Improving care planning and communication for frail older persons across the primary-secondary care interface

Collaboration between general practitioners (GPs) and geriatricians should be at the forefront of the design and delivery of the care of frail older people. Primary care teams require high-quality, relevant and timely communication around assessment and care plans when patients return home from secondary care settings. The aim of this project was to develop effective handover communication between the frailty team and primary care for patients assessed and transferred home from an emergency department. The 'frailty letter to the GP' was designed, tested and adapted to accomplish this aim. This involved two PDSA (plan, do, study, act) cycles through which the letter was tested and adapted. Our measure of improvement was GPs' satisfaction with the letter with regards to its usefulness. Based on feedback, the letter was edited to reflect what the GPs needed in order to continue their patients' care. Joint planning with the clinical commissioning group GP leads, as well as the trust's transformation lead, was crucial to the final design of the letter that was well received by the GP colleagues. Local departments should examine current communication mechanisms for these patients, and, if found lacking, work collaboratively to improve these while also tracking relevant clinical outcomes.