway, a number of local factors need to be taken into account when designing the future model. However, using best practice guidance and available research, some key improvements to support the existing pathways can be made to make the future model a success, and could include:

  • Early identification of frail patients in ED using care plans and inclusion criteria
  • Frailty assessment performed in the right place on a dedicated frailty unit
  • A multidisciplinary team trained to look after frail elderly focusing on rapid assessment, treatment and rapid discharge
  • Integration patient's care across primary, secondary, community and social care within the frailty unit
  • Coordinated rapid and safe discharge from the hospital through a team of care coordinators and care navigators working together
  • Proactive follow-up for stabilization in patient's home environment and early identification of patient's changing needs
  • Rapid notification and access to a frailty team where patient's condition deteriorates to help avoid readmissions. 

Achieving an effective design

There are a number of challenges that you will need to overcome during the design phase, the biggest one being to ensure that all stakeholder organizations are aligned to achieve what is best for the patients, even if from their own different perspectives. Whilst everyone wants to do their best for the patients, different organizations are under different kinds of pressures, which makes it difficult, for example to commit resources. A funding mechanism which separates health and social care provision, and even the different incentive structures between commissioner and provider organizations makes it difficult sometimes to agree to a future clinical model.

From our experience we have found the following design principles to be quite effective:

  • Co-development with organisations across the health economy, including the voluntary sector
  • Strong clinical leadership from different stakeholder organisations to champion the scheme locally and to drive recruitment
  • Use of an agile approach, starting the scheme quickly and building on the initial footprint towards the final model
  • A structured approach to design, with a series of workshops to design the operational details
  • Engagement and communication with patients and carers.

In addition, a change of this magnitude requires effective change management, including a series of financial, governance and contractual controls to support the delivery of a sustainable model.


A future scheme that overcomes the barriers which prevent frail patients from getting a timely, safe discharge from the hospital will also prevent them from getting readmitted to the hospital by supporting them in their home environment. Patients will benefit from a service model based around ongoing proactive, person-centred and co-ordinated care via care and support planning. This will enable the system to move away from organ and disease-related medical approaches towards a more integrated, holistic and person-centered model of care.

Find out more

For more information on frailty pathway redesign or help with tackling some of the challenges raised in this paper, please contact Adrian Woolmore at or Suraj Bassi at 

[1] Safe, compassionate care for frail older people using an integrated care pathway; NHS, February 2014 

About the authors

  • Dr Suraj Bassi is a healthcare management consultant and a clinician by background. He is currently working as a Principal Consultant within Capita's Healthcare Advisory team.
  • Dr Surinder Chaggar is a GP in Coventry and is the clinical lead for strategic integration for Coventry and Rugby CCG.
  • Adrian Woolmore is the Commissioning Director at Capita.




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