Case study provided by Dulce Silva (Frailty Advanced Clinical Practitioner) at West Suffolk Hospital NHS Foundation Trust.
Click here to download a PDF version of this document by visiting the NHS Learning Hub
Summary
The Ageing Well Advice Line was developed to provide rapid access to specialist frailty advice for community clinicians, improving pathway selection and reducing unnecessary Emergency Department attendance for older people living with frailty. Over its first 13 months, the service became an established whole-system frailty pathway, demonstrating increasing utilisation, improved multidisciplinary working and effective admission avoidance.
Organisation
The Ageing Well Advice Line is delivered by the Frailty Team in partnership with the East of England Ambulance Service (EEAST), primary care and community services.
What was the problem?
Older people living with frailty frequently experienced fragmented urgent care pathways, leading to avoidable Emergency Department attendance and hospital admission.
A baseline review over a two-week period in May 2025 identified that:
- 54% (173/317) of patients could have been referred to the Frailty Team but were not.
- 20% (64/317) may have been suitable for alternative care pathways rather than Emergency Department management.
- Community clinicians lacked rapid access to specialist frailty advice.
- Referral pathways were inconsistent and relied on individual clinician knowledge.
- Opportunities for Comprehensive Geriatric Assessment and community-based management were frequently missed.
What was done?
The Ageing Well Advice Line was launched in June 2025, providing direct telephone access to specialist Frailty Advanced Practitioners and Consultant Geriatricians during weekdays (09:00–17:00).
The service accepts referrals from all community clinicians, including:
- Paramedics
- General Practitioners
- Community Nurses
- Therapists
- Other healthcare professionals
Each referral receives rapid specialist assessment incorporating Comprehensive Geriatric Assessment principles, risk stratification and navigation to the most appropriate pathway, including:
- Community management
- GP support
- Frailty Same Day Emergency Care (SDEC)
- Acute Assessment Unit (AAU) Frailty
- Frailty Virtual Ward
- Emergency Department when clinically appropriate
Implementation was supported through PDSA cycles, stakeholder engagement, education, regular data collection and continuous service evaluation.
Challenges
Introducing a new cross-organisational pathway required significant engagement with ambulance, primary care and community services to increase awareness, build confidence and embed consistent referral practices. As with many new services, referral numbers were initially low while clinicians became familiar with the pathway and its benefits. Sustained education, regular communication, stakeholder engagement and feedback were essential to increase utilisation and encourage appropriate referrals.
Engagement with some receiving clinical areas, including Frailty Same Day Emergency Care (SDEC), also presented challenges. Patients referred through the Advice Line are often older, frailer and have greater clinical complexity than the traditional SDEC population. This required additional education, collaborative working and confidence-building to ensure staff felt supported in managing higher-acuity frailty presentations and applying Comprehensive Geriatric Assessment principles.
Demonstrating the value of the service through robust prospective data collection and regular reporting was critical to securing stakeholder confidence and supporting continued pathway development and expansion.
As awareness of the Advice Line has grown, demand has increased substantially. While this reflects the success of the service, meeting the increasing referral volume within the existing workforce and operational hours has become an ongoing challenge. Ensuring adequate clinical capacity, protected staffing and dedicated time for the Advice Line—particularly with the planned introduction of video triage—will be essential to maintain timely access, sustain service quality and support future expansion.
Impact
Between June 2025 and June 2026:
- 286 referrals were received.
- Activity increased steadily, including a 24% increase between May and June 2026.
- 55 referrals were received in June 2026—the highest monthly activity since the service launched.
- The majority of referrals involved patients aged over 80 years with Clinical Frailty Scores of 4–7.
- Falls, infection, delirium and functional decline were the most common reasons for referral.
- 81.8% of June referrals were managed through alternative pathways without direct Emergency Department attendance.
- Paramedics remained the largest referral source, with increasing referrals from primary care and community teams.
Case review demonstrated:
- Rapid specialist frailty assessment.
- Application of Comprehensive Geriatric Assessment principles.
- Low readmission rates.
- High levels of multidisciplinary collaboration.
Qualitative feedback also demonstrated increased clinician confidence and improved navigation across urgent care services.
Learning points
- Early specialist frailty input can safely support admission avoidance while improving person-centred decision-making.
- Providing community clinicians with direct access to specialist advice increases confidence in community-based management.
- Strong multidisciplinary collaboration across ambulance, community and hospital services is fundamental to successful frailty pathways.
- Continuous data collection and regular feedback are essential to demonstrate impact and support service improvement.
Next steps and sustainability
The next phase of development is the implementation of frailty video triage, enabling real-time virtual assessment alongside paramedics to further enhance clinical decision-making, optimise pathway selection and support safe admission avoidance.
Future plans include expanding the service’s capacity and availability by extending operational hours and introducing weekend cover, increasing access for community clinicians, and strengthening admission avoidance pathways across the local healthcare system. The team is also developing a business case for a dedicated Frailty AP to provide protected time for both the Advice Line and video triage. This dedicated role will improve service responsiveness, support continued pathway development and ensure sustainability as demand continues to grow.
As the pathway matures, evaluation will extend beyond referral activity and patient outcomes to include wider system metrics, such as ambulance handover delays and ambulance stack times, to assess the pathway’s impact on patient flow, ambulance availability and urgent care performance. Ongoing monitoring of patient outcomes, service utilisation and stakeholder feedback will continue to inform quality improvement and demonstrate value.
The long-term ambition is to develop the Ageing Well Advice Line into a sustainable, seven-day, whole-system frailty service that can be adapted and replicated across other healthcare organisations, improving outcomes for older people while reducing pressure on emergency and urgent care services.
Contact
West Suffolk NHS Foundation Trust – Frailty Team
01284712712 – option 3