Abstract
Introduction
The Frailty Network, initiated in November 2023, aims to enhance care for frail patients through multidisciplinary collaboration across acute and community settings. By fostering partnerships with Health and Social Care teams, GPs, district nurses, and third sector organisations, the Network strives to provide realistic and patient-centric improvements in Lanarkshire. The initiative focuses on proactive, personalised, and coordinated support to help frail older adults maintain independence and well-being.
Methods
The Frailty Network is supporting multiple teams to implement new pathways to streamline care and improve outcomes. The aim is to understand our systems and have a focus on the data impacting our older adults. Stakeholder Engagement Table was utilised to show project success so far. Quantitative methodology such as LOS, number of referrals will be used to show impact. With a progress / Driver Diagram to show Quality Improvement Journey thus far. As the Network is a large piece of work, many aims are long term.
Results
The implementation of the Frailty Network has resulted in notable improvements in communication, engagement, collaboration and innovation. There has been reduced LOS in the frailty wards, improved transfers to community hospitals and more pathways to keep people at home. There are structures now imbedded to encourage multi system working from all settings.
Conclusion
The Frailty Network's innovative design has begun to successfully improve care for frail older adults in Lanarkshire. The collaboration between acute and community teams, combined with proactive interventions and the use of digital technology, has started the journey to a more sustainable future. Continued focus on integrated leadership and shared goals will further refine and sustain these improvements, setting a gold standard for frailty care in the region. Further research is required to assess long-term impacts.