Current Care Pathways Research Articles

Age and the distribution of major injury across a national trauma system.

BackgroundTrauma places a significant burden on healthcare services, and its management impacts greatly on the injured patient. The demographic of major trauma is changing as the population ages, increasingly unveiling gaps in processes of managing older patients. Key to improving patient care is the ability to characterise current patient distribution.ObjectivesThere is no contemporary evidence available to characterise how age impacts on trauma patient distribution at a national level. Through an analysis of the Trauma Audit Research Network (TARN) database, we describe the nature of Major Trauma in England since the configuration of regional trauma networks, with focus on injury distribution, ultimate treating institution and any transfer in-between.MethodsThe TARN database was analysed for all patients presenting from April 2012 to the end of October 2017 in NHS England.ResultsAbout 307,307 patients were included, of which 63.8% presented directly to a non-specialist hospital (trauma unit (TU)). Fall from standing height in older patients, presenting and largely remaining in TUs, dominates the English trauma caseload. Contrary to perception, major trauma patients currently are being cared for in both specialist (major trauma centres (MTCs)) and non-specialist (TU) hospitals. Paediatric trauma accounts for <5% of trauma cases and is focussed on paediatric MTCs.ConclusionsWithin adult major trauma patients in England, mechanism of injury is dominated by low level falls, particularly in older people. These patients are predominately cared for in TUs. This work illustrates the reality of current care pathways for major trauma patients in England in the recently configured regional trauma networks.

An evaluation of the current clinical care pathway of patients referred to a large UK Tertiary Centre with suspected PCOS

An evaluation of the current clinical care pathway of patients referred to a large UK Tertiary Centre with suspected PCOS

Regional Wait Times for Patients With Nonmelanoma Skin Cancer in Southwestern Ontario.

Nonmelanoma skin cancer (NMSC) affects many Canadians. Although morbidity and mortality are rare, the burden to patients and the health-care system is significant. This study aims to evaluate current plastic surgery wait times and care pathways for patients with NMSC in Southwestern Ontario. A retrospective chart review of 225 patients treated in Ontario from 2015 to 2018 was conducted. Inclusion criteria included patients with an NMSC managed with surgical excision. Referral information was compared. Primary outcomes were wait times: from referral to consultation, referral to excision, and consultation to excision. Data were analyzed using Student t test with equal variance. One-hundred forty-three patients were included from the academic cohort and 82 from the community cohort. Referrals to academic and community surgeons included lesion location (90% and 97.6%, respectively), but less frequently included size (18% and 29.2%, respectively). Most referrals to academic surgeons included biopsy results (78.6%), as opposed to community referrals (25.6%). Patients in the academic cohort waited 15.3 ± 12.7 weeks from referral to consultation, and 15.7 ± 13 weeks from referral to excision. Patients from the community cohort waited significantly shorter periods of 4.9 ± 3.1 (P < .001) and 11.7 ± 9.9 weeks (P = .016), respectively. However, patients of the academic cohort waited 2.4 ± 7.1 weeks from consultation to excision, while patients in the community cohort waited 6.7 ± 9.6 weeks (P < .001). Rates of negative peripheral margins on pathology were similar between groups, at 89.5% of the academic cohort and 88.9% of the community cohort. Deep margins were positive 5.7% of the time at the academic sites and 6.2% of the time in the community. Patients referred to academic centres waited significantly longer periods of time in several parameters compared to those referred to a community surgeon. However, academic surgeons often had expedited consultation-to-excision time frame. This study provides important data for future quality improvement initiatives in NMSC care.

Management of Atrial Fibrillation in Europe: Current Care Pathways and the Clinical Impact of Antiarrhythmic Drugs and Catheter Ablation

Atrial fibrillation (AF), the most common form of arrhythmia, increases the risk of heart failure, stroke, and death. Management of AF focusses on effectively and safely controlling irregular heart rhythm, improving symptoms, and reducing complications. Early treatment of AF is important as it may improve patient life expectancy and quality of life (QoL). Current European guidelines recommend an integrated approach to AF management that involves shared decision making between patients and multidisciplinary teams of healthcare professionals to improve access to care and patient compliance. Treatment options include the use of anticoagulants, cardioversion, rate control therapies, and rhythm control therapies. Over the long term, rhythm control strategies that include antiarrhythmic drugs (AAD) and catheter ablation are the most common methods for controlling AF. The objective of this review is to highlight current European AF care pathway management recommendations and to examine the clinical, economic, and patient impact of different treatment options, including AAD and catheter ablation. While AAD have been shown to improve QoL and are affordable in the short term, treatment is moderately effective, associated with significant side effects, and can be costly long term. Catheter ablation is a highly effective therapy choice that improves patient wellbeing and is associated with a low rate of ablation-related complications. Compared to drug therapy, catheter ablation provides a significant reduction in AF burden, reduces rates of recurrence, provides a greater improvement in QoL, and facilitates long-term cost savings.

Musculoskeletal care pathways for adults with hip and knee pain referred for specialist opinion: a systematic review

ObjectiveMusculoskeletal care pathways are variable and inconsistent. The aim of this systematic review was to evaluate the evidence for the clinical and/or cost effectiveness of current care pathways for adults...

Accessing palliative care for multiple sclerosis: A qualitative study of a neglected neurological disease

BackgroundDespite the global consensus on the importance of palliative care for patients with multiple sclerosis (MS), many patients in developing countries do not receive palliative care. Improving access to palliative care for MS requires a contextual understanding of how palliative care is perceived by patients and health professionals, the existing care pathways, and barriers to the provision of palliative care. ObjectiveThis study aims to examine and contrast the perceptions of MS patients, neurologists, and palliative care physicians towards providing palliative care for patients with MS in Malaysia. Methods12 MS patients, 5 neurologists, and 5 palliative care physicians participated in this qualitative study. Each participant took part in a semi-structured interview. The interviews were transcribed verbatim, and analysed using an iterative thematic analysis approach. ResultsPatients and neurologists mostly associated palliative care with the end-of-life and struggled to understand the need for palliative care in MS. Another barrier was the lack of understanding about the palliative care needs of MS patients. Palliative care physicians also identified the scarcity of resources and their lack of experience with MS as barriers. The current referral-based care pathway itself was found to be a barrier to the provision of palliative care. ConclusionsMS patients in Malaysia face several barriers in accessing palliative care. Overcoming these barriers will require improving the shared understanding of palliative care and its role in MS. The existing care pathway also needs to be reformed to ensure that it improves access to palliative care for MS patients.

Vulnerabilities in diabetic eye screening for children and young people in England.

Children and young people (CYP) living with diabetes require integrated child-centered care. We hypothesized that suboptimal uptake to diabetic retinopathy screening in CYP may be partly related to the degree of services integration. We investigated the structure of the current pediatric diabetic eye care pathway and associations between service-level characteristics and screening uptake. A quality improvement project between January and May 2017 comprising a survey of practice of all 158 pediatric diabetes services (pediatric diabetes units, PDUs) across England and secondary data analysis of routinely collected service data. Generalized linear models for proportional responses were fitted to investigate associations between reported PDU characteristics and screening uptake. 124 PDUs (78%) responded. In 67% (n = 83), patients could be referred directly to screening programs; the remainder relied on primary care for onward referral. 97% (n = 120) considered eye screening results useful for counseling patients but only 65% (n = 81) reported it was "easy" to obtain them. Factors independently associated with higher screening uptake were a higher proportion of patients referred from primary care (OR = 1.005; 95%CI = 1.004-1.007 per 1% of increase), absence of "out-of-catchment area" patients (OR = 1.13; 95%CI = 1.04-1.22), and easy access to eye screening results (OR = 1.45; 95%CI = 1.34-1.56). There is limited direct communication between the services involved in diabetic eye care for CYP in England. This risks reducing the effectiveness of diabetic retinopathy screening. Similar vulnerabilities are likely to exist in other countries where retinopathy screening for CYP has been "bolted on" to provision for adults.

A NEW BREATH FOR MALIGNANT HYPERTENSION

Objective: This registry aims to assess modern epidemiology of the disease, diversity of current management and care pathway, to deepen our pathophysiological knowledges, to modernize the definition of this form of hypertension and its diagnostic criteria. The network that will emerge will finally lead to the opportunity of setting up therapeutic trials and establishing recommendations based on solid scientific evidence. Design and method: We will conduct the first prospective multicentric observational cohort about malignant hypertension. We aim to recruit at least 500 patients with a 5 years follow up. Our main objective will be to define their prognosis at 5 years. The impact of the patient's phenotype, type and number of target organs affected will be studied. A modern definition, adapted to these results, could be proposed. The epidemiology of the disease, the care pathways, the target organ disorders and the management carried out in the centers will be described in detail. Results: We recruited more than thirty centers frequently involved in malignant hypertension management. We are ready to start the inclusion. Conclusions: We will conduct the first prospective multicentric observational cohort about malignant hypertension. It should make it possible to deeply increase our knowledges about the disease, and finally to modernize the guidelines on this topic.

Can the current hypodontia care pathway promote shared decision-making?

To determine the extent to which the current care pathway in hypodontia promotes shared decision-making (SDM). Exploratory cross-sectional study using qualitative methods. Orthodontic department of two NHS teaching hospitals in Yorkshire. Young people aged 12-16 years with hypodontia of any severity and at any stage of treatment, and their parents and guardians. (1) Observation and audio-recording of interdisciplinary consultation in hypodontia clinics (n = 5) without any researcher interference; (2) short, structured interviews with young people with hypodontia (n = 8) and their parent (n = 8) using a topic guide to explore themes around decision-making. Audio-recordings were transcribed and analysed using a thematic framework. Consultations were used as an opportunity for interdisciplinary discussion, information provision and treatment planning. Evidence of good communication was observed but patient engagement was low. The decision to be made was usually stated and treatment options discussed, but time constraints limited the scope for adequate information exchange and assessment of understanding. No methods were used to establish patient and family preferences or values. Interviews suggested parents expect the dental team to make decisions and young people rely on parental advocacy. Despite little evidence of SDM, participants reported satisfaction with their treatment. The current care pathway for hypodontia does not support clinicians in the steps of SDM. Recommendations for improving SDM processes include support to identify preference-based decisions, greater access to comprehensive and accessible patient information to enable preparation for consultation, alternative methods for effective communication of complex information and use of preference elicitation tools to aid value-driven decision-making.

PMH67 USING REAL WORLD DATA TO PROFILE CURRENT STANDARD OF CARE FOR SCHIZOPHRENIA PATIENTS AT A MENTAL HEALTH HOSPITAL IN RWANDA, AFRICA

This study was set up to collect real world data for patients in Rwanda receiving treatments for schizophrenia and to use this data to profile the current standard of schizophrenia care in Rwanda. Staff at Ndera Neuropsychiatric Hospital in Kigali independently identified a randomized group of patients with schizophrenia. Paper notes for 79 patients (58 male, 21 female) were extracted and provided to a qualified psychiatrist appointed by Rwanda Biomedical Centre (RBC). Notes were a combination of free-form notes in French, payment slips, prescription records and demographic forms. The psychiatrist reviewed the notes and transferred anonymous, non-identifiable patient data for recording by the research team. Supporting information collected included the annual report and other documents on hospital tariffs, travel costs from all districts, medicines formulary, etc. Patient records covered a span of 1-36 years (average 10 years treatment in hospital). At initial diagnosis, 80% of patients were under the age of 35 (age at first referral 16-56 yrs). Only 4% of patients did not have any inpatient admissions. Nearly 75% of carers were immediate family members. Regarding pharmaceutical treatments, 90% of patients were prescribed haloperidol and/or chlorpromazine (70/79). The only second-generation antipsychotics used were olanzapine and risperidone (18/79). Nearly 50% (37/79) had physical health checks done, most systematically in recent (<5) years. Weighted across patients and years in which activity was recorded, outpatient visits per year was 6.1 (range 2.6-9.4), inpatient admissions per patient per year was 1.2 (range 1.0-3.0), inpatient bed days per admission was 39.2 (range 9.5-135.0). A significant proportion of patients (19/79; 24%) had co-morbidities (biggest of these were alcohol and drugs). This pioneering study using real world data from schizophrenia patients in Rwanda shows that the current care pathway involves first-generation antipsychotics, long inpatient stays and significant travel burden.

A Novel, Synergistic Model in Total Joint Arthroplasty: A Report of 2 Specialty Hospitals With Joint Ownership Between Physicians and Healthcare Systems

BackgroundIn 2010, the Affordable Care Act introduced new restrictions on the expansion of physician-owned hospitals (POHs) due to concerns over financial incentives and increased costs. The purpose of this study is to determine whether joint ventures between tertiary care and specialty hospitals (SHs) allowing physician ownership (POHs) have improved outcomes and lower cost following THA and TKA. MethodsAfter institutional review board approval, a retrospective review of consecutive series of primary THA and TKA patients from 2015 to 2016 across a single institution comprised of 14 full-service hospitals and 2 SHs owned as a joint venture between physicians and their health system partners. Ninety-day episode-of-care claims cost data from Medicare and a single private insurer were reviewed with the collection of the same demographic data, medical comorbidities, and readmission rates for both the SHs and non-SHs. A multivariate regression analysis was performed to determine the independent effect of the SHs on episode-of-care costs. ResultsOf the 6537 patients in the study, 1936 patients underwent a total joint arthroplasty at an SH (29.6%). Patients undergoing a procedure at an SH had shorter lengths of stay (1.29 days vs 2.23 days for Medicare, 1.15 vs 1.86 for private payer, both P < .001), were less likely to be readmitted (4% vs 7% for Medicare, P = .001), and had lower mean 90-day episode-of-care costs ($16,661 vs $20,579 for Medicare, $26,166 vs $35,222 for private payers, both P < .001). When controlling for the medical comorbidities and demographic variables, undergoing THA or TKA at an SH was associated with a decrease in overall episode costs ($3266 for Medicare, $13,132 for private payer, both P < .001). ConclusionEven after adjusting for a healthier patient population, the joint venture partnership with health systems and physician-owned SHs demonstrated lower 90-day episode-of-care costs than non-SHs following THA and TKA. Policymakers and practices should consider these data when considering the current care pathways.

Postoperative Mortality After Nonelective Surgery for Inflammatory Bowel Disease Patients in the Era of Biologics.

The aim of the study was to analyze recent trends in the rate of nonelective surgery and corresponding mortality for inflammatory bowel disease (IBD) patients since the rise of biologic use. Modern biologic therapy has improved outcomes for IBD, but little is known about the impact on mortality rates after nonelective surgery. New York's Statewide Planning & Research Cooperative System was queried for hospital admissions for ulcerative colitis (UC) with concurrent colectomy and Crohn disease (CD) with concurrent small bowel resection or colectomy from 2000 to 2013. Mixed-effects analyses assessed patient, surgeon, and hospital-level factors and hospital-level variation associated with 30-day mortality after nonelective surgery. Between 2000 to 2006 and 2007 to 2013, the number of unscheduled IBD-related admissions increased by 50% for UC and 41% for CD, but no change in the proportion of nonelective surgery cases was observed (UC=38% vs 38%; CD=45% vs 42%) among 15,837 intestinal resections (UC=5,297; CD=10,540). Nonelective surgery mortality rates between 2000 to 2006 and 2007 to 2013 were high and increased for UC (10.2% vs 15%) but decreased for CD (3.3% vs 2.2%). Nonelective surgery in 2007 to 2013 was associated with an 82% increased risk of 30-day mortality in UC cases (odds ratio: 1.82; confidence interval: 1.19-2.62). After controlling for patient-level factors, large hospital-level variation was observed with 23-fold difference in mortality for both UC and CD. Although nonelective IBD surgery rates have remained stable, associated 30-day mortality for UC has doubled in recent years despite advances in medical management. Current clinical decision-making and care pathways must be further evaluated to improve outcomes in this high-risk population.

Understanding and improving the care pathway for children with autism.

The purpose of this paper is to describe current care pathways for children with autism including enablers and barriers, as experienced by health professionals, education professionals and families in South Wales, UK. This study is based on a mixed-methods approach using focus group discussions, creative writing workshops and visualisation using rich pictures. The experiences of the care pathways differed significantly across the three groups. Health professionals described the most rigidly structured pathways, with clear entry points and outcomes. Education professionals and parents described more complex and confusing pathways, with parents assuming the responsibility of coordinating the health and education activity in a bid to link the two independent pathways. All three groups identified enablers, although these differed across the groups. The barriers were more consistent across the groups (e.g. poor communication, missing information, lack of transparency, limited post-diagnosis services and access to services based on diagnosis rather than need). This research could inform the design of new services which are premised on multi-agency and multi-disciplinary working to ensure children with Autism spectrum disorders (ASD) receive joined up services and support. Although this study did not represent all professional groups or all experiences of autism, the authors examined three different perspectives of the ASD pathway. In addition, the authors triangulated high-level process maps with rich pictures and creative writing exercises, which allowed the authors to identify specific recommendations to improve integration and reduce duplication and gaps in provision.

An exploration of the experiences of women treated with radiotherapy for breast cancer: Learning from recent and historical cohorts to identify enduring needs.

Recent decades have seen improvements in UK breast cancer services and treatments. Despite this, it is recognised that a range of patients' psychological and emotional needs remain unmet, both at the time of treatment and into survivorship. Using data from two distinct cohorts of women: those treated with radiotherapy for breast cancer historically, and women treated more recently, this study sought to identify and explore those needs and concerns that have continued to persist, despite advances in treatment and care. Data from N = 13 semi-structured interviews were analysed using Interpretative Phenomenological Analysis. An heuristic framework was applied to extract themes common to both participant cohorts. Participants' data evidenced an enduring vulnerability amongst cancer patients that has not diminished with new treatment pathways. Themes common to both cohorts highlighted the ongoing importance of personal factors such as resilience, and strategies to help retain a sense of normality. Extrinsic support was important too, especially high quality communication by healthcare professionals and having access to ongoing emotional support from others, particularly when active treatment ends. Participants' suggestions for future service development included the provision of ongoing continuity of care and greater access to emotional support services. This study highlights the psychological needs and concerns of breast cancer patients that have persisted, despite the many advances in patient-centred care. Findings are of value to nurses and other healthcare professionals in highlighting the ongoing importance of recognising, acknowledging and addressing patients' concerns and needs, even within current cancer care pathways.

A value proposition for trough level-based anti-TNFα drug dosing

Treatment of inflammatory bowel diseases and rheumatic disorders with anti-tumor necrosis factor alpha (TNFα) drugs is expensive, while a significant proportion of patients does not show adequate clinical response. Therapeutic drug monitoring (TDM) enables patient-specific anti-TNFα therapy. The role of laboratory tests in clinical care has recently been described in a value proposition framework. It describes care processes, stakeholders, costs, risks, benefits and patient outcomes based on the use of a laboratory test in a clinical care pathway. We have applied this concept to the use of TDM for anti-TNFα drugs, describing evidence that supports the intervention and its cost effectiveness, steps that need to be adjusted in the care pathway, possible treatment algorithms and measures to assess adoption of this framework into clinical practice.For effective TDM, an assay for measurement of drug levels together with appropriate target ranges and an anti-drug-antibody assay have to be implemented. Also, instead of only reporting the drug concentration, laboratorians, pharmacists and clinicians should deliver added value by introducing a TDM-based treatment algorithm into clinical practice. Thus, to maximize effectiveness of TDM of anti-TNFα therapy in routine care, adjustment of current care pathways and cooperation of many stakeholders are needed.

Allergologie : une spécialité à l’heure des parcours de soins

Following an inventory of care pathways in 2011, the French Federation of Allergology conducted two surveys amongst allergy training directors and allergists that focused on current allergy care pathways. These are in line with the proposals of the 2017 White Paper on severe respiratory allergies. The establishment of pathways is one of the major challenges for the years to come. These surveys help in updating therapeutic proposals and in identifying the constraints and benefits for the profession of establishing such coordinated care pathways as well as initiatives already in place. While the Federation is sad to report a fifty percent reduction in the total number of allergists over the last ten years, it is delighted to highlight more than forty initiatives, which have resulted in the issuance of six proposals to foster a dynamic pathway of care in allergy management for the coming years.

What you should know about the low anterior resection syndrome – Clinical recommendations from a patient perspective

IntroductionFunctional bowel complaints, referred to as Low Anterior Resection Syndrome (LARS), are common after sphincter-saving surgical procedures and have a severe impact on quality of life (QoL). Care for LARS patients is complex and surgeons underestimate or misinterpret its associated symptoms. This study aimed to explore the impact of LARS from a patient perspective facilitating the construction of a set of recommendations improving current care stratagems. MethodsIn a non-academic Dutch teaching hospital, three focus group sessions were conducted with 16 patients (males = 50%) who had undergone colorectal surgery between 2012 and 2017. A trained moderator orchestrated patient-discussion regarding illness perception and health-care needs. Transcripts were analysed using inductive content analysis. ResultsThree themes were identified: illness perception, preoperative care and postoperative supportive care. Specific attention and screening for LARS is deemed necessary for breaking the taboo surrounding it. Extension of preoperative counselling on the normal postoperative course, including ways to optimize social support, were identified as crucial. After discharge, patients experienced a lack of supportive care regarding functional complaints and did not know who to counsel. In addition, they felt intrinsically motivated to actively prepare for surgery, i.e. by participating in prehabilitation programs. ConclusionExploring perspectives in LARS patients resulted in the identification of potential improvements in current care pathways. Recommendations on ways to improve information provision, screening of LARS and methods to intervene in the gap of supportive care after discharge are presented. We recommend to implement these measures as QoL of patients undergoing colorectal cancer surgery may be improved.

Freestyle Libre: available on the NHS?

In 2017 the FreeStyle Libre flash glucose monitor became available on the NHS Drug Tariff. Clinicians and funders across the UK have had to debate where this device sits in the care of people with diabetes. While some would argue that this device is a replacement for self-monitoring of blood glucose and should therefore be widely available for those who may benefit, the financial climate in the NHS has demanded a more conservative approach. This article considers the current evidence to support the use of the FreeStyle Libre, its position in current and future care pathways and gaps in available evidence.

Identifying trial recruitment uncertainties using a James Lind Alliance Priority Setting Partnership \u2013 the PRioRiTy (Prioritising Recruitment in Randomised Trials) study

BackgroundDespite the problem of inadequate recruitment to randomised trials, there is little evidence to guide researchers on decisions about how people are effectively recruited to take part in trials. The PRioRiTy study aimed to identify and prioritise important unanswered trial recruitment questions for research. The PRioRiTy study - Priority Setting Partnership (PSP) included members of the public approached to take part in a randomised trial or who have represented participants on randomised trial steering committees, health professionals and research staff with experience of recruiting to randomised trials, people who have designed, conducted, analysed or reported on randomised trials and people with experience of randomised trials methodology.MethodsThis partnership was aided by the James Lind Alliance and involved eight stages: (i) identifying a unique, relevant prioritisation area within trial methodology; (ii) establishing a steering group (iii) identifying and engaging with partners and stakeholders; (iv) formulating an initial list of uncertainties; (v) collating the uncertainties into research questions; (vi) confirming that the questions for research are a current recruitment challenge; (vii) shortlisting questions and (viii) final prioritisation through a face-to-face workshop.ResultsA total of 790 survey respondents yielded 1693 open-text answers to 6 questions, from which 1880 potential questions for research were identified. After merging duplicates, the number of questions was reduced to 496. Questions were combined further, and those that were submitted by fewer than 15 people and/or fewer than 6 of the 7 stakeholder groups were excluded from the next round of prioritisation resulting in 31 unique questions for research. All 31 questions were confirmed as being unanswered after checking relevant, up-to-date research evidence. The 10 highest priority questions were ranked at a face-to-face workshop. The number 1 ranked question was “How can randomised trials become part of routine care and best utilise current clinical care pathways?” The top 10 research questions can be viewed at www.priorityresearch.ie.ConclusionThe prioritised questions call for a collective focus on normalising trials as part of clinical care, enhancing communication, addressing barriers, enablers and motivators around participation and exploring greater public involvement in the research process.

Integrated Care in Practice: A Novel Approach

Introduction: The current care pathway for frail patients in the UK in need of assessment is often into hospital, usually through accident and emergency and then onto a variety of wards. We have an excellent award winning proactive elderly care team in reach service but it can be several days before a comprehensive geriatric assessment (CGA) is commenced. Length of stay can be prolonged and some patients are left ‘stranded’ in hospital. It was felt that a change to the frailty pathways across multiple organisations was needed. A collaboration between the CCG, Lancashire Care Foundation Trust and Lancashire Teaching Hospitals NHS Foundation Trust was initiated. Practice Change and Implementation: 2 new services have been offered primarily to GP’s as an alternative to the inefficient pathway described above: 1- A community based frailty assessment service (FAS) to provide an alternative to acute admission for GPs with patients aged 75+ identified as potentially frail using the Rockwood and Bournemouth criteria. 2- A hospital based acute frailty unit (AFU). Based at the heart of the hospital it aims to admit frail patients directly from the community. It is especially for the more unstable frail patients who may have been excluded from FAS. Aim and theory of change: Our aim is provide excellent, efficient and timely CGA for frail patients. This will lead to reduction in acute admissions, reduced length of stay if admission is unavoidable and a reduction in re-admissions. The community based FAS is, as far as we know, totally unique and innovative to the UK. It is untested but existing evidence has been extensively incorporated into its design (eg frailty scores, CGA models, PECT model). The AFU will complement FAS so that more unwell frail patients are not excluded from CGA and care plans. The theory used to implement both of these new services are based on our well established and successful PECT service. Targeted populations and stakeholders: We will initially target the over 75’s and we will use frailty criteria to identify these patients. Our main stakeholders are the patients and their families/carers, our GP’s, social services, North West ambulance service, the CCG, LCFT and the acute hospital Trust. Timeline: FAS commenced 28th November 2016, AFU intends to start imminently. Both units hope to be fully operational by early 2017 with initial results available likely March 2017. Highlights: Highlights include all 3 main service providers collaborating to initiate new services specifically to improve frailty pathways. Sustainability: Both new services are starting off small and expand as staffing and resources allow Transferability: AFUs are already well established across the UK but the community FAS is a new concept. We envisage that both services will complement each other, and this model should be easily transferable across the UK. Conclusions and Lessons Learnt: We envisage a truly integrated care pathway for patients with frailty across the local health economy. Collaborative working can lead to innovation and the delivery of new and high quality services.