Integrated Care for Frailty

Integrated care for frailty improves quality of life and may reduce adverse outcomes, though more high-quality research is required. This chapter explores key components of effective integrated care for frailty, drawing on learning from the European Frailty Prevention Approach, a collaborative joint action involving 23 countries. The integrated model spans the continuum of prevention and health promotion, acute treatment, rehabilitation, proactive chronic care, long-term care, and palliative and end-of-life care. It requires a capable multidisciplinary workforce with knowledge, skills, and competencies in relational practice and comprehensive assessment. Care should be collaborative, outcomes focused, based on what matters to the individual and their caregivers, and include behavioural health and restorative approaches that support self-management and optimise functional ability, particularly when transitioning between care settings. The challenge for all systems is to understand how to adapt this model to their local context and to create the conditions to scale-up and sustain integrated care.