To keep more people with frailty at home

1. Alternatives for paramedics

1.1. Shared record

1.2. Urgent GP line

2. Reduce admissions

2.1. Reduce exacerbations

2.1.1. Improve self care

2.1.1.1. Assess activation

2.1.1.2. Increase use of patient education

2.1.1.3. More use of care plans

2.1.2. Improve management

2.1.2.1. More proactive approach to recall

2.1.2.2. Improve continuity for target patients

2.1.2.3. Training

2.1.2.3.1. Heart failure

2.1.2.3.2. COPD

2.1.3. Community solutions

2.1.3.1. Reduce social isolation

2.1.3.2. Night sitters

2.2. Improve non-admission response

2.2.1. More discharge-to-assess schemes

3. Reduce DToC