Background
Following the establishment of Many Care 5 years ago the Isle of Man Government issued a Manx Care Mandate under which it would work. The implementation of a Home first Strategy and the requirement to reduce the number of unnecessary hospital stays then fuelled the drive to change the patient pathways away from secondary care and in to an Intermediate care service delivery model.
Approach.
We identified the types of patients who would benefit from an Integrated Intermediate Care Team which offered, Crisis response, facilitated discharge, community and bed based rehabilitation. We adopted a whole system approach to gathering the data via a point prevalence and incident audit.
The data collection demonstrated that 30 % of patients in hospital could be supported at home with Intermediate care services. There were 30 patients per week who could have stayed out of hospital had there been a crisis response service and 18 of those patients would not have needed an ambulance had an intermediate care service been available.

We then followed this up with targeted focus groups across Health and Social care, third sector, family and users groups we identified a list of priories which was deemed necessary for any intended Intermediate care system to have going forward.
These included Single point of access, Free rehabilitative care, Accepting risk keeping patients at home with a requirement for advanced clinical knowledge and skills within the team, Redesign pathways for patients into the community rather than hospital, Rapid access to care and equipment
,Timely access including weekends

We identified gaps between the Reablement service and the proposed Integrated Intermediate Care Service and put this together with the identified needs and brought together the pathway in which the model of care could be delivered and the gap analysis then formed the basis of a comprehensive Business case. The delivery of the new service would be across the 4 pillars of Intermediate care and offered via a single access point, which is available 8 am till 8 pm , 7 days per week.
Results at end of year 1
The BAU Budget year on year is £1,249,151 and the transformation budget used in 24/25 was £1,136,971. Therefore the total budget budget used in 24/25 is £2,386,122. This was offset by a cost avoidance of £4,748,796 in year 1.
The change in flow metrics demonstrated that the:
• ALOS down from 44 days to 23 days , offering 21 days reduction.
• Emergency Department attendance is down 4.2%
• Mean number of medical outliers down from 25 to 14
• Readmission rates reduced
• the number of Opel 4 days at the hospital decreased
Key Learning
we adopted a wider criteria which included a discharge to assess process using a duty therapist , an optimisation of care package pathway from the social worker team, the non weight bearing pathway with support in the bed based Intermediate care. We also developed a web based referral form which could be used by clinicians when out at patients homes

Background: Although many care home residents with to avoid hospital transfers and prefer to receive care in familiar settings, their preferences are often overlooked in acute situations. Person-centered care requires that the resident’s values and wishes guide decisions, yet in practice, choices are frequently shaped by others, such as relatives and staff. As health systems move toward more integrated, home-centered models of care, it remains unclear how care home residents themselves experience and influence these processes. Greater attention to residents’ perspectives is essential to ensure truly person-centered care in acute situations. To address this gap, we explore how acute events are experienced from the perspectives of care home residents and relatives, with special emphasis on how to maintain residents’ personal integrity in these situations.

Approach: A qualitative study was performed with a phenomenological and hermeneutic approach. Field observations and semi-structured interviews were used as method. Data were collected in four care homes in one urban municipality between October 2024 and June 2025. In total, 180 hours of field observations and 14 semi-structured interviews were conducted. Purpose sampling was done to include residents, who had experienced an acute event in the care home recently, and/or their relatives. Data analysis was inspired by Paul Ricoeurs Interpretation Theory. Stakeholder involvement was highly valued in this study. An advisory group consisting of representatives from the municipality's council for the elderly represented the perspectives of older citizens and relatives and contributed to all research phases. Additionally, an intersectoral Steering Committee consisting of researchers and municipal leaders and chiefs ensured practical anchoring and relevance.

Results: Data was collected between March 2025 and June 2025. Preliminary findings may be presented in spring 2026.

Implications: This study contributes important insight into the experiences and perspectives of a group, who is historically excluded from research. To provide person-centered care and treatment for care home residents in acute situations, it is essential to understand how these events are experienced by the residents themselves. Findings may inform the development of care models and decision-making processes that are more aligned with residents’ values and preferences. This has implications for clinical practice and health policy aimed at improving care in acute situations.

Background
Older people with frailty frequently experience fragmented, reactive care across multiple services, leading to avoidable hospital admissions, deconditioning, and poor outcomes. Working with partners across the system, we co-designed an Integrated Frailty Crisis Pathway, across both community and acute Hospital based services, underpinned by evidence base behind Comprehensive Geriatric Assessment (CGA). This was supported by the Frailty Academy to build workforce capability. The programme aimed to reduce hospital demand, improve flow, and ensure consistent, high-quality care closer to home.

Approach
transformation programme was implemented using A3 Quality Improvement (QI) approach including:
- Co-designed with older people, carers, and professionals using Whose Shoes? workshops and Experience-Based Design (EBD) tools.
- A system wide frailty strategy, multi-agency governance structure and vision for joined up frailty crisis service.
- A QI programme built new services including a community single point of access (SPoA), Urgent Community Response (UCR), Hospital at Home (H@H), Frailty Same Day Emergency Care (FSDEC) unit. This created alternatives to Hospital admission.
- daily tests of change using PDCA cycles and "Big Room" improvement meetings every month.
- The Frailty Academy delivered tiered frailty education aligned with the national core capabilities framework and QI Practitioner training.
- Governance: Clinical leadership, project management, and data oversight ensured accountability at Trust, and system levels.
- Development of an integrated clinical governance processes including a acute hospital and community morbidity and mortality meetings.
- Development of a frailty dashboard to track outcomes and measure improvement.

Results
Service impact:
- 25% reduction in time spent in ED for over-85s and 40% increase in same-day discharge for over-75s.
- UCR two-hour response improved from 40.6% to 80.8%.
- 14.2% reduction in medical admissions for people aged 75+ via ED.
- Average LOS reduced by 15%, median LOS by 22%, and ‘super stranded’ (LOS > 28 days) patients by 41%.
- Discharges to new care home following admission to Hospital fell by 66%
-45% reduction in 28-day readmissions for over-85s.
- Estimated savings > £5 million through reduced admissions, shorter stays, and fewer care-home placements.

Implications
The Integrated Frailty Crisis Pathway at Royal Surrey NHS Foundation Trust transformed outcomes for older people by joining up acute and community services. Co-designed with patients, carers, and system partners, the pathway embedded Comprehensive Geriatric Assessment and Quality Improvement methods to improve safety, flow, and experience. Outcomes include a 66% reduction in care-home discharges, 41% fewer super stranded patients, and a doubling of Urgent Community Response performance. Over 1,800 staff were trained through the Frailty Academy, embedding capability and culture. This scalable model demonstrates how workforce development and co-production can deliver safer, more integrated, person-centred care.

This demonstrates the impact of integrated care across acute and community based services and outlines the value of teams working together towards the same vision. Our frailty strategy has been adapted by over 14 other healthcare systems in the NHS. Our methodology for change is subject of widespread interest and out dashboard demonstrating measurement for improvement principles has influenced national policy.

Background

Urgent Community Response (UCR) services were established through the NHS Long Term Plan to provide care within two hours for people experiencing a frailty crisis. These services play a vital role in keeping older people safely at home, yet performance had declined locally, with variation in workforce skills and limited integration across acute and community teams. Improving UCR responsiveness was essential to meet the Ageing Well ambitions and deliver person-centred, timely care. A rapid improvement approach was used to restore performance, strengthen workforce capability, and embed sustainable integrated practice.

Approach

A structured six-week rapid improvement cycle was implemented using the Trust’s A3 Quality Improvement (QI) methodology, supported by daily Plan–Do–Check–Act (PDCA) huddles.

Understand Phase:

Process mapping identified delays, duplication, and unclear handovers between teams.

A fishbone analysis highlighted multifactorial barriers including inconsistent triage, limited feedback loops, and gaps in clinical confidence.

Staff were benchmarked against the Frailty Core Capabilities Framework and UCR/Virtual Ward competencies to identify development needs.

Staff experience was captured using Experience-Based Design emotional mapping, revealing the stress caused by fragmented communication.

Improvement Phase:

Co-developed a shared vision for a fully integrated UCR service focused on safe, effective, and compassionate care.

Introduced standard work for handovers, board rounds, and staff allocation.

Created new leadership roles — Clinician in Charge and Enhanced Clinical Practitioner (ECP).

Co-located the Clinician in Charge with the Single Point of Access (SPoA) and Hospital@Home teams to streamline coordination.

Designed bespoke development plans aligned to the Frailty Academy education tiers, ensuring targeted training for each staff member.

Daily improvement huddles were used to test and refine changes in real time, embedding QI tools and visual management techniques to sustain momentum.

Results

Performance improvement:

UCR two-hour response improved from an average of 56.5% (range 46–68%) to 81.3% within six weeks.

Sustained improvement over 12 months at an average 83.8% (range 78.9–87.3%).

Proportion of referrals allocated to a two-hour pathway increased from 35% to 65%.

Workforce development:

100% of staff completed QI basics; three achieved QI Practitioner status.

80% completed health assessment modules, with four staff progressing to Enhanced Clinical Practitioner roles.

All staff completed Tier 1 frailty training; 50% achieved Tier 2 competency.

0% of staff had QI training pre-intervention compared with 100% post-programme.

Cultural impact:
Staff reported improved collaboration, clearer leadership, and increased confidence in rapid clinical decision-making. The service shifted from a “two-day” to a “two-hour” culture — transforming expectations and responsiveness.

Implications

This initiative demonstrates how structured improvement science and workforce development can deliver measurable, sustained impact in urgent community care — a challenge shared by health systems globally. Embedding education, leadership, and co-designed service redesign created an empowered workforce and improved patient experience. The model offers an adaptable framework for international systems seeking to strengthen community-based crisis response, integrate multidisciplinary care, and build local capacity for safe, timely support for older people living with frailty.

Background
Interprofessional Collaboration (IPC) enables healthcare professionals (HCPs) to deliver coordinated, high-quality care, and is a cornerstone of the World Health Organisation’s Integrated Care for Older People framework. In the Irish context, the ECLECTIC Framework identifies communication and information sharing as essential for effective IPC within specialist community teams integrating care for older adults (ICPOP-CSTs). This study aims to explore and describe the communication and information-sharing practices of ICPOP-CSTs as a lens through which to view IPC and identify the factors that enable effective collaboration in these teams.
Approach
This qualitative study used semi-structured interviews with four ICPOP-CSTs in Ireland. Participants (N = 39) represented all team disciplines, including geriatricians, operational leads, nurses, physiotherapists, occupational therapists, social workers, dietitians, speech and language therapists, and administrative staff. Data were collected between May and July 2024 and analysed using thematic analysis. An inductive coding approach was applied, with codes derived directly from the data. Braun and Clarke’s six-phase framework guided the analysis.
Results
Three main themes were identified. 1) Structural factors, including information and communication technology systems, resources, training, governance, and co-location. This theme provided the foundation that enables theme 2) Operational factors, such as joint assessments, learning and engagement activities, emails, phone calls and informal chats, data logs and shared folders, weekly meetings, and building links with other teams to support integration of care. These operational processes, in turn, fostered 3) Relational factors, which also fed back into shaping structural and operational practices, highlighting the dynamic and interdependent nature of interprofessional communication. Relational elements included psychological safety and openness, trust and respect, interpersonal and interprofessional relationships, supportive behaviours and approachable leadership, and effective communication.
Implications
Effective communication and information sharing are fundamental to IPC and care integration. The findings highlight practical ways to strengthen communication within and across community-based interprofessional teams, thereby supporting IPC and care integration for older people and their caregivers. Careful planning of communication pathways within and across organisational levels is crucial for care integration as older people transition across care boundaries in primary and community settings.