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Frailty - ACE

Checked: 20-03-2024 by 3 Vicky Ryan Next Review: 08-01-2026

Overview

Frailty-ACE (Assessment and Coordination for Emergency and urgent care) specifically aims to support frail patients who would otherwise be admitted or conveyed to hospital, recognising the balance of risks and benefits associated with admission are often more finely balanced, or even unfavourable, for frail people. 

What is Frailty-ACE?

The F-ACE team brings together Sirona ACP(s), Primary Care GPs/ ACPs and Social Worker expertise in a co-located hub, supported by Consultant Geriatrician specialist advice. The F-ACE hub is hosted by BrisDoc and works alongside the Severnside Weekday Professional Line (which facilitates BNSSG adult medical admissions and supports alternatives to admission), System CAS (multi-professional team consulting patients who would otherwise be directed to ED or Cat 3/ 4 ambulance by NHS111) and Mental Health Integrated Access Partnership.

F-ACE receives referrals from paramedics on scene who are planning or likely to convey a frail person to hospital. In addition, the co-located Weekday Professional Line can pass cases to the Frailty-ACE service as an alternative to admission for eligible frail patients. The F-ACE team provides comprehensive assessment of frail patient’s urgent care needs, including those of their carers/ family, and is person-centred and holistic in its approach. When community management is preferred and/ or in the best interests of the patient, F-ACE will seek to coordinate the community, medical and/or care service(s) required to manage often complex, multi-faceted needs at home. This integrated physical health, mental health and social care approach has achieved alternatives to admission for 70% of patients, with excellent feedback from referrers, patients and F-ACE colleagues alike, and positive impact on the BNSSG urgent and emergency care system.

Frailty-ACE clinical criteria

To be eligible for referral to the Frailty-ACE service, patients must meet one or more of the inclusion criteria with no exclusion criteria

Patients meeting the above criteria are not eligible for referral to F-ACE if any of the following situations apply

  • Existing pathway can be accessed to support continued management at home eg. Urgent Community Response referral, own GP follow up (following paramedic attendance), hot clinic referral
  • Trauma requiring x-ray

Referral

F-ACE takes referrals 9am to 4.30pm Monday to Friday. The F-ACE intervention is targeted specifically and only for frail patients who would otherwise be admitted or conveyed and is therefore accessed by one of two HCP referral routes 

  1. General Practice and Community HCP referrers seeking adult medical admission via the Severnside Weekday Professional Line (WDPL). The WDPL team can refer directly to F-ACE as an alternative to medical admission for frail people. This flow chart outlines when General Practice should call the Sirona SPA or the Weekday Professional Line
  2. Paramedics on scene who are planning or likely to convey a frail person. The Frailty-ACE team can support any clinical presentation, including time-critical presentations (especially if person is very frail, likely terminal event or palliative), head injuries on anticoagulation and all NEWS. Please see the SWASFT F-ACE flyer for more information. 

Frequently Asked Questions

  • When General Practice or Community HCPs call the WDPL seeking medical admission for a frail person who meets the F-ACE inclusion criteria
    • If the Clinical Frailty Scale (CFS/ Rockwood) is 8 or 9, the referrer may be passed directly to the F-ACE clinical team. This reflects that the balance of risks and benefits are likely to strongly favour community-based management for this group severely/ terminally frail patients. If F-ACE capacity cannot enable immediate/ prompt transfer, your call will be passed to a WDPL clinician who can then hand over the case to F-ACE
    • For all other patients meeting F-ACE inclusion criteria the WDPL caller will be transferred to a WDPL clinician as usual, who will consider F-ACE referral as an option. If this is agreed, the WDPL clinician may seek additional information to support transfer of the case to F-ACE to minimise the need for the F-ACE team to call the original referrer back
  • If the Frailty-ACE team are unable for any reason to facilitate community-based management, they will facilitate direct specialty admission without coming back to the original referrer. More broadly, the F-ACE team aims to manage patients without making other urgent asks of General Practice, instead utilising community-based services to support ongoing monitoring, clinical follow up and treatment for the urgent care episode
  • Documentation of the Frailty-ACE intervention will be visible on Connecting Care approximately an hour after the F-ACE digital case record is closed (as a document within the Integrated Urgent Care section in the left hand menu). This documentation will also land in the practice EMIS records in the same way as Severnside/ BrisDoc 'Out of Hours' Post Event Messages, though this may take longer to be visible depending on how practices manage this correspondence. We therefore recommend viewing Connecting Care if the information is not visible within EMIS, noting that F-ACE cases can take several hours to complete and there are occasions where the F-ACE team may hold a case into the following day or four OOH follow up
    • All F-ACE Post Event Messages will include fixed wording reflecting that the case has been managed by the F-ACE team (rather than OOH)
    • The F-ACE clinical team are asked to document a problem list and listed plan to aid handover to the service(s) that will continue to manage the patient after the F-ACE intervention. Actions relevant to General Practice will most likely relate to enabling ongoing proactive care following the ACE intervention (eg requests for structured medication review, discussion/ review at PCN/ practice MDT, coding of carers if they are also registered at the practice). 

Feedback about Frailty-ACE

This is a new service and will continue to evolve and improve so your feedback is invaluable - please share via this BrisDoc's learning event and service feedback portal to enable us to review and action learning. 



Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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