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Galway University Hospitals service helps older people remain well at home

 Smiling patient Kathleen O Sullivan seated in her home in Galway with GUH Frailty Team’s Therapy Assistant, Patricia Duffy who has her arm around Kathleen's shoulder.



“The team showed unbelievable compassion, respect, patience and understanding to my mum and her needs,” according to Ultan, whose mum Kathleen O’Sullivan was recently referred to the Frailty at the Front Door (FFD) service at Galway University Hospitals.

A Galway native, Kathleen was referred to the team after she became unwell. Ultan describes the service as a “hugely positive experience. Prior to mum arriving home from hospital, the frailty therapists came out to assess the space and to see what equipment would be required to allow her recover from her setback.”

Ultan praised the team for their efficiency and professionalism and also for fully consulting with him as Kathleen’s main carer:

“During mum’s recovery, the team made several visits to her home to monitor her progress, to give support and advice. In addition, they reached out to other local community services such as PHN, home help and physio services. As a direct result of their interventions, together with the other great local health services, mum has made a full recovery and regained her independence to continue to live with dignity in her own home.”


The new FFD service at Galway University Hospitals (GUH) has seen over 2,200 older patients benefit from targeted assessment and interventions to help them remain well at home. It commenced in 2021 and consists of a team of physiotherapists, clinical nurse specialists, occupational therapists and geriatricians who work with patients over the age of 75 who present to the Emergency Department with frailty. This usually arises after a fall or because of changes in a patient’s ability to complete everyday tasks. The service uses a holistic and multi-disciplinary approach to help these patients avoid a hospital stay by intervening at the earliest point in the patient’s journey - at the front door in the Emergency Department.


Many older patients express a preference to recover from a health setback in their own home and a large part of the FDD service involves supporting the patient with a safety net of clinical services when they are discharged from the Emergency Department.

This year the team supported discharge directly to home in over 60% of frailty cases presenting to the Emergency Department. This involves working with colleagues in Galway’s Integrated Care Programme for Older Persons to ensure that patients can safely recover at home with access to the appropriate clinical specialists as and if required.

Orla Sheil, a Senior Occupational Therapist in the FDD service, describes some of the work carried out by the team: “Early assessment means we find out what’s important to our patients and what their needs are. Early intervention means we find ways to support their safe recovery at home. This approach has really significant outcomes both in terms of patient flow in the hospital setting and it also leads to shorter length of stay. It further enhances mobility, recovery and independence for our frailty patients.

“Some of the interventions we carry out include a review of medications; addressing incontinence issues; assessing mobility; providing exercise and activity programmes; recommending necessary equipment to maintain independence at home and linking patients with resources in their own community to better manage their own health.”

Dr Cliona Small, Consultant Geriatrician, added that “the Frailty at the Front Door service here in Galway is in constant evolution. We are continually developing and expanding the service to meet increasing demands. Our overall goal is to prevent hospital-acquired disability by reducing hospital stays for frail patients and facilitating a safe discharge home with appropriate follow-up. It’s important to note that this service is only one component of a patient’s journey with the healthcare system and we work closely with community care teams and our integrated care colleagues to provide optimal care to our older patients.”

The frailty service is part of the Enhanced Community Care programme (ECC) to improve and expand community health services and reduce pressure on hospital services. The National Integrated Care Programme for Older Persons aims to develop primary, secondary and acute care services for older people with a specific focus on those with more complex needs and frailty.