Timely Access to Experts


Timely access to experts offering frailty-based care in hospital with frailty assessment, diagnostics and pathways.

Hospital care requires a caring frailty environment that allows for front door recognition of frailty, followed by Comprehensive Geriatric Assessment and best practice care for frailty syndromes (falls, immobility, incontinence, polypharmacy, delirium), together with early inter-agency planning for discharge home to optimise care and prevent hospital related complications and deconditioning.

The following are examples of what to consider when thinking about developing specialist frailty care, pathways and services within the hospital setting.


  • Expert decision makers are available at the front door of the acute hospital from 8am to 8pm, seven days a week.
  • Specialist assessment should be available within 12 hours of admission, seven days a week (ideally, proactive identification of frailty within 4 hours).
  • The presence of one or more frailty syndromes should trigger a comprehensive geriatric assessment.
  • Sufficient specialty and community hospital beds to look after all frail older patients with complex needs and enough relevantly trained staff to deliver high-quality care and assessment for them.
  • Employ ‘trusted assessment’ to identify those who will benefit from intermediate care.
  • Strategies to reduce avoidable unexpected mortality should be in place – warning scores, critical care outreach, regular senior review and adequate access to high dependency beds.
  • Hospitals make safer care for older people a key priority – prevention and treatment of falls, pressure sores, hospital-acquired infection, medication errors, deep vein thrombosis and malnutrition, delirium and immobility as a result of bed rest.
  • Minimising in-patient moves for those older people identified as frail especially those with delirium.
  • Liaison and in-reach services for frail older people under other medical and surgical specialities including psychiatric services (e.g. dementia and mental health problems).
  • An identified Frailty Unit/Service may be considered and desirable with staff trained in how to look after frail people focusing on rapid assessment, treatment and rapid discharge.
  • Adequate and timely information must be shared between services whenever there is a transfer of care between individuals, carers (paid or unpaid) and services.
  • The recognition of carers (formal and informal) as crucial parts of the team.
  • Advice on appropriate housing and adaptations.


N.B. Many of the resources in the previous section are also relevant here. 


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