Respond to respond appropriately to needs, goals and priorities that have been identified as part of the CSP approach (‘actions and review’), the following should be readily available in local health and care systems to prevent and support people, carers and families living with frailty:

  • Healthy ageing and caring approaches with signposting to keeping active, engaged and independent, including access to frailty friendly living and homes.
  • Community connectivity with access to and involvement of the Voluntary, Community and Social Enterprise sector.
  • Specific, tailored support for Long Term Conditions, including supportive self-management and shared decision making to develop a self-management plan (with contingency planning), to optimise:
    • falls and immobility,
    • medicine /polypharmacy and
    • mental health.
  • Access to specialist interagency teams for a comprehensive geriatric assessment [CGA] and case management including the development of an emergency health care plan to coordinate care and optimise;
    • nutrition and hydration,
    • bowel and bladder care,
    • vision and hearing,
    • cognition and dementia care, and
    • end of life .
  • Access to community crisis and recovery services (with active recuperation, rehabilitation and reablement) including:
    • frailty-focused transport and
    • timely transfers of care from hospital, involving carers and families.
  • Access to experts offering frailty-based care in hospital with frailty assessment, diagnostics and pathways.