Background According to the Office for National Statistics census 2021, over 1/6 of the UK population is aged 65+. In our local area, the population has 21% over 65 years old. This will increase in frailty by 34% by 2030. We also have a higher than the national average over 85+. We provide palliative care for those living with a terminal diagnosis and frailty through Hospice at Home, Wellbeing/Volunteer Visitor Services.

Aim To launch a service supporting those with advancing frailty, helping them make small measurable changes, signposting to appropriate services and community volunteer led hubs. As social isolation is a known factor of frailty, we aim to connect those with a palliative diagnosis to a community that provides support and companionship.

Method A Care Connector was implemented to assess, support and signpost those with advancing frailty utilising the EQ-5D-3L questionnaire and Rockwood Frailty Score (Moorhouse, Rockwood. J R Coll Physicians Edinb. 2012;42(4):333–40). Visiting patients at home; providing personalised support to enable acts of daily living; signposting/referring to other services e.g. volunteer led community groups, hospice bereavement groups and working with NHS teams. Targeting patients with lower scores (4–6), as those with higher scores already have good support; implementing support before reaching higher scores.

Results Six months interim analysis shows we have seen 42 patients. We have signposted five who didn’t meet criteria, 12 have been discharged, one has reduced their score, the rest have remained the same. On this trajectory, we aim to support 90+ patients by project end.

Conclusion Visiting patients in person has meant we can observe patients in their own environment, gaining context of surroundings and support. Whilst we haven’t reduced the majority of patients’ frailty score, we have provided support and knowledge of community networks or services, developing strong connections with community teams and paused the clock on frailty.