Frailty-ACE (Assessment and Coordination of Emergency and urgent care) is an innovative approach to coordinating the health and care responses required to manage frail people at home, when a crisis would otherwise result in conveyance to the Emergency Department (ED) and/ or medical admission. The intervention is targeted to support our frailest patients who are at greatest risk of long admissions with ‘no criteria to reside’ in hospital.
The co-located F-ACE ‘team of teams’ comprises experienced urgent Primary Care and community clinicians, social worker and remote specialist frailty expertise, and works alongside our integrated mental health team. They remotely assess and manage frail people’s urgent physical health, mental health and care needs, including support for carers. F-ACE is closely integrated with Urgent Community Response, Frailty NHS@Home (virtual ward), social care, Frailty Same Day Emergency Care and 24-hour General Practice, enabling face to face assessment, and/ or ongoing monitoring and health, therapies or care interventions at home.
During the 6-week pilot, F-ACE managed 222 frail, complex and comorbid patients who were referred for medical admission, or by paramedics planning to convey, via a single point of access. ACE-F managed an unprecedented 65% without admission. Working as a joined-up, single team built trust, relationships and understanding across traditional service boundaries. These were key enablers for supported risk holding, shared decision making and person-centred coordination to tailor responses to patient’s needs and wishes. ACE colleagues consistently reported how rewarding and enjoyable the work was, and valued the rich learning environment. Patient and carer feedback has been positive, with excellent paramedic and GP feedback.
The pilot period was associated with a step change in ED 4-hour performance for major cases of all ages, which appears to have been driven by people aged 80+. We estimate that coordination and collaboration between existing services during the ACE-F pilot saved up to 2016 bed days and £760,000, based on an average length of stay of 14 days each costing £5,300.
