Table 1 Five priority areas for enhanced service delivery; related interventions and patient-centred evaluation outcomes

Collaboration along an integrated care continuum for frail older patients

a) Early identification of frail patients upon admission

b) Addressing organisational barriers on integrated care pathway

Rockwood frailty: Numbers screened

Development of frailty index and its association with length of stay, mortality and discharge destination

Improved bi-directional flow between primary care, acute and community based rehab or step-down institutions

Improved discharge planning processes to the integrated community care team

Rapid access pathways between GP and day hospital (bi-passing ED).

Continence care

a) Intentional rounding (IR)

b) HCA skills fare

Personal needs

Access to call bell and drink

Clutter free bed space

Access to sensory equipment

Number of falls

Improved mobility

a) Introduction of FITT team in the emergency department

b) End PJ Paralysis scheme

Hours from ED admission to first FITT therapy attendance (OT, PT, Dietetics and SLT)

Numbers screened as frail who had FITT service and their average length of stay

Patients mobilising on the ward

Patients sitting out of bed on the ward

Access to food and hydration

a) HCA dedicated role in ED

b) Intentional rounding

c) Red Tray

d) HCA skills fare

Access to a drink on ward (IR)

Access to a drink in ED (HCA)

Energy and protein consumption

Improved patient information and signage

a) IR and use of notice boards on ward

b) Written daily care plans with goals

c) Patient information leaflet regarding mobilisation

d) Establishment of Environmental Dementia Committee

Comment and feedback from patients regarding information dissemination

Signs at the correct height

Writing large enough and easy to read (Colours and readability)

Patients able to find their way around using signs alone