1. Frailty identification and management
North Sydney Local Health District and
Sydney North Primary Health Network
Cynthia Stanton: General Manager, Primary Care Advancement & Integration SNPHN
Chanelle Stowers: Integrated Care and HealthPathways Redesign Project SNPHN
Lyn Olivetti: Service Development Manager: Chronic & Complex Medicine, Rehabilitation & Aged Care NSLHD

2. Problem Statement
Frailty is a common syndrome effecting 25-27% of the popn aged 70+ (approx. 35,000).
It is associated with vulnerability and poor health outcomes. Frail older people have increased risk of falls, longer length of hospital stay, decline in function, increased chance of institutionalisation, and death
Early identification and direct intervention can reduce frailty and improve health outcomes for patients.

3. Aim and Objective
The aim of the Frailty Project is to implement an integrated model of care that supports the delivery of a frailty identification tool in people aged 70+ and supporting management plans to address the reversible contributing factors to frailty.
Outcomes includes:
Reversal of frailty in some cases
Reduced adverse patient outcomes
Increase hospital avoidance
Reduced length of hospital stay
To optimise patient wellness and QOL

4. Approach
Aligned with current evidence and the 2017 Asia Pacific Guidelines:
Implementation of a simple screen to identify frailty (FRAIL Scale) in
Acute care, ED
Hospital Inpatient
Primary Care
Implement associated management model that includes
Physical activity plan
Address polypharmacy
Nutrition plan for weight loss with appropriate supplements
Addresses self reported exhaustion
Vitamin D deficiencies

5. Key Items for exploration
Consolidate research and background into workable practical, logical and simple framework for delivery
Map processes, establish timelines, pilot sites/size and change management approach
Develop implementation workplan that can be utilised in both hospital inpatient and primary care settings
How to set up process and capacity building for ongoing project success
Work as a system across full patient lifecycle and journey (not in silo)