• Run by Barnsley Hospital NHS Foundation Trust.
  • Aimed at increasing the percentage of frail older people receiving the care they need in the most appropriate place and reducing the exposure of frail older people to a high risk patient environment.
  • Used both qualitative and quantitative data collection methods.

The project focused on what happens to a frail older person when they need care for an acute illness.

The existing process was examined including three main elements which became the focus of the work streams:

  • pre-hospital care
  • in hospital care (arrival at hospital)
  • discharge.

The key activities involved:

  • patient and family shadowing - real time observation of patients and their families as they moved through each step of a care experience
  • process mapping of the current model with the ideal
  • patient and family story telling and informal questionnaires
  • informal staff questionnaires
  • interrogation of existing data.


  • A new pathway that results in every frail older person getting the assessment that they need, as close to home as is feasible, with the minimum exposure to inpatient care and a rapid and appropriately supported return to their usual place of care.
  • Length of stay for frail older people minimised and unplanned readmissions to inpatient hospital care reduced, while improving the quality of the experience of care and the health outcomes.

Who was involved?

Three working groups were established to focus on each of the work streams.

The project team included:

  • Trust senior management
  • clinical leads
  • care givers in with patients
  • patients and families
  • external organisations.

Further reading


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